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Background: For digital tools to have high usability and fit service users' health needs and socio-environmental context, it is important to explore usability with end-users and identify facilitators and barriers to uptake. Objective: To conduct user testing of the smartphone health application, PeerTECH, in a Norwegian community mental health setting. Methods: Semistructured interviews and usability testing of the PeerTECH app using the Think-Aloud approach and task analysis among 11 people (three individuals with a serious mental illness, two peer support workers, and six mental health professionals). Results: Study participants perceived PeerTECH as a relevant tool to support self-management of their mental and physical health conditions, and they provided valuable feedback on existing features as well as suggestions for adaptions to the Norwegian context. The task analysis revealed that PeerTECH is easy to manage for service users and peer support workers. Conclusions: Adapting the PeerTECH smartphone app to the Norwegian context may be a viable and useful tool to support individuals with serious mental illness.
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International Journal of
Environmental Research
and Public Health
Article
Usability Testing of a Mobile Health Application for
Self-Management of Serious Mental Illness in a Norwegian
Community Mental Health Setting
Marianne Storm 1, * , Hilde Marie Hunsbedt Fjellså 1, Jorunn N. Skjærpe 1, Amanda L. Myers 2,
Stephen J. Bartels 3and Karen L. Fortuna 4


Citation: Storm, M.; Fjellså, H.M.H.;
Skjærpe, J.N.; Myers, A.L.; Bartels,
S.J.; Fortuna, K.L. Usability Testing of
a Mobile Health Application for
Self-Management of Serious Mental
Illness in a Norwegian Community
Mental Health Setting. Int. J. Environ.
Res. Public Health 2021,18, 8667.
https://doi.org/10.3390/
ijerph18168667
Academic Editors: Natasha Reid,
Maike Neuhaus and
Paul B. Tchounwou
Received: 9 June 2021
Accepted: 13 August 2021
Published: 17 August 2021
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iations.
Copyright: © 2021 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
1Department of Public Health, Faculty of Health Sciences, University of Stavanger, 4021 Stavanger, Norway;
hildemarie.fjellsa@uis.no (H.M.H.F.); jorunn.n.skjerpe@uis.no (J.N.S.)
2School of Public Health, Rivier University, Nashua, NH 03060, USA; amyers1@rivier.edu
3Mongan Institute, Massachusetts General Hospital, Harvard Medical School, Harvard University,
Boston, MA 02114, USA; SJBARTELS@mgh.harvard.edu
4Department of Psychiatry, Geisel School of Medicine, Dartmouth College, Lebanon, NH 03766, USA;
Karen.L.Fortuna@Dartmouth.edu
*Correspondence: marianne.storm@uis.no
Abstract:
Background: For digital tools to have high usability and fit service users’ health needs
and socio-environmental context, it is important to explore usability with end-users and identify
facilitators and barriers to uptake. Objective: To conduct user testing of the smartphone health
application, PeerTECH, in a Norwegian community mental health setting. Methods: Semistructured
interviews and usability testing of the PeerTECH app using the Think-Aloud approach and task
analysis among 11 people (three individuals with a serious mental illness, two peer support workers,
and six mental health professionals). Results: Study participants perceived PeerTECH as a relevant
tool to support self-management of their mental and physical health conditions, and they provided
valuable feedback on existing features as well as suggestions for adaptions to the Norwegian context.
The task analysis revealed that PeerTECH is easy to manage for service users and peer support
workers. Conclusions: Adapting the PeerTECH smartphone app to the Norwegian context may be a
viable and useful tool to support individuals with serious mental illness.
Keywords: mobile health; user-testing; usability study; serious mental illness; peer support
1. Background
Mobile health applications are being developed at a fast pace and show promis-
ing evidence of promoting positive health behavior change such as monitoring physical
activity and mental health symptoms [
1
,
2
]. Individuals with a serious mental illness
(i.e., schizophrenia spectrum disorders, major depressive disorders and bipolar disorders,
personality disorders, along with persistent functional impairment [
3
]), could benefit from
using digital tools such as mobile health applications (apps) that promote health literacy
and positive behavior changes [
1
,
2
,
4
], as they experience early mortality health disparity
and die up to 32 years earlier than the general population, mainly due to poor health
behaviors [
5
,
6
]. As such, technology-supported integrated medical and psychiatric self-
management interventions for people with serious mental illness have received attention.
