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      Co-designing a Self-Management App Prototype to Support People With Spinal Cord Injury in the Prevention of Pressure Injuries: Mixed Methods Study

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          Spinal cord injury is a complex chronic health condition that requires individuals to actively self-manage. Therefore, an evidence-based, self-management app would be of value to support individuals with spinal cord injury in the prevention of pressure injuries.


          The main objectives of this study were to (1) establish a co-design approach for developing a high-fidelity prototype app for the self-management of individuals with spinal cord injury, (2) design the prototype that resulted from this process, and (3) conduct the first usability assessment of the prototype app.


          We adopted a co-design approach to develop an evidence-based app prototype. Starting from a preliminary content model (based on clinical guidelines for the prevention of pressure injuries) and three research-based user personas, we conducted an ideation workshop involving individuals with spinal cord injury and health care professionals. The ideation workshop formed the basis for two consecutive design sprints. The result of this co-design phase was an interactive app prototype. The prototype was evaluated in two rounds of usability testing (N=4 and N=15, respectively) using a combination of qualitative and quantitative methods.


          The co-design process resulted in a high-fidelity prototype with two key components: a self-management component and a communication component. The final prototype included a combination of features to support individuals with spinal cord injury in the prevention of pressure injuries, namely a smart camera, pressure injury diary, expert consultation, reminders, and knowledge repository. Findings of the usability testing showed that most participants navigated the app fluently with little back and forth navigation and were able to successfully complete a set of assigned tasks. These positive results are supported by the average system usability score achieved (78.5/100; range 47.5-95.0) and our qualitative analysis of the semistructured interviews. Despite an overall positive evaluation of the app prototype, we identified areas for improvement (eg, inclusion of a search function).


          Individuals with spinal cord injury often need to navigate competing interests and priorities, paired with uncertainty about the accuracy and relevance of clinical recommendations. Understanding what matters to individuals with spinal cord injury can help guide the design of behavioral interventions that are useful and acceptable to these individuals in their daily lives. This study shows that involving individuals with spinal cord injury and health care professionals in co-designing a self-management app can foster knowledge cocreation at the intersection of lived experience, medical expertise, and technical solutions.

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          Most cited references 48

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          Designing eHealth that Matters via a Multidisciplinary Requirements Development Approach

          Background Requirements development is a crucial part of eHealth design. It entails all the activities devoted to requirements identification, the communication of requirements to other developers, and their evaluation. Currently, a requirements development approach geared towards the specifics of the eHealth domain is lacking. This is likely to result in a mismatch between the developed technology and end user characteristics, physical surroundings, and the organizational context of use. It also makes it hard to judge the quality of eHealth design, since it makes it difficult to gear evaluations of eHealth to the main goals it is supposed to serve. Objective In order to facilitate the creation of eHealth that matters, we present a practical, multidisciplinary requirements development approach which is embedded in a holistic design approach for eHealth (the Center for eHealth Research roadmap) that incorporates both human-centered design and business modeling. Methods Our requirements development approach consists of five phases. In the first, preparatory, phase the project team is composed and the overall goal(s) of the eHealth intervention are decided upon. Second, primary end users and other stakeholders are identified by means of audience segmentation techniques and our stakeholder identification method. Third, the designated context of use is mapped and end users are profiled by means of requirements elicitation methods (eg, interviews, focus groups, or observations). Fourth, stakeholder values and eHealth intervention requirements are distilled from data transcripts, which leads to phase five, in which requirements are communicated to other developers using a requirements notation template we developed specifically for the context of eHealth technologies. Results The end result of our requirements development approach for eHealth interventions is a design document which includes functional and non-functional requirements, a list of stakeholder values, and end user profiles in the form of personas (fictitious end users, representative of a primary end user group). Conclusions The requirements development approach presented in this article enables eHealth developers to apply a systematic and multi-disciplinary approach towards the creation of requirements. The cooperation between health, engineering, and social sciences creates a situation in which a mismatch between design, end users, and the organizational context can be avoided. Furthermore, we suggest to evaluate eHealth on a feature-specific level in order to learn exactly why such a technology does or does not live up to its expectations.
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            Assessing the quality and usability of smartphone apps for pain self-management.

            To evaluate smartphone apps intended for self-management of pain using quality assessment criteria and usability testing with prospective users. 1) Survey and content analysis of available apps; and 2) individual usability study of two apps. University of Leeds, United Kingdom. Forty-one participants (aged 19-59 years) with experience of chronic or recurrent pain episodes. We undertook a survey, content analysis, and quality appraisal of all currently available mobile phone apps for self-management of pain. Two apps were then selected and assessed with usability testing. Twelve apps met the inclusion criteria. The quality assessment revealed wide variation in their clinical content, interface design, and usability to support self-management of pain. Very little user or clinician involvement was identified in the development of the apps. From the usability testing, participants stated a preference for an interface design employing a lighter color scheme and particular text font. Although very few participants were aware of pain-reporting apps prior to participation, many would consider use in the future. Variation in app quality and a lack of user and clinician engagement in development were found across the pain apps in this research. Usability testing identified a range of user preferences. Although useful information was obtained, it would be beneficial to involve users earlier in the process of development, as well as establishing ways to merge end user requirements with evidence-based content, to provide high-quality and usable apps for self-management of pain. Wiley Periodicals, Inc.
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              A systematic review of therapeutic interventions for pressure ulcers after spinal cord injury.

              To systematically review evidence on the prevention and treatment of pressure ulcers in those with a spinal cord injury (SCI). For this evidence-based review, the following data sources were used: MEDLINE/PubMed, CINAHL, EMBASE, and PsycINFO. To be selected for inclusion in the current review, there had to have been an intervention, studies had to have 3 or more subjects, and 50% or more of the participating group had to have an SCI. Data extracted included study design, subject demographics, inclusion and exclusion criteria, study type, sample size, outcome measures used, and study results. Articles selected for this review were organized into 1 of 2 categories: prevention or treatment. Within each broad category, several smaller ones were created, and articles were grouped according to the prevention (direct or indirect) or treatment intervention discussed. Of the 26 articles selected for inclusion in the systematic review, 7 were randomized controlled trials (RCTs) that dealt with treatment for pressure ulcers, and there was 1 RCT on prevention. Despite the cost-effectiveness of prevention, little research exists on preventative interventions, and what does exist is mostly level 4 evidence. More research is needed for both prevention and treatment, but especially the former.

                Author and article information

                JMIR Mhealth Uhealth
                JMIR Mhealth Uhealth
                JMIR mHealth and uHealth
                JMIR Publications (Toronto, Canada )
                July 2020
                9 July 2020
                : 8
                : 7
                [1 ] Swiss Paraplegic Research Nottwil Switzerland
                [2 ] Health Ethics and Policy Lab Department of Health Sciences and Technology ETH Zurich Zurich Switzerland
                [3 ] Institute of Communication and Health University of Lugano Lugano Switzerland
                [4 ] Department of Health Sciences and Medicine University of Lucerne and Swiss Paraplegic Research Lucerne Switzerland
                [5 ] Swiss Paraplegic Center Nottwil Switzerland
                Author notes
                Corresponding Author: Julia Amann julia.amann@
                ©Julia Amann, Maddalena Fiordelli, Mirjam Brach, Sue Bertschy, Anke Scheel-Sailer, Sara Rubinelli. Originally published in JMIR mHealth and uHealth (, 09.07.2020.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR mHealth and uHealth, is properly cited. The complete bibliographic information, a link to the original publication on, as well as this copyright and license information must be included.

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