title: The PAediatric Risk Assessment (PARA) Mobile App to Reduce Postdischarge Child Mortality: Design, Usability, and Feasibility for Health Care Workers in Uganda.
abstract: BACKGROUND
  Postdischarge death in children is increasingly being recognized as a major contributor to overall child mortality. The PAediatric Risk Assessment (PARA) app is an mHealth tool developed to aid health care workers in resource-limited settings such as Sub-Saharan Africa to identify pediatric patients at high risk of both in-hospital and postdischarge mortality. The intended users of the PARA app are health care workers (ie, nurses, doctors, and clinical officers) with varying levels of education and technological exposure, making testing of this clinical tool critical to successful implementation.
  
  
  OBJECTIVE
  Our aim was to summarize the usability evaluation of the PARA app among target users, which consists of assessing the ease of use, functionality, and navigation of the interfaces and then iteratively improving the design of this clinical tool.
  
  
  METHODS
  Health care workers (N=30) were recruited to participate at Mbarara Regional Referral Hospital and Holy Innocents Children's Hospital in Mbarara, Southwestern Uganda. This usability study was conducted in two phases to allow for iterative improvement and testing of the interfaces. The PARA app was evaluated using quantitative and qualitative measures, which were compared between Phases 1 and 2 of the study. Participants were given two patient scenarios that listed hypothetical information (ie, demographic, social, and clinical data) to be entered into the app and to determine the patient's risk of in-hospital and postdischarge mortality. Time-to-completion and user errors were recorded for each participant while using the app. A modified computer system usability questionnaire was utilized at the end of each session to elicit user satisfaction with the PARA app and obtain suggestions for future improvements.
  
  
  RESULTS
  The average time to complete the PARA app decreased by 30% from Phase 1 to Phase 2, following user feedback and modifications. Participants spent the longest amount of time on the oxygen saturation interface, but modifications following Phase 1 cut this time by half. The average time-to-completion (during Phase 2) for doctors/medical students was 3 minutes 56 seconds. All participants agreed they would use the PARA app if available at their health facility. Given a high PARA risk score, participants suggested several interventions that would be appropriate for the sociocultural context in southwestern Uganda, which involved strengthening discharge and referral procedures within the current health care system.
  
  
  CONCLUSIONS
  Through feedback and modifications made during this usability study, the PARA app was developed into a user-friendly app, encompassing user expectations and culturally intuitive interfaces for users with a range of technological exposure. Doctors and medical students had shorter task completion times, though all participants reported the usefulness of this tool to improve postdischarge outcomes.
authors.affiliation: School of Medicine, University of North Carolina, Chapel Hill, NC, United States.
authors.forename: Lauren Lacey
authors.identifier: http://orcid.org/0000-0003-1631-8382
authors.initials: LL
authors.lastname: English
authors.forename: Dustin
authors.identifier: http://orcid.org/0000-0001-9717-3685
authors.initials: D
authors.lastname: Dunsmuir
authors.forename: Elias
authors.identifier: http://orcid.org/0000-0001-7206-0609
authors.initials: E
authors.lastname: Kumbakumba
authors.forename: John Mark
authors.identifier: http://orcid.org/0000-0001-8427-2035
authors.initials: JM
authors.lastname: Ansermino
authors.forename: Charles P
authors.identifier: http://orcid.org/0000-0002-6179-7485
authors.initials: CP
authors.lastname: Larson
authors.forename: Richard
authors.identifier: http://orcid.org/0000-0003-1759-2236
authors.initials: R
authors.lastname: Lester
authors.forename: Celestine
authors.identifier: http://orcid.org/0000-0001-8184-4720
authors.initials: C
authors.lastname: Barigye
authors.forename: Andrew
authors.identifier: http://orcid.org/0000-0002-9984-3221
authors.initials: A
authors.lastname: Ndamira
authors.forename: Jerome
authors.identifier: http://orcid.org/0000-0003-1912-1032
authors.initials: J
authors.lastname: Kabakyenga
authors.forename: Matthew O
authors.identifier: http://orcid.org/0000-0002-3287-5181
authors.initials: MO
authors.lastname: Wiens
keywords: Africa; infectious disease; mHealth; postdischarge mortality; prediction model; resource-limited settings; risk assessment; usability