JMIR Publications

ABSTRACT

Background:

Healthcare systems are rapidly deploying digital tools with the goal of improving chronic disease management, yet few studies evaluate their usability by vulnerable populations. To understand barriers to lower rates of app use among vulnerable populations, we employed user-centered design (UCD) methods in the development of a new text messaging app.

Objective:

We describe variations in engagement in design process, focusing specifically on limited health literacy (LHL), limited English proficiency (LEP), and limited digital literacy (LDL).

Methods:

We conducted 20 in-depth semi-structured interviews with primary care patients at a public healthcare system in San Francisco. We used open-ended discussions and cardsorting tasks to seek input about mobile phones and text messaging. We used open coding to categorize patterns of mobile phone use and to evaluate engagement in the cardsorting process. We examined qualitative differences in engagement by examining the extensiveness of participant feedback on existing and novel text messaging content. We calculated the proportion of patients providing extensive feedback on existing and novel content, overall and by health literacy, English proficiency, and digital literacy.

Results:

Participants were 59 (+/-8) years old; 65% were female, 90% were non-white, 80% had LHL, 65% had LEP. All had depression and 70% had diabetes. Most participants had smartphones (18/20) and regularly used text messaging (15/20), but 70% reported having difficulty, such as inability to type, physical disability, and low literacy. We identified 10 participants as specifically having LDL; 7 of these participants had LEP and all 10 had LHL. Half of participants required a modification of the cardsorting activity due to not understanding it or not being able to read the cards in the allotted time. The proportion of participants who gave extensive feedback on existing content was lower in participants with limited versus adequate English proficiency (30% vs 70%), limited versus adequate health literacy (44% vs 75%), and limited versus adequate digital literacy (40% vs 60%); none of these differences were statistically significant. When examining the proportion of patients who gave extensive feedback for novel messaging content, those with LHL were less engaged than those with adequate health literacy (50% vs 100%); there were no statistical differences by any subgroup.

Conclusions:

Despite widespread mobile phone use, digital literacy barriers are common among vulnerable populations. Engagement in the cardsorting activity varied among participants, and appeared to lower among those with LHL, LEP, and LDL. This suggests that researchers employing traditional UCD methods should routinely measure these communication domains among their end user samples. Future work is needed to replicate our findings in larger samples, but augmentation of cardsorting with direct observation and audiovisual cues may be more productive in eliciting feedback for those with communication barriers.