Background
Digitalization can play an important role in delivering health services to individuals and communities. Hospitals have been digitalizing their services and renovating the whole process of health care. Digitalization not only helps to improve patient safety and satisfaction but also keeps health statistics of the population up-to-date. Since an approximate of 6 billion people (around 75% of the world population) have access to mobile phones, mobile health applications have become an important channel for providing healthcare services by healthcare service providers [
1]. Therefore, mHealth (mobile health) as a field of research has become prominent in recent years. In general, the term mHealth refers to the practice of using mobile devices in health care services [
2]. The Global Observatory for eHealth defines mHealth as “
medical and public health practice supported by mobile devices, such as mobile phones, patient monitoring devices, personal digital assistants (PDAs), and other wireless devices” [
3]. The mHealth applications include the use of mobile devices to improve the process of medical data collection [
4], service delivery [
5], patient-doctor communication [
6], and real-time monitoring and adherence support [
7].
The mHealth applications have even been widely used in the remote villages of developing countries [
8]. For example, doctors in Tanzania can use
Afya Mtandao (Swahili for Health Network) network from anywhere in the country even during the surgical operation through mobile phones [
9]. United States Agency for International Development (USAID) has built the foundation of Mobile Alliance for Maternal Action (MAMA), a support for the development of a health informatics network for maternal patients using mobile phones. Monitoring and Evaluation to Assess and Use Results (MEASURE) is another US (United States) funded project that focuses mainly on the development of mobile platforms for monitoring health in developing countries [
10]. Most of these mHealth services in developing countries rely on text messaging [
10] in health related issues such as HIV (human immunodeficiency virus) prevention [[
11‐
14]]. These messages are also used to bridge the community and the health worker [
15].
In Bangladesh, a number of initiatives on mHealth have already been taken by the government and the non-government organizations. These include developing mobile applications for health care service delivery, personal health tracking, remote consultation, and information delivery. However, the outcomes of these initiatives are not well understood. There has been very little research in the mHealth domain of Bangladesh. There are a few studies, which mainly focused to assess the opportunities, and challenges of using Information Technology in the health sector of Bangladesh [
16‐
19]. However, very few studies have been conducted that evaluate the mHealth applications in Bangladesh in terms of usability. Usability is defined as the effectiveness, efficiency, and satisfaction with which users achieve specified goals in a specific context of use [
20]. Usability is one of the key quality attributes for the successful development and adoption of mHealth apps like any other digital applications [
21‐
24] . Therefore, the objective of this research is to understand the state of the art of the mHealth applications developed in Bangladesh, and to assess the overall usability of these applications. Consequently, this paper addresses the following research questions:
To attain this research objective, this paper follows a 3-stage research process: systematic application review, expert inspection, and user studies. The findings suggest that the usability of the mHealth apps in Bangladesh is not satisfactory in general. Based on the findings, the paper provides several actionable guidelines for the practitioners.
ICT (Information and Communication Technology) in healthcare services has brought revolutionary changes by enhancing service quality, ensuring safety and clinical effectiveness. Research on health informatics, in the form of mHealth, has gained much attention [
25]. A synopsis on the impact of mobile applications in public health can be found in the study of Fiordelli et al. [
25]. They reviewed mHealth related studies published between 2002 and 2012 and found that mHealth services are mostly focused on chronic conditions. They also found a lack of mHealth related studies in Asia. In fact, very few studies have been conducted on the influence and adequacy of mHealth services in developing countries like Bangladesh.
In order to understand the influence of mHealth on public health services, Ahmed et al. [
19] studied the existing eHealth and mHealth enterprises and assessed their prospects in Bangladesh. They found that tele-consultation, prescription, and referral are the most common initiatives. They also suggested that the availability of trained health care professionals, capacity building, research support, and experience factors sharing are the key for promoting and implementing mHealth services in Bangladesh. In another study, Prodhan et al. [
26] investigated the telemedicine initiatives and their interoperability. They found that most of the initiatives have different formats of data. Different data format along with lack of proper data storage facilities greatly affect the interoperability among the existing health care services. They further found that most of these projects work well at the beginning, but fail in the long run due to lack of publicity and user acceptance. Thus, they recommend for a standard data storage policy as well as a proper awareness program to increase the usage of telemedicine services.
Ahsan et al. [
27] conducted a survey on the subscribers of
Aponjon, an app that serves pregnant women or new mother. This study concludes that mHealth can significantly contribute to improving health status. Prue et al. [
28] found that mobile phone services could assist health professionals by rapidly detecting and treating patients with Malaria in a remote area in Bangladesh. Khatun et al. [
29] conducted a survey on 4915 randomly selected personals and proposed a framework to assess the community readiness (in terms of technological, motivational and resource) towards mHealth services in Bangladesh. The study found that the community has access to mHealth services, but a noticeable gap is present between the users’ readiness and technological competencies. In another study, Khatun et al. [
30] reaffirmed this framework by conducting 37 in-depth interviews with the aim to identify the potential obstacles and possible solutions for mHealth services in Bangladesh. Similarly, another in-depth interview study was conducted by Eckersberger et al. [
31] to explore if women are interested to receive text messages on their phone for contraceptive use and family planning in Bangladesh. Huda et al. [
32] explored the feasibility, acceptability, and perceived appropriateness of using the mobile phone (in a poor rural community in Bangladesh) to receive a voice message, direct counselling, and unconditional cash transfers to provide food and nutrition guide during pregnancy and the first year of a child’s life. The study found that most of the mothers did not feel any major problem to operate mobile phones and the mothers provided very positive feedbacks that support the feasibility, acceptability, and appropriateness of the mobile messaging program.