One example is the PeerTECH smartphone health app (PeerTECH app) developed by
Digital Peer Support in Nashua, NH, USA. The term PeerTECH originates from the inte-
gration of technology into traditional peer support services [
7
9
]. PeerTECH is informed
by Integrated Illness Management and Recovery (I-IMR) for individuals with a serious
mental illness and medical comorbidity and helps to self-manage medical and psychiatric
conditions [
8
]. A core feature of the PeerTECH app is the components of peer support,
sharing lived experience, and self-determination. PeerTECH is delivered by a peer support
Int. J. Environ. Res. Public Health 2021,18, 8667. https://doi.org/10.3390/ijerph18168667 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2021,18, 8667 2 of 11
specialist and is designed to improve self-management and empower people to address the
vulnerability that may lead to new or worsening medical and psychiatric symptoms and
conditions. Key components in the PeerTECH app include the following: (1) education to
improve knowledge about managing mental and medical illness (i.e., psychoeducation,
medical management, social skills training); (2) healthy behaviors (e.g., diet, exercise)
and behavior change; (3) training and planning to prevent relapses, and (4) increased
coping skills from defining personalized goals associated with medical and mental health,
learning from similar others lived experiences of recovery and referral to resources, as
needed [10,11].
For a digital tool, such as the PeerTECH app, to have high usability and likelihood to
fit the context and end users’ mental and physical health needs, it is important to identify
the use of existing digital tools in service provision, as well as facilitators and barriers
to uptake and use of the mobile app in various contexts [
2
,
12
]. Usability can be defined
as the “extent to which a system, product or service can be used by specified users to achieve
specified goals with effectiveness, efficiency, and satisfaction in a specified context of use” [
13
].
Usability is a factor in the adoption of mobile health apps when people who need to use
them may have problems interacting with an app due to their health conditions [
2
,
7
]. For
example, usability testing provides a unique opportunity to promote engagement and have
direct data on the end users’ interactions with the technology, thus providing a picture
of how useful the system will be for individuals with serious mental illness within their
socio-cultural environment [
14
]. A recent systematic review by Borghouts et al. identified
social connectedness, increased insight into one’s own health, and a feeling of being in
control, as important factors facilitating continuous user engagement with a digital mental
health intervention [4].
We conducted usability testing of the American prototype PeerTECH app to test
PeerTECH with Norwegian end-users (i.e., mental health service users, peers support
workers) and mental healthcare professionals. Early inclusion of relevant end-users in the
development of a Norwegian version of PeerTECH is important to get feedback on what
is important to end-users, as well as needs for adjustments in the content and the design
of the smartphone app to adapt it for use with individuals with serious mental illness
receiving community mental health services [
12
,
15
]. Community engagement and user
participation when developing and adapting digital interventions can ensure relevance and
appropriateness [
16
] and facilitate continuous engagement with health interventions [
4
].
The objective of this study is to assess the usability of the PeerTECH app with relevant end-
users engaged in Norwegian community mental health services, and to identify facilitators
and barriers to uptake and implementation of PeerTECH. In this paper, we use the term
community mental health services when referring to services provided to residents with a
serious mental illness in the municipality.
2. Methods
2.1. Study Design
We performed usability testing of the American prototype PeerTECH app with a pur-
posive sample [
17
] of mental health service users, peers support workers and mental health
professionals from community mental health services in two municipalities in Western
Norway. The usability testing included individual semistructured interviews to explore
facilitators and barriers to the use of digital tools in community mental health services
and perceived utility of the PeerTECH app, “Think-Aloud” method, and task analysis
for direct testing of key aspects of the usability of PeerTECH app. The “Think-Aloud”
method allowed end-users to say aloud their thoughts, feelings, and the observations they
made when testing the smartphone application [
7
,
14
,
18
]. Task analyses were employed to
assess features and the user interface of the PeerTECH app [
18
] with service users and peer
support workers.
