Usability of a prototype application for self-care of people with heart failure

Sousa, Mailson Marques de; Lopes, Camila Takáo; Almeida, André Atanasio Maranhão; Silveira, Rayane Monteiro; Almeida, Taciana da Costa Farias; Gouveia, Bernadete de Lourdes André; Oliveira, Simone Helena dos Santos

doi:10.37689/acta-ape/2025AO0002132

Abstract

Objective: To evaluate the usability of a mobile application prototype to promote self-care for people with heart failure.

Methods: A descriptive, cross-sectional study was conducted with 16 people with heart failure undergoing outpatient follow-up. The Smartphone Usability QuestionnaiRE (iRE), with scores ranging from zero to 124 and classified from a usability level of 30 (totally or partially disagree) to 80 (totally agree), was used in the assessment of usability. Scores ≥ 70 points indicate good levels of usability. Data were analyzed using descriptive statistics.

Results: Male participants corresponded to 62.5% of the sample; 62.5% were married/in a stable relationship, with complete elementary education; 75% had non-ischemic etiology and reduced left ventricular ejection fraction. The average score of the Smartphone Usability QuestionnaiRE was 109.75 ± 3.47, with a minimum of 102 and a maximum of 114 points. Usability was classified as level 80. All participants fully agreed on the clarity of information, language used in the texts, ease of use, usefulness of instructions provided and would recommend using the application.

Conclusion: The application prototype showed good levels of usability, indicating that end users fully agreed on the technological innovation that met the recommendations for satisfaction, effectiveness and efficiency of use. Future studies will be conducted to evaluate its impact on self-care behavior and clinical health outcomes in people with heart failure.

Resumo

Objetivo: Avaliar a usabilidade de um protótipo de aplicativo móvel para promoção do autocuidado de pessoas com insuficiência cardíaca.

Métodos: Estudo descritivo, transversal, realizado com 16 pessoas com insuficiência cardíaca em seguimento ambulatorial. A usabilidade foi avaliada pelo Smartphone Usability questionnaiRE, cuja pontuação varia de zero a 124 e é classificada de um nível de usabilidade de 30 (possibilidade de discordar totalmente ou parcialmente) até 80 (concordam totalmente). Escores ≥ 70 pontos indicam bons níveis de usabilidade. Os dados foram analisados por meio de estatística descritiva.

Resultados: Eram do sexo masculino 62,5% participantes; 62,5% eram casados/união estável, com Ensino fundamental Completo; 75% tinham etiologia não isquêmica e fração de ejeção de ventrículo esquerdo reduzida. A pontuação média do Smartphone Usability questionnaiRE foi de 109,75 ± 3,47, com mínimo de 102 e máximo de 114 pontos. A usabilidade foi classificada no nível 80. Todos os participantes concordaram totalmente com a clareza das informações, a linguagem utilizada nos textos, a facilidade de manuseio e a utilidade das orientações fornecidas e indicariam o uso do aplicativo.

Conclusão: O protótipo de aplicativo apresentou bons níveis de usabilidade, indicando que os usuários finais concordaram totalmente com a inovação tecnológica, atendendo às recomendações de satisfação, eficácia e eficiência de uso. Estudos futuros serão realizados para avaliar seu impacto no comportamento de autocuidado e desfechos clínicos em saúde em pessoas com insuficiência cardíaca.

Descritores
Insuficiência cardíaca; Autocuidado; Aplicativos móveis; Telemedicina

Resumen

Objetivo: Evaluar la usabilidad de un modelo de aplicación móvil para promover el autocuidado de personas con insuficiencia cardíaca.

Métodos: Estudio descriptivo, transversal, realizado con 16 personas con insuficiencia cardíaca bajo seguimiento ambulatorio. La usabilidad se evaluó mediante el Smartphone Usability questionnaiRE, cuyo puntaje varia de 0 a 124 y se clasifica con un nivel de usabilidad de 30 (posibilidad de discordar total o parcialmente) hasta 80 (concordancia total). Los puntajes de ≥ 70 indican buenos niveles de usabilidad. Los datos fueron analizados por medio de estadística descriptiva.

