title: Usability and feasibility of a tablet-based Decision-Support and Integrated Record-keeping (DESIRE) tool in the nurse management of hypertension in rural western Kenya.
abstract: BACKGROUND
  Mobile health (mHealth) applications have recently proliferated, especially in low- and middle-income countries, complementing task-redistribution strategies with clinical decision support. Relatively few studies address usability and feasibility issues that may impact success or failure of implementation, and few have been conducted for non-communicable diseases such as hypertension.
  
  
  OBJECTIVE
  To conduct iterative usability and feasibility testing of a tablet-based Decision Support and Integrated Record-keeping (DESIRE) tool, a technology intended to assist rural clinicians taking care of hypertension patients at the community level in a resource-limited setting in western Kenya.
  
  
  METHODS
  Usability testing consisted of "think aloud" exercises and "mock patient encounters" with five nurses, as well as one focus group discussion. Feasibility testing consisted of semi-structured interviews of five nurses and two members of the implementation team, and one focus group discussion with nurses. Content analysis was performed using both deductive codes and significant inductive codes. Critical incidents were identified and ranked according to severity. A cause-of-error analysis was used to develop corresponding design change suggestions.
  
  
  RESULTS
  Fifty-seven critical incidents were identified in usability testing, 21 of which were unique. The cause-of-error analysis yielded 23 design change suggestions. Feasibility themes included barriers to implementation along both human and technical axes, facilitators to implementation, provider issues, patient issues and feature requests.
  
  
  CONCLUSIONS
  This participatory, iterative human-centered design process revealed previously unaddressed usability and feasibility issues affecting the implementation of the DESIRE tool in western Kenya. In addition to well-known technical issues, we highlight the importance of human factors that can impact implementation of mHealth interventions.
authors.affiliation: Icahn School of Medicine at Mount Sinai, New York, NY, USA. Electronic address: rajesh.vedanthan@mssm.edu.
authors.forename: Rajesh
authors.initials: R
authors.lastname: Vedanthan
authors.affiliation: Icahn School of Medicine at Mount Sinai, New York, NY, USA.
authors.forename: Evan
authors.initials: E
authors.lastname: Blank
authors.affiliation: Academic Model Providing Access to Healthcare, Eldoret, Kenya.
authors.forename: Nelly
authors.initials: N
authors.lastname: Tuikong
authors.affiliation: Academic Model Providing Access to Healthcare, Eldoret, Kenya.
authors.forename: Jemima
authors.initials: J
authors.lastname: Kamano
authors.affiliation: Academic Model Providing Access to Healthcare, Eldoret, Kenya.
authors.forename: Lawrence
authors.initials: L
authors.lastname: Misoi
authors.affiliation: Academic Model Providing Access to Healthcare, Eldoret, Kenya.
authors.forename: Deborah
authors.initials: D
authors.lastname: Tulienge
authors.affiliation: Icahn School of Medicine at Mount Sinai, New York, NY, USA.
authors.forename: Claire
authors.initials: C
authors.lastname: Hutchinson
authors.affiliation: Icahn School of Medicine at Mount Sinai, New York, NY, USA.
authors.forename: Deborah D
authors.initials: DD
authors.lastname: Ascheim
authors.affiliation: Academic Model Providing Access to Healthcare, Eldoret, Kenya; Moi University, College of Health Sciences, School of Medicine, Department of Medicine, Eldoret, Kenya.
authors.forename: Sylvester
authors.initials: S
authors.lastname: Kimaiyo
authors.affiliation: Icahn School of Medicine at Mount Sinai, New York, NY, USA; Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.
authors.forename: Valentin
authors.initials: V
authors.lastname: Fuster
authors.affiliation: Academic Model Providing Access to Healthcare, Eldoret, Kenya; Indiana University School of Medicine & Regenstrief Institute, Inc., Indianapolis, IN, USA.
authors.forename: Martin C
authors.initials: MC
authors.lastname: Were
mesh_terms: D001291:Attitude of Health Personnel; D001292:Attitude to Computers; D034201:Computers, Handheld / Q000706:statistics & numerical data; D003299:Cooperative Behavior; D020000:Decision Support Systems, Clinical / Q000706:statistics & numerical data; D057286:Electronic Health Records; D019544:Equipment Failure Analysis; D005240:Feasibility Studies; D017144:Focus Groups; D006801:Humans; D006973:Hypertension / Q000628:therapy*; D007630:Kenya; D009726:Nurses / Q000523:psychology*; D012424:Rural Population; D014584:User-Computer Interface
keywords: Clinical decision support systems; Electronic health records; Feasibility studies; Hypertension; Nurses; World health