Int. J. Environ. Res. Public Health 2021,18, 8667 3 of 11
2.2. Study Setting, Recruitment, and Participants
Norway has a publicly-funded health service system. Municipalities are respon-
sible for providing health services (primary, mental health) and social services to their
residents [
19
]. The municipalities offer mental health services based on assessments of
individual resources, self-management capacity, and primary care needs. The services
include preventive measures, training and supervision, rehabilitation, and assistance to
support the individual’s independent living and meaningful life in the community [
20
].
Study participants were recruited from two similar-sized municipalities in the western part
of Norway with a population of approximately 20,000 inhabitants in each municipality.
We contacted the community mental health services via email with information about
the research project to assess interest in participating in the study. In the first municipality,
two mental health professionals were interested and agreed to participate in an interview.
From the second municipality, the researchers were invited to a staff meeting to inform
the team about the project, the PeerTECH app, and to explore interest in participating in
usability testing. Interviews were then scheduled and conducted with service users, peer
support workers, and mental health professionals based on the participants’ interest and
experience with using digital tools and smartphone apps and willingness to participate in
the study. Data collection was conducted by the first author and was carried out during the
daytime in the offices of the community mental health services. Each interview included
“Think-Aloud” and task analyses, and lasted between 30 min to 1.5 h.
Participants were provided written information about the project, including details
regarding voluntary participation and how confidentiality would be ensured. All subjects
gave their informed consent before participating. The project was approved by NSD—
Norwegian center for research data (id 769409) and was conducted according to the
guidelines of the Declaration of Helsinki.
There was a total of 11 study participants including three individuals with serious
mental illness (one woman, two men, ages ranging between 20–60 years) receiving com-
munity mental health services at home, two peer support workers (one woman and one
man, ages ranging between 20–50 years), and six mental health professionals specialized in
mental health nursing and social work, (six women, ages ranging between 20–50 years).
All the study participants owned a smartphone and reported using it daily.
2.3. PeerTECH App
The PeerTECH app is designed for service users to reinforce skills learned from in-
person sessions with a peer support specialist. PeerTECH includes the following features:
(1) a peer support specialist facing app with a curriculum to guide the peer support special-
ist during in-person meetings with the service user to deliver and support self-management
skill development; (2) a patient-facing app that includes: (a) access to personalized self-
management support; (b) the service users’ personal wellness needs and goals; (c) a chat
feature for use between peer support specialist or a mental health professional and the
service users’ smartphone app to support self-management gains; and (d) an on-demand
library including self-management videos and materials to discuss the interconnection
between mental health, physical health, and social health, the role of stress in mental and
physical health, coping skills training, and lived experiences of self-management challenges
and successes. The PeerTECH library includes classes to be conducted by the service user
together with a peer support specialist during weekly in person-meetings or using the
phone. Additionally, library features can be accessed offline.
As illustrated in Figure 1, The PeerTECH app can be accessed by service users and
peer support specialists from either a mobile phone or a tablet. The service user interface
includes access to messaging directly with an assigned peer support specialist, goals,
wellness, surveys, and a resource library on the home screen. The peer support interface
allows peer support specialists to message directly with assigned service users, view
service users’ goals and wellness plans, and view service users’ progress through the
resource library.
Int. J. Environ. Res. Public Health 2021,18, 8667 4 of 11
Int. J. Environ. Res. Public Health 2021, 18, x 4 of 11
includes access to messaging directly with an assigned peer support specialist, goals, well-
ness, surveys, and a resource library on the home screen. The peer support interface al-
lows peer support specialists to message directly with assigned service users, view service
users’ goals and wellness plans, and view service users’ progress through the resource
library.
Figure 1. Illustrates the PeerTECH mobile app.