Resultados: El 62,5 % de los participantes era de sexo masculino, casado/unión de hecho y con educación primaria completa; el 75 % tenia etiologia no isquémica y fracción de eyección de ventrículo izquierdo reducida. El puntaje promedio del Smartphone Usability questionnaiRE fue de 109,75 ± 3,47, con un mínimo de 102 puntos y un máximo de 114 puntos. La usabilidad se clasificó en el nivel 80. Todos los participantes concordaron totalmente con la claridad de la información, el lenguaje utilizado en los textos, la facilidad de manejo y la utilidad de las instrucciones proporcionadas, y recomendaron el uso de la aplicación.

Conclusion: El modelo de la aplicación presentó buenos niveles de usabilidad, lo que indica que los usuarios finales concordaron totalmente con la innovación tecnológica, que cumple las recomendaciones de satisfacción, eficacia y eficiencia de uso. Se realizarán estudios futuros para evaluar su impacto en el comportamiento del autocuidado y los resultados clínicos de salud en personas con insuficiencia cardíaca.

Descriptores
Insuficiencia cardíaca; Autocuidado; Aplicaciones móviles; Telemedicina

Introduction

Heart failure (HF) is a public health problem due to high rates of hospitalizations, morbidity and mortality, low quality of life and financial costs in healthcare. The worldwide prevalence is 1–3% of the adult population. It is estimated that 64.3 million people live with the disease.(¹) In the United States, six million Americans have HF; in Canada, 1.5–1.9% and, in Europe, 1–2% of the population.(²) Data from the Brazilian Ministry of Health indicate that, in the period from 2021 to 2022, 364,475 hospital admissions due to HF were authorized in the Unified Health System (SUS), with a hospital mortality rate of 12.9% in the period.(³)

Despite the therapeutic advances of recent years, people with HF present a variety of symptoms, such as fatigue, dyspnea, lower limb edema, reduced tolerance to activities of daily living, difficulty sleeping, anxiety and low adherence to treatment, which directly impacts health-related quality of life.(⁴)

In this context, it is essential that people with HF adopt self-care behaviors to maintain functional capacity, disease stability, well-being and reduce unfavorable clinical outcomes. Previous studies highlight that self-care levels in this population are unsatisfactory and need to be improved.(⁵, ⁶, ⁷) Factors such as knowledge, skills, confidence, health literacy and social support influence the individual’s involvement in self-care.(⁶, ⁸)

Mobile health (mHealth) has been used as a support strategy to enhance self-care and treatment adherence in people with chronic diseases.(⁹) In general, the term mHealth refers to the practice of using mobile and wireless technology in health services (smartphones, digital assistants and monitoring devices). Studies highlight its applicability and benefits for people with HF.(¹⁰, ¹¹)

Mobile phone applications can assist in self-monitoring of physiological data, early recognition of symptoms of clinical decompensation, and the provision of reminders and personalized feedback for ongoing care.(¹²) In Brazil, such applications are particularly interesting, as data from the Brazilian Institute of Geography and Statistics indicate that mobile phones are the most widely used tool to access the internet in the country.(¹³)

A benchmarking study of mobile applications on HF searched for applications in the Play Store and App Store virtual stores of the Android (Google) and iOS (Apple) operating systems, respectively, and found only three Brazilian applications, of which two were aimed at health professionals and one was limited to the monitoring of signs and symptoms after the discharge of patients with HF by specialist nurses, without focusing on other aspects of self-care.(¹⁴) Later studies conducted abroad, describing the creation and evaluation of the usability of applications for individuals with HF, were focused on the remote monitoring of vital signs, medication adherence,(¹⁵) monitoring of fluid balance,(¹⁶) and did not encompass comprehensive aspects of self-care.

From this perspective, the creation of a mobile application as an educational tool to promote self-care for people with HF was considered pertinent in Brazil, which has its own guidelines for the care for people with HF,(¹⁷) and peculiar characteristics, such as a universal health system, although with difficult access, an average salt consumption of 9g/day(¹⁸) (almost double the amount recommended by the WHO), a climate that makes the adherence to the recommended amount of fluids difficult, and a specific vaccination schedule.

