The present study aims to develop and evaluate a self-management mobile application for individuals with MS. This study was conducted in three phases:
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1.
Determining the MS self-management needs (content preparation phase)
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2.
Designing a self-management mobile application (app design phase)
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3.
Evaluating the app from users’ perspectives (app evaluation phase) (Fig. 1).
Phase 1: Content preparation
Mobile content is defined as any form of media (pictures, music, text, videos) contained in mobile apps for the mobile device (cell phone or tablet) [37]. The initial content was prepared after extracting MS self-management needs based on the information available in guidelines and guides, paying attention to the results of our two previous studies in the field of existing apps for MS self-management and extracting needs by interviewing MS patients [27, 28].
First, the researchers searched websites of MS international organizations and accredited associations to retrieve MS self-management authoritative guides and guidelines. Then they extracted available resources [10,11,12,13,14,15,16,17,18]. The resources were reviewed to achieve the MS self-management framework.
Considering various dimensions of MS self-management (having awareness about MS, monitoring MS status, having a healthy lifestyle, managing fatigue, managing mental status, setting short-term and long-term self-management goals, developing support networks, and restructuring cognition) and the impossibility of focusing on all dimensions in one app, the researchers decided to design application concentrating on four dimensions of MS self-management, ranging from awareness of MS to healthy lifestyle in MS (nutrition and exercise in MS), MS monitoring, and fatigue management. First, the researchers (ZS and SS) reviewed the existing guidelines and guides in the four dimensions. The preliminary content was extracted after a comparative study of the different guidelines and guides. In disagreements between various sources, the guidelines were given priority. All the selected guidelines and guides are listed in Additional file 1. Finally, the initial content was given to three specialists (one neurologist, one nutritionist, and one physiotherapist) to get expert opinions. The initial content was finalized after applying experts' opinions and getting their' confirmation.
Phase 2: The mobile application design
The mobile app design phase was conducted in five steps:
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defining app functionalities
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depicting the app wireframe
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preparing the media
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coding the app
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testing the app’s performance.
Defining functionalities of the mobile app
The expected and necessary functionalities of the app were determined and finalized according to the results of our previous studies [27, 28] and the final content of the app was defined. The use-case diagram was deployed to model, present, and analyze the application's essential functionalities using Rational Rose software version 8 and UML language.
Depicting the wireframe of the mobile app
The researchers started the app design by depicting the app wireframe. The wireframe is a basic design or visual representation of a mobile application, website, system, or application before implementation. In this technique, the frame of the desired product is considered, and then with smooth lines and simple geometric shapes, the way of placing the components in it is determined. It is possible to produce wireframes in both paper and digital methods. Drawing a wireframe saves time, sets system priorities, improves content display, facilitates needed changes, and helps achieve better results [38]. The app's wireframe was sketched manually to show the app's different sections. Then the structure of the content in other parts of the application was also defined. Based on the drawn wireframe, five main sections were considered for the app and it was decided to use text, audio, and video formats in different parts of the app.
Preparing the media
After finalizing the structure and key aspects of the content, the researchers prepared different elements and media for the app. These parts included: images, logo, texts, video and audio files. All images used for the app's main parts were manually drawn, painted, and digitized.
To make the app logo, we used the orange ribbon (as the awareness symbol of MS), a symbol of man and nerve, as the main components of the logo. Then, based on an initial idea, the initial design of the logo was drawn manually and was implemented using Adobe Photoshop cc 2017 software. In the next step, the opinions of a graphic expert were obtained about the initial design, and the required changes were applied.
iSpring suite 8 was used to prepare the video files. A custom character was designed for the app using Adobe Illustrator cc 2017 to illustrate the physical activity and movements required in the video files and use a single character in all parts of the application. At first, the custom character was designed, and the 12 exercises movements for the video files were implemented using Adobe After Effect cc 2017 and the character rigging technique on the designed character. In addition, Avidemux 2.7 software was used to edit and resize the video files. The audio files were recorded using recorder and were edited using two software; mp3cutter Pro v3.0.0 and Adobe Audition CC 2017 v10.0 × 64. Eventually, selecting the appropriate font was one of the steps taken to create a good and user-friendly look for the application.
App coding
The MS self-management application (IDoThis) was developed using the Android Studio environment and Java programming language. The app works on devices running the Android operating system version 4.4 to 12. The application was developed in the Persian language, which was selected according to the geographic area. Of course, developing the app in English is also possible, and the researchers plan to provide the app in English in the future.
