Optimization of a Web-Based Self-Assessment Tool for Preconception Health in People of Reproductive Age in Australia: User Feedback and User-Experience Testing Study

Introduction

Overview

Preconception care aims to optimize the physical and psychological health of women and their partners prior to conception [1]. Good preconception health reduces the incidence of preventable morbidity and mortality for women and their babies [1,2]. In Australia, there is a need to increase awareness about the importance of good preconception health and access to preconception care [3]. This is evidenced by the high proportion of women entering pregnancy above a healthy weight, the low proportion of women taking folic acid before conception, and the low rate of good prepregnancy glycemic control in women with diabetes [4-7].

Barriers to the delivery of preconception care include inadequate knowledge in the community about the importance of optimal preconception health and a lack of presentation to health care providers for preconception assessment [8,9]. Additional barriers include women from low socioeconomic backgrounds having lower levels of functional health literacy [10]. This is associated with lower rates of consulting a health professional for preconception care and worse preconception health behavior [10,11]. Women also identify lack of time and living in rural and remote communities as prohibitive factors to seeking preconception care [12].

Evidence suggests that people of reproductive age are keen to learn about preconception health and adopt positive health behavior change before a pregnancy. Most women of reproductive age report a preference for internet-based information sources [13] and use technology to find information on pregnancy health [13,14]. Digital health tools, such as web-based self-assessment tools, are a promising medium to increase knowledge and awareness about preconception health among people of reproductive age across geographical locations [15,16]. This includes increased understanding of the benefits of good preconception health, the risks of poor preconception health, and the opportunities to improve health before conception [17,18]. Impacts of web-based preconception health self-assessment tools include reduced rates of preconception alcohol consumption, improved uptake of folic acid supplementation [19], and also act as a catalyst for clients to initiate discussions with health care providers [17].

The Healthy Conception Tool

The Healthy Conception Tool (HCT) was an existing web-based preconception health self-assessment tool, developed by YourFertility, a Commonwealth-funded fertility health promotion program in Australia. The HCT asks questions about a person’s general and reproductive health from which people then get a personalized output of results. They are then encouraged to take the results to their doctor to discuss what they can do to optimize their health. The HCT contains a section for both women and men. The HCT was developed in 2017 in collaboration with academics, clinicians, and researchers at the Robinson Research Institute. Some feedback from users was used in the initial development of the HCT; however, formal usability testing was not performed. Exploring usability can identify issues with how people engage and interact with a tool, and the findings can be used to improve experience to maximize the effectiveness and efficiency of the tool [20].

As the HCT is a potential enabler to promote the importance of preconception health, particularly for people in rural and remote areas who face additional challenges in accessing health care, optimization and usability testing can enhance a tool for these populations. This paper describes the process taken to engage with communities using a person-centered approach to assess usability and optimize an existing web-based preconception health self-assessment tool for people in Australia.

Methods

Overview

In-depth user interviews and usability testing were used to optimize the existing HCT (Figure 1).

A rural women’s health consumer advisory group (RWH-CAG) was established to oversee this body of work and ensure person-centered design in all aspects. A total of 6 women aged 19‐30 years old, who resided in rural and remote locations in Australia, were selected from a pool of 17 applicants. Selected applicants had lived experience and demonstrated knowledge of issues around the access of sexual and reproductive services to rural Australian women, particularly in the areas of family planning and preconception care. The role of the RWH-CAG was to inform the study design and recruitment methods (Figure 1).

‎

Recruitment

People of reproductive age (18‐41 years old), residing in Australia, who could speak and read English, were eligible to participate in both the interviews and user-experience testing. People of all relationship statuses were eligible to take part.

Recruitment for interviews was via social media with advertisements targeting regional and remote community parent groups and noticeboards. Recruitment for user-testing was coordinated through a user-experience agency (Nomat Australia) with an Australia-wide registered pool of user-experience participants. The participants meeting the recruitment specifications listed above were sent an invitation to take part.