The application called TumTum was developed and presented adequate evidence of validity in a previous study. It contains information about the disease, signs and symptoms, tips for improving self-care, and features to support pharmacological and non-pharmacological management.(¹⁹)

The development of mobile applications involves several steps and one of them is measuring usability by checking how people interact with the product, which is a quality requirement in software engineering.(²⁰) In usability, the use of a product by specific users to achieve objectives with effectiveness, efficiency, and satisfaction in a context of use is measured.(²¹)

Although, the use of the Internet has expanded in different geographic regions of Brazil in recent decades(¹³) and applications in the area of Cardiology have been developed(¹⁴, ²²) in the country, usability studies of mHealth technologies for people with heart disease are still scarce. Therefore, we sought to test the level of usability of the TumTum application prototype from the perspective of end users before making it available on online platforms. The results of this study will allow the conclusion of the development of the application and the testing of intervention strategies that may be applicable in clinical practice.

The objective of this study was to evaluate the usability of a prototype mobile application to promote self-care for people with HF.

Methods

A descriptive, cross-sectional study to evaluate the usability of a mobile application was conducted from January to April 2023. Usability heuristics are general evaluation techniques that describe common properties in interfaces present in the interaction between user and system.(²¹) Through usability, it is possible to examine the user’s speed to perform tasks (efficiency), ease of use, design, learning ability, memorization, error rates, and satisfaction in interacting with the software.(²⁰)

The study was developed in a cardiology outpatient clinic of a university hospital managed by the SUS, located in João Pessoa, Paraíba, Brazil, and a reference in medium and high complexity care. In this outpatient clinic, users were referred by the municipal health network for specialized cardiology consultations that take place weekly on Mondays.

The population consisted of individuals diagnosed with HF, regardless of the etiology, and undergoing follow-up treatment at the selected institution. The inclusion criteria were age ≥ 18 years; having a smartphone; and having completed elementary school (≥ eight years of study). The educational level criterion was adopted to reduce measurement bias. Individuals in their first outpatient consultation, with cognitive deficits confirmed in medical records and on the wait list for a heart transplant were excluded.

Based on the requirements for assessing the quality of software products of the Brazilian Association of Technical Standards (ABNT), a sample of eight or more users is recommended for usability testing. (²⁰) Therefore, a non-probabilistic and intentional sample of 16 individuals with HF was recruited during the data collection period.

The TumTum mobile application prototype was developed by professors from public federal institutions and validated by nurses with a PhD in Cardiology and individuals with HF. The app provides educational information (the concept of HF, signs and symptoms, diagnosis and treatment) and non-pharmacological guidance on self-care in HF (weight monitoring, dietary care, physical exercise, sexual activity, medication use, sleep hygiene, mental health, vaccination and smoking cessation). It offers features for recording appointments and exams, reminders to take medication at scheduled times, recording of daily body weight and for reporting signs and symptoms of the disease. Graphs with weight fluctuations are generated, as well as red flags for signs of clinical decompensation, for seeking health services.(¹⁹)

The JavaScript programming language and the React Native library were used to implement the application prototype. These allow writing a single code and generating native applications for the Android and iOS mobile platforms. In the final version of the application, user information will be stored in the cloud and managed through a back-end application. The goal is to offer greater security in terms of data maintenance, while ensuring user rights and complying with the General Data Protection Law. It will use an offline-first implementation in the front-end application to deal with situations of non-connectivity while using the application.(¹⁹)

People with HF scheduled for a cardiology appointment were invited to participate in the study and introduced to its objective. The research team presented the mobile application prototype to participants in person in a private environment and after completing the demonstration, a smartphone with the Android operating system was made available to them. Then, they could test it, enter information about their treatment, read the educational guidelines and learn about TumTum’s features, such as reminders for taking medication, viewing graphs, scheduling appointments and exams. The prototype usage time varied from 30 to 45 minutes and data collection instruments were answered subsequently.