2.4. Data Collection
We used a semistructured interview guide based on the Consolidated Framework
for Implementation Research (CFIR), which is a practical guide for assessing barriers and
facilitators when preparing for the implementation of an innovation such as PeerTECH
[21]. The guide included four open-ended questions about the use of mobile smartphone
apps and digital technologies in community mental health services, facilitators, and bar-
riers to the use of digital tools in community mental health services. We used the same
interview guide with mental health service users, peer support workers, and mental
health professionals.
We applied the “Think-Aloud” method and task analysis stepwise with the re-
searcher taking notes for each step. In Step 1 the participants were asked to say aloud their
first impression of the PeerTECH app. We asked about: the perceived usefulness and rel-
evance of the PeerTECH app to their situation, and suggestions for elements that could be
added to adapt the PeerTECH app to the Norwegian context for mental health service
provision in the municipality. In Step 2 we conducted task analysis with service users and
peer support workers including scoring of task performance on a scale from 0–3 (0 = can-
not do the assignment, 1 = carry out the assignment with physical guidance, 2 = carry out
Figure 1. Illustrates the PeerTECH mobile app.
2.4. Data Collection
We used a semistructured interview guide based on the Consolidated Framework for
Implementation Research (CFIR), which is a practical guide for assessing barriers and facili-
tators when preparing for the implementation of an innovation such as PeerTECH [
21
]. The
guide included four open-ended questions about the use of mobile smartphone apps and
digital technologies in community mental health services, facilitators, and barriers to the
use of digital tools in community mental health services. We used the same interview guide
with mental health service users, peer support workers, and mental health professionals.
We applied the “Think-Aloud” method and task analysis stepwise with the researcher
taking notes for each step. In Step 1 the participants were asked to say aloud their first
impression of the PeerTECH app. We asked about: the perceived usefulness and relevance
of the PeerTECH app to their situation, and suggestions for elements that could be added
to adapt the PeerTECH app to the Norwegian context for mental health service provision
in the municipality. In Step 2 we conducted task analysis with service users and peer
support workers including scoring of task performance on a scale from 0–3 (0 = cannot
do the assignment, 1 = carry out the assignment with physical guidance, 2 = carry out
the assignment with oral guidance, 3 = carry out the assignment independently). We
asked participants to give their oral feedback when performing the following specific tasks:
(1) open the app, (2) start one of the learning modules in the app, (3) start and stop the
video, (4) assess the volume, (5) open the icon goals (6) write a proposal for a personal goal,
(7) open the icon Messages, and (8) change the text size.
Int. J. Environ. Res. Public Health 2021,18, 8667 5 of 11
2.5. Data Analysis
Written notes were taken by the researcher during the individual interviews when the
participants were “Thinking-Aloud”, and while conducting task analysis as participants
interacted with the PeerTECH app, and constitute the qualitative data material. Data
analysis was informed by the study objective to assess the usability of the PeerTECH app for
the Norwegian community mental health services and facilitators and barriers to uptake of
PeerTECH. We were interested in the study participants’ views on the information provided
within the PeerTECH app (i.e., too much or too little information and information content),
perceptions of graphics and text, difficulties with navigating, overall understanding of the
PeerTECH app, and perceived relevance for Norwegian end-users. These aspects have
been reported to be relevant aspects when assessing feasibility studies of information
systems [
22
]. The task analysis included numeric scorings of how well the participant
performed the task assignment.
3. Results
3.1. Digital Technology Tools for Self-Management in Mental Health Service Provision
According to the interview participants, there are few digital tools used in community
mental services in the municipalities. Mental health professionals had some experience
with a computer-based individualized care planning system containing the service users’
personal goals and measures to facilitate collaboration between the service users, family
members, mental health professionals. However, the professionals mentioned barriers to
the use of the care planning system including a poor user interface, a complicated login
procedure, insufficient applicability for mobile devices, and employee resistance.
Assisted self-help for individuals with anxiety disorders and moderate depression,
includes a psychology-based computer program including phone follow-up from com-
munity mental health care to assess symptom reduction. The program contains learning
modules about anxiety and depression and how to cope, as well as quizzes and movie clips.
