Our lives are being changed by the increasing presence of smartphones. In fact, a recent survey found that more than half of US mobile subscribers now own one . As a result of this growth, numerous mobile health (mHealth) applications are becoming ingrained in our everyday lives. Furthermore, the usage of mHealth applications is growing at a much more rapid rate than that of other applications . Consequently, companies such as Apple and Google are increasing their presence in the mHealth space because of the interest that users have in these types of applications . mHealth applications focus on a variety of issues, ranging from medication reminders to wellness . Along with the growth of these pervasive and ubiquitous health tools, there is also an increasing focus on patient-centered care . A key feature of this approach, especially as people deal with more chronic conditions, is that individuals will have to be responsible for managing more of their own health issues and interact with a variety of clinicians and specialized care providers. Consequently, mHealth applications will play an increasing role in supporting individual needs, ranging from monitoring health status to connecting with healthcare providers.
The concept of ubiquitous computing (Ubicomp) -where technologies are no longer visible, but can disappear and blend in with the environment-is currently being realized. This is particularly true in the healthcare domain, where there has been a great deal of interest in mHealth applications from researchers in the pervasive computing community . Yet, for all the success that has been achieved in designing these applications, a number of challenges still remain. Some of these challenges include: (1) identifying appropriate users and maintainers of the applications; (2) supporting the social network around the patient/individual; and (3) incorporating appropriate motivational challenges.
Consequently, to design pervasive and ubiquitous mHealth applications that appropriately support the user, we need to include a sociotechnical perspective in the design process.
The Sociotechnical Perspective
While traditional design analysis often focuses on what the technology should do (that is, in terms of its functionality), sociotechnical analysis looks at how the technology will be incorporated into the user's activities. This type of analysis is based on the observation that designing and implementing a successful technology requires a thorough understanding of the organizational context, including its structure, workflow, and employees.
Therefore, from a sociotechnical perspective, it is impossible to separate the organizational or social issues from the technical issues. Instead, the organization/social context and the technology are interwoven to form a sociotechnical system . In the context of mHealth application design, utilizing this perspective allows designers to better understand: (1) what people actually do instead of what the process says they should do , and (2) the role of context in what people do. In particular, the sociotechnical approach allows us to better understand user needs and activities and answer questions about how and why an activity takes place. The primary approach to incorporating a sociotechnical perspective into the design process is through the use of qualitative research methods. Qualitative methods are leading methods for investigating technology design and implementation in the human-computer interaction (HCI) community and are particularly useful for examining complex environments where technical, organizational, and social factors intersect, such as in healthcare.
Understanding User Interactions with mHealth Applications
A typical example of an mHealth application is Glucose Buddy (www.glucosebuddy.com), which focuses on a common chronic condition — diabetes. It is a free mobile iPhone application that allows users to store information, such as medication and food logs, necessary to manage their diabetes. Users upload the information to an associated online logbook. This information can then be used to graph trends, to identify problem areas, and for other related activities.
As more individuals use mHealth applications, there is a growing need to understand how they can be better designed for wider acceptance and increased utilization. The sociotechnical perspective highlights the importance of understanding the social features that affect how users interact with and utilize mHealth tools. Designers must address a number of challenges.
Challenge 1: Identifying the appropriate users and maintainers of the technology
An important question for a designer to ask is, “Who will be using this system?” While the answer may seemingly be simple, that is often not the case. Consider the electronic health record (EHR). In the early days of EHR design, it was thought that these systems would be primarily used by physicians. However, it turned out that the most common users of the system were nurses. Yet, because the system focused on physician use, it did not support the nurses in an effective manner. Similarly, it is important to consider who the actual users of an mHealth application will be. For instance, will it be the individual who has the issue or will it be someone else connected to that individual (for instance, a sibling, spouse, or parent)? This could be very different from the designer's idea of who will use it. Furthermore, unlike clinical systems where an IT professional can be called in to deal with a maintenance issue or a problem, mHealth systems will generally be maintained by a non-IT professional. Finally, the maintainer of the technology may not be the same person as the user. Therefore, the design of these applications must take these issues into account. Consequently, when designing these systems, the following questions would be helpful to ask:
- (a) Who will be using the system?