Process

In-Depth Interviews

In-depth interviews to understand participants’ experiences of using the HCT were performed from February to September 2021. In particular, what features of the HCT were most likely to increase their knowledge and influence behavior change, and to explore ways in which the tool could be improved. Given COVID-19 quarantine restrictions, interviews were conducted via telephone or internet-based videoconferencing at the participants’ request. Before the interview, participants were required to complete the HCT. Interviews were recorded and transcribed, and data were analyzed by two researchers who have reproductive and public health expertise, using an inductive thematic approach [21,22]. Data were coded, manually without assistance of software programs, to identify consumer likes and dislikes across content and design features of the self-assessment tool. These findings were further discussed among all members of the research team, and agreement was reached on key domains and features for optimization

Prototype Development

A series of strategy, planning, and design workshops were held with a digital solutions consultant (Sentius Australia). These workshops aimed to develop creative and digital solutions for the new tool design, informed by the interview findings. A prototype was developed by Sentius and the research team, with a list of features identified for user testing.

Optimization of Prototype With User Testing

The prototype underwent user-experience testing, conducted by a user-experience specialist to identify any usability issues and validate design changes that had been made from May to June 2022. Again, given the COVID-19 pandemic restrictions, the participants took part in a 1-hour videoconferencing call for user-experience testing. In this call, the participants completed the HCT in their chosen setting, to reflect their typical context. The participants shared their smart device screen so that their tool navigation could be directly observed. The participants completed the System Usability Scale (SUS) [23] and had the option to provide additional feedback on their experience. The SUS is a 10-item questionnaire to enable a standardized assessment of usability of an interface (Figure 2) and is an accepted tool to benchmark the usability of Digital Health Applications [24]. Usability problems were categorized as minor, moderate, or critical relating to the impact they had on tool engagement and completion (Table 1).

‎

Prototype Refinement and Enhancements

User-experience testing results informed additional changes to the tool. Another round of planning workshops was held to decide on the final changes to the tool. These were tested amongst the research group for quality assurance.

Launch

When all changes were made, the enhanced tool was launched on the internet.

Ethical Considerations

This study was approved the University of Sydney Human Research Ethics Committee (2020/430; June 22, 2020). Verbal consent was obtained prior to the interview and user testing. Recruitment for both processes ended when no new data were obtained, and previously identified themes were repeating. Participants were given a Aus $50 (US $37.50) VISA gift card in recognition of their time.

Results

Overview

In-depth interviews with 20 women and 5 men, and user-experience testing with 6 women and 5 men of reproductive age were performed. The participants included people planning and not planning a pregnancy in the next 12 months, from metropolitan, regional, and remote locations in Australia. The participant demographics are shown in Table 2.

Interview Results

All participants completed the HCT prior to their interviews, using either a mobile device or laptop, with some completing the tool on both a mobile and laptop device. Attributes of the self-assessment tool, as identified from the interviews, are presented below.

General Features

Overall, participants were very positive about the HCT. Most participants liked that it was quick to use, taking on average 5 minutes to complete, and that it was a single source for multiple topics of pregnancy preparation.

Source Credibility

The participants expressed that it was important to know the tool was from a credible source. This was attributed to endorsement from reputable professional organizations such as academic institutions.

I look for does it come from a trusted source, is it from the Royal Children’s Hospital website or is it from Breastfeeding Victoria’s website, not just a mummy blog or a website that has obvious ads or links to creams that they want to sell you.
[P19, female, regional, nonplanner]

Target Audience

Participants liked that the tool was inclusive of partners with information for both men and women.

I liked that it had a section for men and women, I think that’s really good, that men are included in it as well.
[P6, female, regional, nonplanner]

Finding the Tool

The participants identified that a good tool is one that is intuitive to find on a simple web-based search. Almost all participants stated that they would not have found this tool on the internet with its current title.

Information Gained

The participants liked the links to further information, particularly the multiple and varied topics that were collated together.

And I think the link that it had when you clicked on the little info icon, they took you to places, and there was like so much information in those places.
[P6, female, regional, nonplanner]

Presentation of Results

The participants stated the presentation of their results was too general and that they wanted more personalized results. Consistently, the participants conveyed that the results must be meaningful to the individual to encourage behavior change.

User Experience

A total of 4 key domains for exploration in the user-experience testing were identified from the interviews:

1. User interface
2. Tool navigation
3. User experience
4. Results

A summary of the features for testing within these 4 domains is shown in Table 3. More details on the interview findings relating to these domains and features are available in Multimedia Appendix 1.

User-Experience Testing

All participants completed all questions in the prototype on their first attempt and responded well to its simplicity. The amount of information provided was considered appropriate, the supplied links were determined to be valuable, and information was perceived to be presented in a way that was easy to digest and use. The average SUS score was 91.82 (SD 4.62), which is a high score compared with an industry average in Australia of 68 (SD 12.5). The participants responded well to the given color scheme.