According to the interviewees who had used the assisted self-help program with service
users, it had been fun to use and the program was flexible and easy to use. However, the
program did not include peer support, physical and dental health, and how to get the
medical and mental health help needed.
Interviewees also mentioned a Norwegian smartphone app that could be downloaded
in the App store called “My crisis plan”. The app is a tool where the service user can register
warning signs, strategies to cope with increasing symptoms, a social network, mental health
helpline, an emergency helpline for children and adolescents, as well as a map and search
function to find the nearest emergency room. One mental health professional used the app
with a service user and reported that it was useful for the service user to access his/her
crisis plan when in the emergency room and being able to share the plan with the staff.
3.2. Communication via Text Messaging
Participants were positive about sending text messages in PeerTECH. They said that
communicating via text messaging using mobile phones is a common and easy way to
communicate between professionals, peer support workers, and service users. A few
service users also used Snapchat for their communication with professionals. According
to mental health professionals, some service users preferred sending short texts about
how they feel and what they are struggling with. Service users considered texting with
professionals as easy; it provides a distance, and at the same time it assures that the message
has been read and that it will open for feedback or a specific focus in the next conversation.
Professionals also considered text messages as useful starting points for their upcoming
meetings and conversations with service users and commonly respond to the messages
with “I see you have sent a message—I will read it and get in touch with you again”. A peer
support worker said “It is less scary to write than to speak. It is easier to write down, it will be
your own words and at the same time it gives a focus to the conversation and ensures that you get
Int. J. Environ. Res. Public Health 2021,18, 8667 6 of 11
feedback on what you want”. Texting is an opportunity for not just talking but is a tool to
support the service users’ self-management of mental illness.
3.3. Graphic Design of PeerTECH Home Screen
Interview participants commented that the graphic design of the home screen of the
PeerTECH app (Figure 2a) was “nice” and “understandable”. They praised the pictures and
reported that the app was easy to navigate. The first module page in the app includes
five icons—survey, wellness plan, goals, library, and messages, and was perceived to be
informative, simple, and provided a good overview of the content of the app. A few
participants suggested adding an icon called resources. Participants also commented on
the white background and suggested including photos or a more colorful background.
One participant suggested that the app could have had a slide function, meaning that
the various icons could be slid to be rearranged (i.e., first goals, then resources, then
wellness plan).
Int. J. Environ. Res. Public Health 2021, 18, x 6 of 11
they feel and what they are struggling with. Service users considered texting with profes-
sionals as easy; it provides a distance, and at the same time it assures that the message has
been read and that it will open for feedback or a specific focus in the next conversation.
Professionals also considered text messages as useful starting points for their upcoming
meetings and conversations with service users and commonly respond to the messages
with “I see you have sent a message—I will read it and get in touch with you again. A peer
support worker said “It is less scary to write than to speak. It is easier to write down, it will be
your own words and at the same time it gives a focus to the conversation and ensures that you get
feedback on what you want. Texting is an opportunity for not just talking but is a tool to
support the service users’ self-management of mental illness.
3.3. Graphic Design of PeerTECH Home Screen
Interview participants commented that the graphic design of the home screen of the
PeerTECH app (Figure 2a) was “nice” and “understandable. They praised the pictures and
reported that the app was easy to navigate. The first module page in the app includes five
icons—survey, wellness plan, goals, library, and messages, and was perceived to be in-
formative, simple, and provided a good overview of the content of the app. A few partic-
ipants suggested adding an icon called resources. Participants also commented on the
white background and suggested including photos or a more colorful background. One
participant suggested that the app could have had a slide function, meaning that the var-
ious icons could be slid to be rearranged (i.e., first goals, then resources, then wellness
plan).
(a) (b)
Figure 2. (a). Screenshot of the home screen in PeerTECH. (b). Screenshot of the instructions to the library module “Re-
covery is a Daily Process”.
Figure 2.
(
a
). Screenshot of the home screen in PeerTECH. (
b
). Screenshot of the instructions to the library module
“Recovery is a Daily Process”.