Testing accuracy and performance of the app
The researchers (RF, ZS) tested the developed app performance separately on several runs, and the bugs encountered at each stage were reviewed and corrected. Performance testing was performed for the app. The performance test of an application or system is exercised by emulating actual users [39]. In each test turn, the app was installed and used by two researchers (RF, ZS) and two independent software developers for two to three weeks. The application's performance was evaluated in different sections. The functions of the reporting section of the app were tested and corrected several times to provide accurate, precise, simple, and understandable charts for users. As a user, each member of the evaluation team recorded data in the app, extracted various reports of the recorded data, and tested the accuracy of the reports provided by the app in each test turn.
Phase 3: App evaluation from perspectives of the end-users
The developed app was evaluated from two aspects: the app's impact on the MS self-management tasks and the app's user-friendliness from the users’ point of view. Twenty participants who were available and willing to cooperate assessed the app. Individuals were eligible to participate in this study if they had been diagnosed as having MS, had an Android smartphone, have the ability and literacy to use applications, and had no cognitive impairment. It should be noted that the participants’ cognitive eligibility was evaluated by the neurologist (SS) in our research team for inclusion in the study. The sampling method for selecting the participants was the snowball sampling method. The app was used for three weeks by the participants. Then their comments were obtained using a researcher-made questionnaire. To facilitate the use of the app, the researchers handed the app guide to each participant in a PDF format and an audio file. After one week from the app installation for each user, the researchers made a telephone call to ask about the use of the app and any need to check and resolve possible issues of the users with the app. Three weeks after the app installation for each participant, a manual or electronic questionnaire was administered to the user based on each participant's convenience. After collecting the users' views, the data were analyzed using the SPSS software (version 24).
The responses to the questions in the questionnaire were based on the Likert five-point scale. The questionnaire validity was assessed by obtaining the opinion of five experts (Health information management field, medical informatics field, and MS fields). Two relative coefficients of content validity ratio (CVR) and content validity index (CVI) were used to check content validity quantitatively.
The content validity ratio (CVR), an item statistic originally suggested by Lawshe (1975), is one of the most widely used methods for quantifying content validity. The panel of experts in the CVR approach is asked to rate each item into one of three categories: “Essential”, “Useful, but not essential”, or “Not necessary”. Items considered “essential” by a critical number of experts are then included in the final form, while items failing to reach this critical level are rejected. CVR is calculated by using this formula: CVR = (Ne − N/2)/(N/2), where Ne is the number of panelists indicating an item as “essential” and N is the total number of panelists [40, 41]. In the present study, all items had a CVR > 0.99 (this value is based on the total number of experts, N = 5, and the numerical values of the Lawshe table) [40]. Therefore, all items were included in the final questionnaire.
CVI is calculated by summing up the agree scores for each item that scored "relevant but needs revision" and "completely relevant" divided by the number of experts. The content validity is confirmed if the CVI score is higher than 0.79, [41]. The CVI was equal to 0.98 in this research.
Cronbach's alpha was calculated separately for two parts of the questionnaire (including the user's perspective on the app's effectiveness in MS self-management and user-friendliness). Cronbach's alpha value was obtained as 0.95 for questions on app effectiveness and 0.64 for user-friendliness questions. Also, alpha was calculated for the sub-sections of the effectiveness section. The alpha values were for the questions in the sub-sections of awareness, behaviour and MS control as 0.86, 0.84 and 0.91, respectively.
The questionnaire consisted of four main sections:1) participant demographic information, 2) App user-friendliness questions, 3) application impact questions, and 4) User comments and Application score (a score between 1 and 5 that each participant considers for the app). The user-friendliness of an application means that the user can easily learn how to work with and use it; overall, if the app is user-friendly, the user has not had to go through a long process to do a simple task [42]. The app's user-friendliness was evaluated with six questions based on a five-point Likert scale ranging from 1 (very difficult or inappropriate) to 5 (very easy or appropriate). App user-friendliness questions were set about how easy it is to install, log in, learn, use, and access the app sections. The impact of app usage was evaluated with 11 questions based on a five-point Likert scale that focused on increasing user awareness in the four dimensions of self-management intended for the app and its impact on changing user behaviour in each of these dimensions. The fourth section of the questionnaire was intended to receive users' feedback on their experience after using the app. In this section, it is possible to express users' opinions about the advantages and disadvantages of the app, prioritize the app modules according to user satisfaction, and users suggestions to improve the app. The qualitative analysis was done for users' comments analysis. The questionnaire is provided in Additional file 2.