A total of 11 usability problems were identified, 4 moderate and 7 minor (Table 4).

Additional observations of significance were the impact of the organizational logos at the bottom of the tool. Without prompting, several participants commented on the organization logos and indicated that seeing this added credibility to the tool. New features to increase reach of the tool were also noted and included the option to share the tool with the user’s contacts.

Additional refinements were made to the tool following user-experience testing to address the problems identified. Some key changes are shown in Figure 3.

‎

Discussion

Principal Findings

This work explored what features of a web-based self-assessment tool for preconception care are important to people of reproductive age. In particular, what features will increase engagement and completion of the tool, and what are the best ways to present the results and information so that a user will act upon them.

Our findings showed that participants value a tool that is intuitive to find in a web-based search and is quick and simple to use. This is consistent with findings of other eHealth modalities, where ease of use and simplicity is a determinant in user engagement [25,26]. Clear information about what each question is asking was important to maintain engagement in the tool. For questions that were not intuitive, or required explanation, an information icon was placed adjacent to the question text, in a different color to emphasize its presence. The information was visible by hovering over the icon, as participants indicated they did to want to be directed to an additional page, as this interfered with user experience. Having information presented in a way that is easily understood by the user has been identified as a key quality indicator of web-based health sites [27].

A key finding in both the interviews and user-experience testing was the need to have information clearly presented and easy to digest at an appropriate health literacy level. The International Reproductive Health Education Collaboration recently devised recommendations for developing and implementing tools to improve fertility literacy [28]. This included the recommendation to understand the target population and include user perspectives when developing education tools. In both the interviews and user-experience testing. there was a balance of planners and nonplanners (those not planning a pregnancy in the next 12 mo) to ensure the information presented was accessible and relevant to all people of reproductive age regardless of pregnancy intention. This also led to some key changes including to the title of the tool. Almost all of the interview participants would not have found the tool on the internet, and as such the tool was renamed with a plain English title as informed by participants of “Healthy you, Healthy baby.”

Another key feature for users was the personalized and ordered presentation of tool results. Results were grouped into categories that required the user’s attention and action. These were color-coded to convey visual priority and accompanied by explanatory text, in a positive tone to complement the color scheme.

The participants expressed the importance of knowing that a source is credible, and this is acknowledged by the inclusion of logos from trusted organisations. Trust in eHealth sites is a recognized determinant of user engagement with web-based health information sources [29]. Accreditation or endorsement with recognized logos from reputable institutions can increase trust in a platform [30].

eHealth platforms have been shown to be effective in improving user health knowledge, behavior change, and health outcomes [31,32]. Several eHealth platforms have been shown to be effective for the communication of preconception health information [33-35]. A web-based app for people with sickle cell disease and sickle cell trait providing information about prepregnancy health was found to be acceptable and usable and increased consumer knowledge [33]. An eHealth lifestyle coaching program for women prior to pregnancy has been shown to increase healthy eating behaviours [34,35].

Studies have suggested improvement in eHealth intervention designs to increase their effectiveness [32]. This includes adopting a holistic approach to promote user engagement [36]. Our approach, informed by a rural women’s health consumer advisory group, of in-depth interviews followed by user-experience testing enabled a detailed understanding of our target audience needs and expectations. The opportunity to test the consumer, informed prototype, and validated design has delivered an enhanced tool for people of reproductive age in Australia.

Strengths

The use of both interviews and user-experience testing techniques are a strength of this study and provided additional iterations to enhance the self-assessment tool. The involvement of the RWH-CAG from conception to completion of this project also ensure a person-centred approach.

Limitations

The tool was only explored by people who can speak and read English, and therefore does not capture the preferences of people from culturally and linguistically diverse backgrounds. As these populations can face challenges with access to care, this is a priority area for future research. This study used the SUS as an instrument within the usability testing. Further enhancements may be achieved by using additional tools such as Neilsen’s guidelines in combination with the SUS [37].

Conclusion

As a web-based tool, “Healthy You, Healthy Baby” has the potential to improve knowledge among people of reproductive age about the importance of optimal preconception health, including those who experience health inequities, such as women and men in rural and remote areas. The tool can be adapted to other priority populations, including people from culturally and linguistically diverse backgrounds to further improve the delivery of preconception care.