3.4. Perceived Relevance of Goals in the PeerTECH App
Goals were perceived as useful to participants. The service users and peer support
workers related goals to their situation, and some users provided examples of their own
goals, that they had many types of goals, how these goals had changed over time and that
they had achieved their goals and set new goals. One service user said “To begin with, my
goal was to remember to take my meds every night, then my goal was to remember to take my meds
Int. J. Environ. Res. Public Health 2021,18, 8667 7 of 11
morning and evening. Eventually, I had a goal to start school. Soon, I have completed this goal
and received a bachelor’s degree”. Participants suggested Goals include short instructions or a
class about how to develop their own goals, provide a few examples of goals, and mark
goals achieved to visualize progression and for positive reinforcement.
3.5. Perceptions of the Content of Information in PeerTECH Library
The PeerTECH app library contains 14 modules. Each module contains goals including
instructions, discussion points with a peer, a short film, tips for how to create your wellness
plan, follow-up on goals, and suggestions for home practice and feedback. Feedback on
the library was that the modules were informative and relevant. Regarding the length of
the modules, one participant commented, “I think they should not be longer than 5–10 min.
These are my courses, and each course must be able to be done on the bus or at the doctor’s office or
when I wait for class.
Participants considered the module on oral health as particularly important and that
specific information about rights within the Norwegian health system to oral treatment
for individuals with a serious mental illness could be added. One professional said, “If the
service user has visits from mental health services once a week over three months, they have a legal
right to free oral treatment.”
We tested the PeerTECH library module “Recovery as a daily process” (Figure 2b)
which was perceived as highly relevant across service users, peer support workers, and
professionals. Service users related the specific content and what to do with their own
situations and warning signs. One peer support worker said that her warning signs were
little sleep, little food, suicidal thoughts, high music. If these symptoms occur, I am to talk to my
boyfriend, my mom, and dad, or my general practitioner.” Participants valued the opportunity
to put their warning signs and measures in the wellness plan. Another comment received
was that the concept of the wellness plan resonated well with both recovery and health.
3.6. Task Analysis of Navigating in PeerTECH App
Five participants (service users and peer support workers) performed eight task
assignments to assess their ability to navigate in the PeerTECH app. The task assignments
were performed on an iPhone used by all participants. Each task assignment was scored by
the interviewer using the codes: 3 = carry out the assignment independently; 2 = Carry out
the assignment with oral guidance; 1 = Carry out the assignment with physical guidance;
0 = Cannot
do the assignment. The results from the task analysis with service users (n= 3)
and peer support workers (n= 2) are presented in Figure 3below.
The three task assignments: Enter the library course “Recovery as a daily process;” Go
through the library course “Recovery as a daily process;” and “Write a proposal for a goal,”
were performed independently by all participants. For the task assignments, start and stop
video about “Recovery as a daily process,” navigate to the icon “goal,” and navigate to the
icon “messages,” one participant needed verbal guidance. For the two task assignments,
check the audio level of video playback and try to change the text size, several participants
required physical guidance to carry out the task. Four participants were not able to change
text size. The tasks were performed on an iPhone, and the participants explained the
difficulties with checking the audio level and changing the text size due to their lack of
familiarity with the iPhone.
Int. J. Environ. Res. Public Health 2021,18, 8667 8 of 11
Int. J. Environ. Res. Public Health 2021, 18, x 8 of 11
Figure 3. Task analysis of navigating the PeerTECH app.
The three task assignments: Enter the library course “Recovery as a daily process;”
Go through the library course “Recovery as a daily process;” and “Write a proposal for a
goal,” were performed independently by all participants. For the task assignments, start
and stop video about “Recovery as a daily process,” navigate to the icon “goal,” and nav-
igate to the icon “messages,” one participant needed verbal guidance. For the two task
assignments, check the audio level of video playback and try to change the text size, sev-
eral participants required physical guidance to carry out the task. Four participants were
not able to change text size. The tasks were performed on an iPhone, and the participants
explained the difficulties with checking the audio level and changing the text size due to
their lack of familiarity with the iPhone.
