Introduction
Breastfeeding has been recognised as an optimal method to nourish an infant as it provides complete nutrition necessary for its full physical and mental development.1–3 Breastfeeding protects against common infections and diseases throughout childhood with effects lasting even into adulthood. Babies who are not fully breastfed for the first 3–4 months of age are at higher risk of health problems, such as gastroenteritis,1,4,5 respiratory infection,1 otitis media6 and urinary tract infection. 6 Benefits of breastfeeding for the mother include a rapid return of post-partum uterine tone and post-partum weight loss, higher bone mass density after menopause, delay of ovulation and decreased risk of breast and ovarian and endometrial cancers.7–9
Introduction of complementary foods should not happen before the sixth month and breastfeeding should continue at least until 12 months of age.3 According to the Centers of Disease Control and Prevention, 74.6% of breastfed babies are ever breastfed in the United States, 44.3% breastfed at 6 months and only 23.8% continue breastfeeding to 12 months.2 In Nebraska, where approximately 30% of the population lives in rural areas,10 the number of ever breastfed and exclusively breastfed babies at 6 months stay below the national average at 72.8% and 13.4%, respectively.2 Healthy People 2020 (HP2020) aim to increase the proportion of ever breastfed babies to 81.9%, 60.6% at 6 months and 34.1% at 12 months.4 The current outcomes are far behind public health goals.
Socio-economic, cultural, attitudinal and familial factors are associated with breastfeeding practices.11,12 Disparities in breastfeeding practices exist across different groups,7,8 and a recent review has indicated the need for more research on culturally tailored interventions to achieve the breastfeeding goals established by HP2020.13 Among Hispanic mothers, perceptions of infant rejection to breastfeeding and milk insufficiency are often reported,14 and formula supplementation is practised among one in three mothers.15 Previous research suggests that initiation of breastfeeding may be more frequent among urban women (59%) compared to that among rural women (49%).16 In urban settings, several longitudinal studies have prospectively examined breastfeeding initiation and discontinuation.17–22 Among urban women, breastfeeding initiation and continuation may be influenced by several factors including participation in the WIC programme,17 support from the health system,19–21 maternal depression21 and return to work or school.18,23
A number of health information technology (IT) solutions assist health care professionals in providing efficient quality care. Technology innovations facilitate presenting culturally relevant and tailored health information24,25 There has been increasing trend of using technologies for supporting health behaviour change such as enhancing physical activity,26–31 healthy diet,32–34 smoking35,36 and self-regulation of emotions.37
Health IT evaluation is complex as it intends to serve various functions. Evaluation involves hardware and information processes in a given environment.38,39 Lack of attention to health IT evaluation reflects an inability to achieve system efficiency, effectiveness and satisfaction. 38,39 There are unique methodological challenges in evaluating how populations use and navigate new technologies. Usability challenges have to be met in programme development and should meet all users’ needs. The errors generated due to complex nature and shortcomings of health care applications have been emphasised in various studies.38 Many health IT usability studies have been conducted to explore usability requirements, discover usability problems and design solutions.38,39 The poor design of interactive health care systems increase their complexity thereby hindering their utilisation and uptake by the users.38,39 Evaluating health technology interventions helps in identifying usability issues such as ease of navigation so as to design and develop solutions in a timely and an effective manner.40
Several methods are available to assess and improve the usability of interactive computer enabled applications. Among the expert-based methods, heuristic evaluation is commonly used.41 Nielson’s heuristics are a set of usability engineering principles developed to identify issues in user interface design and involves analysis of the interface. 42,43 Ten essential criteria constitute the Nielson’s heuristics and they include visibility of system status, match between system and the real world, user control and freedom, consistency and standards, error prevention, recognition rather than recall, flexibility and efficiency of use, aesthetic and minimalist design, recovery from errors and help and documentation. 42 Severity indexes ranging from negligible usability issues represented by zero (I don’t agree that this is a usability problem at all) to one (Cosmetic problem only: need not be fixed unless extra time is available on project), two (Minor usability problem: fixing this should be given low priority), three (Major usability problem: important to fix, so should be given high priority) and four (Usability catastrophe: imperative to fix this before product can be released) are utilised in assessing the extent to which such errors can hamper utilisation of the system.42 The majority of the errors can be identified in a systematic process, such as instructions and functionality problems, simplified representation and improved labeling.43 Heuristic evaluations require fewer resources than other methods to predict major usability problems.44,45 According to Nielson’s heuristics, a minimum of three and maximum of five raters are required to conduct a heuristic evaluation.45 Additional raters might not necessarily discover useful information.45
The objective of this study was to conduct a heuristic evaluation of an interactive, bilingual, touchscreen-enabled breastfeeding educational programme for Hispanic women living in rural settings.