- (b) Who will be maintaining the system?
- (c) What kind of knowledge will the maintainer need to maintain the system?
Challenge 2: Supporting the user's social network
Most current mHealth applications are designed for the individual user. However, when dealing with health issues, it is rarely just the individual user who is involved in the process. More often, there is a wide social network of family and friends who support the individual's health goals. These individuals can range from very close family members to friends the user interacts with outside the home. Studies have shown that including an individual's social network in the care process can improve the chances that the individual will improve from the condition he or she faces . For instance, rarely will a technology be as effective as a spouse in ensuring that an individual stays on his or her medication. Yet, most mHealth applications do not have features to provide support for the social network that has built up around the patient. Rather, the focus is on the application itself providing the motivation to the individual. While the tool certainly can and does play an important role in motivation (as discussed in the next challenge), it cannot replace the role of the individual's social network. So, for instance, if the individual allows it, an mHealth application could inform the user's social network (as defined by the user) about changes in the individual's health status or provide updates based on the data entered in the application by the individual. Therefore, it is important to consider the following questions:
- (a) Who could provide social support for the users in this particular context?
- (b) What types of social support would be useful in this particular context?
- (c) How can the social support features be designed into the application/system without taking away from the main focus of the application?
Challenge 3: Incorporating motivational challenges into the design
Unlike clinical healthcare applications where the patient is often a passive participant (for instance, when the applications will be used by the staff to take care of the patient), in mHealth applications, the patient has to be an active participant. In other words, the patient has to want to follow the guidance of the mHealth application. This requires that the application "motivate" the user to follow its guidance . Although it is not often thought of as a design issue, it is becoming one of the most important challenges in designing mHealth applications. Consequently, designers need to consider the following questions:
- (a) What will motivate the users of this application?
- (b) What might demotivate users from using this application?
- (c) What features can we include in the application that would help motivate the user?
These challenges highlight a primary issue for designers: understanding the users' context. Context is difficult to design into systems. The traditional view of context argues that it is easily representable in systems because it is stable and can be separated from the activity that it surrounds. This representational view has been one that system developers have traditionally used when designing for context in computational systems. However, Dourish  argues that an alternative view more accurately captures the challenges of context. In this view, context is dynamic and cannot be separated from a particular activity. Since individuals may have their own particular techniques and methods for managing their health issues, there is often a great deal of uncertainty that these applications have to deal with. This uncertainty could "cause malfunctions in applications rendering them useless to users because of their lack of confidence in their robustness" . Consequently, mHealth applications have to be robust enough to handle the dynamic and uncertain aspects of a user's context.
Designing and Evaluating mHealth Applications
Traditional design techniques focus predominantly on the technical features and constraints of an application. However, as described in the earlier sections, there are several issues that are not purely technical in nature. Consequently, utilizing a sociotechnical perspective will focus designers not only on the technical challenges that need to be addressed, but also on the social challenges related to the goals of the application and how it will be used. Evaluating mHealth applications in light of these design considerations will require ongoing interaction between the designers and users throughout the entire design process. One form of interaction that has been widely used in the human-computer interaction community is participatory design (PD) . PD techniques such as low-tech prototyping, storyboard prototyping, and mockups allow users to provide feedback on the system design without the high costs associated with fully implemented applications.
The design and evaluation of these types of applications will also require software engineers, user interface (UI) designers, and other technical personnel to work with healthcare specialists. Interdisciplinary teams are important for the development of a truly successfully mHealth application .
The sociotechnical design perspective allows us to take into account the diverse environments and needs of the mHealth application users. Traditional design practices, which focus on the technology, often miss crucial aspects of the complex environments in which the application is implemented. It is only through closely examining and understanding the users' activities that designers can develop mHealth applications that fully support their needs. Consequently, we need to move toward involving users more deeply in the design process , as well as understanding the social context in which these applications will be used.
Created: Feb 5 2013
Last updated: Aug 29 2014
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