4. Discussion
The objective of this study was to assess the usability of the American prototype Peer-
TECH app with relevant end-users in Norwegian community mental health services and
to identify facilitators and barriers to the uptake of PeerTECH. Study results showed that
there are some digital tools available to service users. The “Think-Aloud” method enabled
the study participants to relate the PeerTECH app to their situations. Participants per-
ceived the app to be useful for texting and a tool to support self-management of their
health condition, and they provided valuable feedback on existing features of the app as
well as suggestions for adaptions that could facilitate uptake and use. The task analysis
revealed that the PeerTECH app is easy to manage for both service users and peer support
workers, which are the key end-users.
Our study presents novel results from usability testing of the prototype PeerTECH
app with Norwegian end-users, including a patient-facing app that offers access to per-
sonalized self-management support; the service users’ personal wellness needs and goals;
a chat feature for text-messaging between peer support specialist or a mental health pro-
fessional and the service users’ smartphone app to support self-management gains; and
an on-demand library of self-management resources. Similar usability testing with the
4
1
1
1
1
2
5
5
5
4
4
4
2
1
012345
Enter the library course "Recovery as a daily
process"
Go through the library course "Recovery as a daily
process"
Write a proposal for a “goal”
Start and stop video about "Recovery as a daily
process"
Navigate to the icon “goal”
Navigate to the icon “messages”
Check the audio level of video playback
Try to change the text size
0 Cannot do the assignment
1 Carry out the assignment with physical guidance
2 Carry out the assignment with oral guidance
3 Carries out the assignment independently
Figure 3. Task analysis of navigating the PeerTECH app.
4. Discussion
The objective of this study was to assess the usability of the American prototype
PeerTECH app with relevant end-users in Norwegian community mental health services
and to identify facilitators and barriers to the uptake of PeerTECH. Study results showed
that there are some digital tools available to service users. The “Think-Aloud” method
enabled the study participants to relate the PeerTECH app to their situations. Participants
perceived the app to be useful for texting and a tool to support self-management of their
health condition, and they provided valuable feedback on existing features of the app as
well as suggestions for adaptions that could facilitate uptake and use. The task analysis
revealed that the PeerTECH app is easy to manage for both service users and peer support
workers, which are the key end-users.
Our study presents novel results from usability testing of the prototype PeerTECH app
with Norwegian end-users, including a patient-facing app that offers access to personalized
self-management support; the service users’ personal wellness needs and goals; a chat
feature for text-messaging between peer support specialist or a mental health professional
and the service users’ smartphone app to support self-management gains; and an on-
demand library of self-management resources. Similar usability testing with the prototype
PeerTECH app has not been performed with American end-users. Our study included
usability testing combined with individual interviews with service users, peer support
workers, and mental health professionals in community mental health services. Future
usability testing could also include other types of direct testing such as “Question Asking
Method” and “Task performance Measurement” and physiological monitoring technology
(i.e., blood pressure, heart rate, head, and eye-tracking), as well as testing usability in both
simulated and real-time environments [
14
]. For future digital technologies, the mobile
app development phase can include a mix of data collection methods (questionnaire
survey, observations, focus-group interviews, self-reporting logs, workshops) and can be
an interactive process over time [
23
]. An iterative approach is deemed necessary when
Int. J. Environ. Res. Public Health 2021,18, 8667 9 of 11
smartphone apps are to be a key component in a health intervention in which the result
of usability testing informs choices and decisions made relating to study design and
content [
12
]. Although our study sample of service users (n= 3) and peer support workers
(n= 2) was small, we believe they were representative of those who are expected to use
the app in Norway and were aligned with usability testing requirements [
22
]. We also
included the perspectives of mental health professionals to get information about available
digital tools and inform the content of the Norwegian version of the PeerTECH app, which
is a strength. Mental health professionals have not been included in pilot studies of the
PeerTECH app in the US [
7
,
8
]. We are aware that the PeerTECH app does not include
communication between the service users and family members or friends which could be
useful. Our study also did not consider the perspective of caregivers, family, and friends,
which can play a vital role in the recovery process for people with serious mental illness.