An instrument used in a previous study, containing demographic variables (age, sex, marital status, education, employment status, and family income) and clinical variables (etiology of HF, New York Heart Association (NYHA) functional class, left ventricular ejection fraction, and current drug therapy) was applied to categorize the sample.(⁷)

When assessing usability, several instruments are used to evaluate mHealth applications to measure the effectiveness, efficiency, and satisfaction with the technological tool for the target audience.(²³) In this investigation, we chose to use the Smartphone Usability QuestionnaiRE (SURE),(²⁴) because it is characteristic for measuring usability in smart-phone applications and has useful evaluation items for better understanding the quality of the software developed. It has also been satisfactorily used in previous Brazilian studies.(²⁵, ²⁶, ²⁷)

SURE is an instrument created in Brazil through systematic review and Item Response Theory. It consists of 31 items with response options using a Likert-type scale, offering the alternatives disagree, partially disagree, agree, completely agree and the additional option not applicable, numbered as 1, 2, 3, 4 and 0, respectively. The sum of the scores for each item corresponds to the usability value. The total score is up to 124 points.(²⁴)

The SURE scores for each participant were categorized according to usability levels of the instrument: level 30 (possible to totally or partially disagree); level 40 (possible to disagree); level 50 (no longer partially to strongly agree); level 70 (strongly agree); and level 80 (totally agree).(²⁴)

After completing the instruments, participants were asked three open-ended questions with the aim to seek suggestions/improvements for use: What did you think of the application? Did you have any difficulty using it? Would you recommend the application?

The data were organized in an Excel spreadsheet for Microsoft Windows and analyzed using the statistical software IBM Statistical Package for the Social Sciences (SPSS) for Windows 22.0. The categorical variables were presented descriptively as simple frequency and percentage, and the numerical variables as mean and standard deviation. The answers to the open-ended questions were grouped and the synthesis of comments about the application are presented in a table.

The study complied with national and international research standards. The project was assessed by the Research Ethics Committee of the selected institution 4.620.748 (Certificate of Presentation of Ethical Assessment: 42685021.0.0000.5183). All participants received verbal and written information about the study and formalized their participation by signing the Informed Consent Form.

Results

The study included 16 people with HF, of whom 62.5% lived in the city of João Pessoa, with an average age of 53.44 ± 9.21 years, ranging from 38 to 68 years; 62.5% were male, 37.5% were white, 62.5% were married/in a stable union, 100% had completed elementary school, 62.5% had an income of one minimum wage, and only 25% were economically active. Regarding clinical conditions, 75% had non-ischemic etiology, 43.8% were in NYHA functional class II, with a mean left ventricular ejection fraction of 39.50 ± 19.70%, and were using beta-blockers and diuretics. Figure 1 shows the TumTum application interface.

Figure 1
TumTum app interface

Regarding the usability assessment, the average SURE score was 109.75 ± 3.47, with a minimum of 102 and a maximum of 114 points. Usability was categorized at level 80. Table 1 presents the description of the frequency of participants’ responses per item of the usability instrument.

Thumbnail

Table 1
Description of the items of the Smartphone Usability QuestionnaiRE

Chart 1 presents the participants’ comments on the use of the prototype application. Potential benefits of TumTum support for self-management of HF are observed. It is noteworthy that all participants would recommend its use.

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Chart 1
Comments on the TumTum application

Discussion

This study evaluated the usability of a mobile application prototype to promote self-care for people with HF. To the best of the authors’ knowledge, this is the first in Brazil supported by a specific smartphone instrument. The participants investigated were in total agreement regarding the TumTum app. They classified it as a technological innovation of good quality and effectiveness of use due to its ease of use, organization of menus, easy-to-understand texts and navigation flow, which represents excellent usability for the prototype and prospects for use in clinical practice.