A few studies also discussed the design, development, evaluation of mobile health applications. For example, Islam et al. [
33] discussed the design and development of a mHealth application named
DiaHealth. They examined the diabetes related health apps and extracted the most important features for developing
DiaHealth app for diabetes. In another study, Shermin et al. [
34] briefly discussed
VirtualEyeDoc app and its effectiveness. This app is designed in Bengali language to help Bangladeshi people to identify their vision problem and maintain good eye health. Zaman & Mamun [
35] designed a preventive app for cardiovascular diseases and depicted the importance of such app in Bangladesh. Hoque et al. [
36] developed a mobile-based remote monitoring system to aid the palliative care treatment for rural breast cancer patients in Bangladesh. Khan et al. [
37] designed a mHealth app,
PurpleAid for the women of Bangladesh. The app is designed to diagnose women specific diseases and provide suggestions to prevent and cure.
A number of studies also investigated the adoption and post-adoption of mHealth applications in Bangladesh. For example, Hoque et al. [
38] proposed a theoretical model that predicts behavioral intention to adopt mHealth applications of the elder citizens in Bangladesh. They used the Unified Theory of Acceptance and Use (UTAUT) model and derived a set factors of mHealth acceptance in Bangladesh. The factors include gender, the experience of using a mobile phone, performance expectancy, effort expectancy, social influence, facilitating condition, hedonic motivation, price, and habit. Akhter et al. [
39] developed a service quality model in the context of mHealth services by framing its relationship with satisfaction, continuance intention and quality of life. In another study, Akhter et al. [
40] developed an mHealth continuance model by incorporating the role of service quality and trust.
Finally, only a few studies investigated usability and user experience of mHealth services. Haque et al. [
36] developed a mobile application for breast cancer patients in Bangladesh by following a participatory design process involving both patients and doctors. They also explored the key quality of such kind of system to accept and adopted by users of Bangladesh. The study found that the quality of such a system might depend on usability (effectiveness, efficiency, satisfaction) and sustainability. In another study, Bhuiyan et al. [
41] proposed an SMS (short message service) based immunization system and then valuated the usability of a SMS alert system for immunization. Two approaches were used to test the usability: (a)
system centric that measures the availability, localizability, supportability, security, and technical feasibility of the mHealth service; and (b)
human centric that measures the knowledge of usage, learnability, memorability, and satisfaction of the user. As outcome, this usability study found that the SMS alert system was effective to the end users, found very easy to use, Learn ability, reliability and satisfaction rate was also higher, and the participants were willing to use the proposed system instead of manual system, which indicate the overall efficacy and efficiency of the proposed SMS based immunization system.
Taken together, our literature review indicates that usability has not been the key focus in most prior research conducted in Bangladesh.
Discussions
Key findings
In this paper, we investigated the overall usability of mobile health applications in Bangladesh through an extensive empirical research. This research provides three main findings. First, we summarized an overview of mHealth applications developed in Bangladesh along with the targeted end users and the features/functionalities provided by the applications. We found 9 categories of applications based on their features/functionalities. The study also found that healthcare professionals, mothers, patients, and other general users have been the targeted end users for the mHealth apps in Bangladesh.
Second, the study found that the usability of selected mHealth applications in Bangladesh in general does not adhere to or follow the design principles. Both expert inspection and SUS technique revealed that the existing mHealth applications would be very hard for the users to use. The results indicate that the lack of usability would be one of the key barriers for adopting mHealth applications in Bangladesh.
Third, we also strived to explore the possible relation among the number of usability problems with the application size (number of UIs), the severity scores, and the SUS score. We found that although positive relations were observed between the number of usability problems with the number of UIs and with the severity score, but the relations were not significant. Furthermore, we found that the number of usability problems had an inverse relation with the SUS score. This indicates that the findings from heuristic inspection and SUS evaluation complement each other.
However, a major limitation of this study is that we conducted the user study with a small number of participants and with a small number of apps. Another limitation is that we have not compared between Government and private apps in this study.
Implications and directions for future research
This research is the first to provide in-depth view on the usability status of mHealth applications in Bangladesh. The findings will greatly contribute to research in health informatics, and to the HCI practitioners, non-government organizations (NGOs) and Government organizations providing health services in Bangladesh. The study provides the following implications: First, our results provide clear empirical evidence that usability has been overlooked in mHealth applications development. These findings could provide important practical implications such as increasing awareness of improving usability in mHealth applications. The results also depicted the type of usability problems (or heuristics violated in development), found in the tested apps. These findings may provide the underlying knowledge (e.g., heuristics often not fulfilled) for usable mHealth applications development. Furthermore, the findings also reveal the necessity of curriculum revision in computer science education to integrate HCI concepts. Consequently, possible future research area could be to investigate the underlying reasons and its possible solutions of why usability was overlooked in the developed mHealth applications.
Second, the findings of this research can guide researchers for further studying mHealth services and plan for usability-based research designs in the context of Bangladesh. The lack of usability in tested apps imposes an important question of to what extent user centered development approaches are actually used in Bangladesh for developing the mHealth applications. Furthermore, it raises the question of to what extent requirements elicitation study for finding the contextual need for developing new and usable mHealth applications has been conducted in developing these applications. All these questions provide further research directions that can be conducted by researchers. Future research, for example, may focus to design, develop and evaluate mHealth applications by following methodologies that keep usability at the center of attention.
Third, this paper is the first to provide a taxonomy of mHealth apps developed in Bangladesh. We found 9 types of mHealth applications available in Bangladesh. Future studies can be conducted to verify the applicability of this taxonomy in other contexts and possibly extend it.
Finally, our study results suggest that there have not been enough effort to develop mHealth apps for marginalized population in Bangladesh. Thus, special emphasis on user profile (such as disability, literacy, etc.) would be required to develop accessible and usable apps for the marginalized citizens of Bangladesh.
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