Available digital tools mentioned by the study participants were a computer-based
individualized care planning system, a psychology-based computer program “Assisted
self-help” for individuals with anxiety disorders and moderate depression, and an app “My
crisis plan” to register warning signs, strategies to cope with symptoms, social network,
also including a mental health emergency helpline and a map and search function to find
the nearest emergency room. None of the available digital tools or interventions mentioned
by the study participants were peer-led, targeted health literacy, physical and mental health,
well-being, and positive behavior change in individuals with a serious mental illness. A
recent systematic literature review performed by Fortuna and colleagues [
16
] identified
11 studies that implemented peer-delivered interventions supported with technology to
individuals with a serious mental illness. The interventions targeted shared decision-
making, cognitive therapy, physical well-being, and weight management. Peers used
smartphone apps, text messaging, web-based platforms and fitness tracking for interaction
with service users and delivering services. Only one study conducted by Fortuna et al. [
9
]
targeted integrated medical and psychiatric self-management and combined in-person
visits with a smartphone app. Promising evidence from our pilot studies indicates that
PeerTECH is feasible, acceptable, engaging, safe, effective, and has been delivered with
high fidelity [
8
,
9
,
24
]. Our results from usability testing can be considered a valuable first
step in adapting the PeerTECH app to the needs of Norwegian service users and peer
support workers. The next steps will require translating the text and video content, as
well as adding context-specific content to tailor the app for use in a peer-led health and
well-being intervention. Such an intervention can be tested in a randomized-controlled
trial to assess the effectiveness of PeerTECH on health literacy, well-being, behavior change,
and service integration for service users with a serious mental illness. It can also be useful
to assess the potential for implementation and use of PeerTECH in Norwegian community
mental health services.
5. Conclusions
Engaging service users, peer support workers, and mental health professionals in
considering what is important to them will enable us to ensure the contextual fit of the
PeerTECH app to service users’ needs. This is particularly important for a vulnerable
population, such as individuals with serious mental illness, who bear a high burden of
diseases and potential cognitive limitations that may impair the ability to engage in self-
management for both physical and mental health. The study provided relevant knowledge
about the use of existing digital tools in community mental health services and factors that
may influence the use of the PeerTECH app.
Author Contributions:
Conceptualization, M.S., H.M.H.F., S.J.B., K.L.F.; methodology, H.M.H.F.,
M.S.; software, A.L.M., K.L.F.; formal analysis, M.S.; investigation and data curation, M.S., J.N.S.;
writing—original draft preparation, M.S.; writing—review and editing, J.N.S., H.M.H.F., A.L.M.,
S.J.B., K.L.F.; visualization, M.S., K.L.F.; funding acquisition, M.S., K.L.F. All authors have read and
agreed to the published version of the manuscript.
Int. J. Environ. Res. Public Health 2021,18, 8667 10 of 11
Funding:
First and corresponding author M.S. received support for this research study by the
University of Stavanger, Norway. The last author K.L.F. was funded by a K01 award from the
National Institute of Mental Health (K01MH117496).
Institutional Review Board Statement:
The study was conducted according to the guidelines of the
Declaration of Helsinki and approved by the NSD—Norwegian center for research data (id 769409)
on 20 February 2020.
Informed Consent Statement:
Informed consent was obtained from all subjects involved in the
study. Service user participants provided their informed written consent.
Data Availability Statement:
The Norwegian dataset generated for this study is available on request
to the first and corresponding author.
Acknowledgments: The authors thank the study participants for taking part in this usability study.
Conflicts of Interest:
The authors declare that the research was conducted in the absence of any
commercial or financial relationships that could be construed as a potential conflict of interest.
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... Storm and coworkers [36] describe a pilot study using semistructured interviews and usability testing in Norway during the implementation of a US smartphone health app supporting self-management of somatic and mental disorders. Three persons with severe mental illness, two peer support workers, and six mental health professionals participated. ...
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