Corroborating this study, another investigation also evaluated the usability of an application for diabetic foot care.(²⁵) Although the overall score of 96.1 points achieved among end users was lower than that found in our study, the items evaluated presented scores that ranged from strongly agree (level 70) to totally agree (level 80), indicating good usability levels.(²⁵) Another study showed an overall mean usability of 105.8 ± 7.44 points in a prototype application for people with arterial hypertension.(²⁶) Benchmarking of mobile applications intended for people with HF identified a wide variety of devices on online platforms, mainly in English, most achieving level 80 of usability in the SURE evaluation items.(¹⁴)

Satisfactory levels of usability were also found in an application that evaluated fluid balance monitoring for people with HF through the System Usability Scale (SUS) assessment, although educational guidelines on health were not included. (¹⁶) Other studies have tested the usability of applications focused on vital signs, laboratory tests, pharmacological therapy and in focus groups with patients and nurses.(²⁸, ²⁹) The SUS is a generic instrument for measuring the ease of use of systems, and the use of specific instruments for assessment of mHealth applications is recommended.(³⁰)

The literature highlights that the use of mobile applications has the potential to support self-management of HF and recommends easy-to-use features, educational information, daily recording of body weight, text messages as reminders and symptom monitoring. Having access to personalized resources can motivate individuals to engage in prescribed self-management skills, thereby achieving better health outcomes.(³¹)

A study that evaluated the functionalities of 34 commercially available mobile applications to support HF symptom monitoring and self-care management using the Mobile Application Rating Scale (MARS) highlighted weaknesses in the quality, content, or functionality of the applications.(³²) This reinforces the need to validate the content of the applications with experts and patients in the development of mHealth technologies.(¹⁹)

An integrative review that analyzed usability data from mobile applications for people with HF highlighted research conducted in countries in North America and Europe, and a shortage in Latin America. The applications evaluated were classified as having low-quality design, incompleteness, and flaws.(¹¹) In the present study, the items evaluated show that users totally agreed with the content and functions presented and were unanimously satisfied with the easy reading and language used in the texts. These resources are indicated as tools that facilitate usability in the use of mobile applications.(¹²)

Digital literacy for people with HF is a challenge for nurses, health professionals, and caregivers. Evidence points to low levels of health literacy in the population with HF, which is a potential barrier to disease management and has negative consequences, such as increased hospitalization and mortality.(³³) Therefore, based on the results achieved, this application has the potential to improve the necessary levels of knowledge for clinical management of HF.

Overall, participants reported that the application would be beneficial for self-management of the disease. They had no problems using it, felt comfortable, and would recommend its use. Usability remained at SURE level 80, corroborating a study that indicates the interest of adults and older adults in accessing health applications with useful and easy-to-use educational resources to meet their needs.(³⁴)

In addition, a study that evaluated the perspectives of people with HF in the use of mHealth technology showed that the usability of the application is important to provide accurate, comprehensive information that can be used in daily self-care. Data protection and the costs associated with use are among the barriers reported.(³⁵) Considering these aspects, the TumTum application will be made available free of charge in online stores and the educational information can be accessed offline, reducing financial difficulties with internet access. Efforts will be made to ensure the preservation of users’ personal data in accordance with current legislation in the country.

In this context, mHealth technology offers users the opportunity to have more control over their health and access information; develop skills to achieve problem-solving and make decisions regarding self-care through the ability to understand, evaluate, use and transform processes, favoring adherence to treatment, with a reduction in the number of hospitalizations and the search for emergency health services.(³⁶)

Although a specific instrument was not applied to assess the level of digital literacy, a limitation of this study was the inclusion of only individuals with complete elementary education, which restricted the use of the application. Navigation time was also limited. Future studies should consider the participation of individuals without education, the inclusion of information resources accessible to this public, and also larger samples and in different healthcare settings. Furthermore, as this is a cross-sectional study, the results found should be evaluated with caution.

The findings are promising and have implications for cardiovascular nursing care. Individuals with HF were included in previous stages of content structuring and use testing, increasing the chances of the application being adopted in clinical practice. Subsequent studies will be conducted to assess the acceptability, feasibility, and impact of this technology on self-care and health outcomes for this population.

Conclusion

The TumTum application prototype presented good levels of usability, indicating that end users fully agreed on the guidelines offered by the technological innovation, meeting the heuristic recommendations for satisfaction and efficiency of use. Further research should be conducted to assess the real-world effectiveness of the technology and potential improvements of the software quality in the medium and long term.

Acknowledgements

This study was supported by Call No. 03/2020 Research Productivity PROPESQ/PRPG/UFPB, research project code PVG13241-2020.

