title: Understanding the barriers to successful adoption and use of a mobile health information system in a community health center in São Paulo, Brazil: a cohort study.
abstract: Mobile technology to support community health has surged in popularity, yet few studies have systematically examined usability of mobile platforms for this setting.
  
  
  
  We conducted a mixed-methods study of 14 community healthcare workers at a public healthcare clinic in São Paulo, Brazil. We held focus groups with community healthcare workers to elicit their ideas about a mobile health application and used this input to build a prototype app. A pre-use test survey was administered to all participants, who subsequently use-tested the app on three different devices (iPhone, iPad mini, iPad Air). Usability was assessed by objectively scored data entry errors and through a post-use focus group held to gather open-ended feedback on end-user satisfaction.
  
  
  
  All of the participants were women, ranging from 18-64 years old. A large percentage (85.7%) of participants had at least a high school education. Internet (92.8%), computer (85.7%) and cell phone (71.4%) use rates were high. Data entry error rates were also high, particularly in free text fields, ranging from 92.3 to 100%. Error rates were comparable across device type. In a post-use focus group, participants reported that they found the app easy to use and felt that its design was consistent with their vision. The participants raised several concerns, including that they did not find filling out the forms in the app to be a useful task. They also were concerned about an app potentially creating more work for them and personal security issues related to carrying a mobile device in low-income areas.
  
  
  
  In a cohort of formally educated community healthcare workers with high levels of personal computer and cell phone use, we identified no technological barriers to adapting their existing work to a mobile device based system. Transferring current data entry work into a mobile platform, however, uncovered underlying dissatisfaction with some data entry tasks. This dissatisfaction may be a more significant barrier than the data entry errors our testing revealed. Our results highlight the fact that without a deep understanding of local process to optimize usability, technology-based solutions in health may fail. Developing such an understanding must be a central component in the design of any mHealth solution in global health.
authors.affiliation: Department of Medicine, San Francisco General Hospital, University of California, San Francisco, 1001 Potrero Avenue, San Francisco, CA, 94110, USA. Jayant.Rajan@ucsf.edu.
authors.forename: Jayant V
authors.initials: JV
authors.lastname: Rajan
authors.affiliation: Faculdade de Ciências Médicas da Santa Casa de São Paulo, Rua Dr. Cesário Motta Jr., 61, Vila Buarque, São Paulo, SP, Brazil.
authors.forename: Juliana
authors.initials: J
authors.lastname: Moura
authors.affiliation: Center for Vulnerable Populations, San Francisco General Hospital, University of California, 1001 Potrero Avenue, San Francisco, CA, 94110, USA.
authors.forename: Gato
authors.initials: G
authors.lastname: Gourley
authors.affiliation: Faculdade de Ciências Médicas da Santa Casa de São Paulo, Rua Dr. Cesário Motta Jr., 61, Vila Buarque, São Paulo, SP, Brazil.
authors.forename: Karina
authors.initials: K
authors.lastname: Kiso
authors.affiliation: Center for Vulnerable Populations, San Francisco General Hospital, University of California, 1001 Potrero Avenue, San Francisco, CA, 94110, USA.
authors.forename: Alexandre
authors.initials: A
authors.lastname: Sizilio
authors.affiliation: Faculdade de Ciências Médicas da Santa Casa de São Paulo, Rua Dr. Cesário Motta Jr., 61, Vila Buarque, São Paulo, SP, Brazil.
authors.forename: Ana Maria
authors.initials: AM
authors.lastname: Cortez
authors.affiliation: School of Public Health, 530 E Li Ka Shing Center, University of California, Berkeley, CA, 94720, USA.
authors.forename: Lee W
authors.initials: LW
authors.lastname: Riley
authors.affiliation: Faculdade de Ciências Médicas da Santa Casa de São Paulo, Rua Dr. Cesário Motta Jr., 61, Vila Buarque, São Paulo, SP, Brazil.
authors.forename: Maria Amelia
authors.initials: MA
authors.lastname: Veras
authors.affiliation: Department of Medicine, San Francisco General Hospital, University of California, San Francisco, 1001 Potrero Avenue, San Francisco, CA, 94110, USA.
authors.forename: Urmimala
authors.initials: U
authors.lastname: Sarkar
mesh_terms: D000293:Adolescent; D000328:Adult; D001291:Attitude of Health Personnel; D001938:Brazil; D015331:Cohort Studies; D003151:Community Health Centers / Q000592:standards*; D003695:Delivery of Health Care / Q000592:standards*; D005260:Female; D063005:Health Information Systems / Q000592:standards*; D006801:Humans; D008297:Male; D008875:Middle Aged; D017216:Telemedicine / Q000592:standards*; D055815:Young Adult
keywords: Brazil; Usability; mHealth