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³⁴ Gordon NP, Crouch E. Digital information technology use and patient preferences for internet-based health education modalities: cross-sectional survey study of middle-aged and older adults with chronic health conditions. JMIR Aging. 2019;2(1):e12243.
³⁵ Son YJ, Oh S, Kim EY. Patients’ needs and perspectives for using mobile phone interventions to improve heart failure self-care: a qualitative study. J Adv Nurs. 2020;76(9):2380–90.
³⁶ Rodriguez Parrado IY, Achury Saldaña DM. Digital health literacy in patients with heart failure in times of pandemic. Comput Inform Nurs. 2022;40(11):754–62.

Edited by

Associate Editor
Juliana de Lima Lopes (https://orcid.org/0000-0001-6915-6781), Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brazil

Publication Dates

Publication in this collection
28 Mar 2025
Date of issue
2025

History

Received
05 Dec 2023
Accepted
14 Oct 2024

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 is properly cited.

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Items	Score
Items	1	2	3	4	NA
1. I found it easy to enter data into these apps. For example, using the picklist, etc	-	3(18.8)	2(12.5)	11(68.8)	-
2. When I make a mistake, it is easy to correct it	-	-	1(6.3)	15(93.8)	-
3. I found the help/hint provided by the app to be useful	-	-	1(6.3)	15(93.8)	-
4. It was easy to find the information I needed	-	-	4(25.0)	12(75.0)	-
5. I felt in control using this app	1(6.3)	-	5(31.3)	10(62.5)	-
6. I found the time it took me to complete the tasks was adequate.	-	-	2(12.5)	14(87.5)	-
7. It was easy to learn how to use this app	-	-	3(18.8)	13(81.3)	-
8. The sequences of actions in the app correspond to the way I normally perform them. For example, the order of buttons, data fields, etc.	-	1(6.3)	5(31.3)	10(62.5)	-
9. It is easy to do what I want to do using this app	-	-	1(6.3)	15(93.8)	-
10. It was easy to navigate the app’s menus and screens	-	1(6.3)	3(18.8)	12(75.0)	-
11. The app meets my needs	-	1(6.3)	2(12.5)	13(81.3)	-
12. I would recommend this app to others	-	-	2(12.5)	14(87.5)	-
13. Even in a hurry, I could still perform tasks in this app	1(6.3)	-	2(12.3)	13(81.3)	-
14. I found the app consistent. For example, all functions can be performed in a similar manner	-	-	1(6.3)	15(93.8)	-
15. It is easy to remember how to do things in this app	-	-	2(12.5)	14(87.5)	-
16. I would use this app often	1(6.3)	-	2(18.8)	13(75.0)	-
17. The organization of menus and action commands (such as buttons and links) is logical, allowing me to find them easily on the screen	-	-	1(6.3)	15(93.8)	-
18. I was able to successfully complete tasks using this app	-	1(6.3)	5(31.3)	10(62.5)	-
19. I enjoyed using this app	-	-	4(25.0)	12(75.0)	-
20. The app provides all the information needed to complete tasks in a clear and understandable way	-	-	1(6.3)	15(93.8)	-
21. I found the app too complicated to use	11(68.8)	1(6.3)	4(25.0)		-
22. The symbols and icons are clear and intuitive	-	-	1(6.3)	15(93.8)	-
23. I found the texts easy to read	-	-	-	16(100)	-
24. I found the app unnecessarily complex. I had to remember, search or think a lot to perform tasks	11(68.8)	3(18.8)	1(6.3)	1(6.3)	-
25. The terminology used in the texts, labels, titles etc. is easy to understand	-	-	-	16(100)	-
26. I would need help from a person to use this app	4(25.0)	-	6(37.5)	6(37.5)	-
27. I felt comfortable using this app	-	-	1(6.3)	15(93.8)	-
28. The app behaved as I expected	-	-	2(12.5)	14(87.5)	-
29. I found it frustrating to use this app	16(100)	-	-	-	-
30. I found that the various functions of the app are well integrated		1(6.3)	1(6.3)	14(87.5)	-
31. I felt very confident using this app	1(6.3)	-	-	15(93.8)	-