Creating a Stroke Rehabilitation App
TEAM-CONSULTING | HEALTHCARE
The challenge
- Stroke survivors are often faced with inadequate rehabilitation plans and a lack of modern services and tools
- Specialist care via nurses and other medical professional is not scalable, especially not in poorer economies
- Engagement with healthcare apps can be short-term due to poor design, lack of features and a lack of understanding of the user problem
Core duties
Project management and resource planning
Managing resource planning for two designers, two Human Factors researchers and a specialist participant recruiter
User Experience Design (native app)
Personas, User Journey Mapping and Wireframing the app
User Interface Design (native app)
Styling and imagery for the app
User Research (in-person)
With real stroke survivors who had experienced a range of impairments
Literature reviews and desk-based research
Broad internet search and review of scientific papers related to subject matter
Subject matter expert interviews
With members of the team from the Stroke Association
Diving into the data
Discovery
The key source for our work was a literature review, often the case when tackling healthcare products. An excellent source we found was the Stroke Association’s 2016 report on the State of The Nation. The Stroke Association is the UK’s leading research and information body related to stroke awareness, treatment and rehabilitation. They work with patients and physicians to create accurate and helpful guidance.
- Over half of stroke survivors have a disability as the result of the stroke or complications thereof
- 43% of stroke survivors wanted more therapeutic support once discharged home, with physiotherapy support being the biggest priority.
- Around 30% of stroke survivors do not receive a care plan nor an assessment of their condition or needs
- 48% of stroke survivors reported problems caused by either poor or non-existent co-working between health and social care providers
It was clear that stroke care was being poorly managed. Survivors did not have consistent access to care plans which are a key tool for their recovery. Without a care plan, and with inconsistent social support, stroke survivors were often left to fend for themselves.
Due to neuro-plasticity in the brain, stroke injuries and disabilities can be mitigated, improved or cured with the right therapy even years after the event. In these cases, it is almost certain that patients would not be under any healthcare or supervision and would not be a priority.
When stroke survivors have a care dependency due to their level of disability, either professional or family carers come into play. Often emotionally burdened, family carers can suffer greatly in their daily duties caring for their loved ones.
There are already certain specialist apps for treating certain parts of rehabilitation like cognitive re-training, performing basic exercises and occupational therapy, but most are very basic and would likely not hold a user’s attention for a long time. This means they would not be effective tools at managing patient recovery over a long time period.
Defining design challenge / hypotheses
We needed to understand who stroke survivors are. They tend to fall into the following categories:
- 55+ years of age
- Medical conditions such as AFib, high cholesterol, type 2 diabetes
- Addictions such as alcohol, drugs or tobacco
- Most have access to a smartphone or tablet
The key context this can give us is that these people are likely in contact with health services for a number of reasons, and there’s a chance that their current approaches may not be successful in improving their outcomes. Services are often rendered in person, which is not scalable and can be costly, or via leaflets and printouts which can be hard for patients to understand or can be misplaced.
We decided that tackling these issues of prevention should be left to other specialist services. We decided to focus on physical and cognitive rehabilitation after acute stroke care has completed.
We believed we should create a stroke rehab companion app with the following qualities:
- Clear connection to an agreed care plan, and the app should act like a digital case worker for the stroke survivor
- Modern look and feel (like Calm, Headspace, Elevate)
Defining behaviours to change
We used the COM-B framework to understand which patient behaviours the app should influence. Here are a few examples of how the COM-B methodology is used to flesh out intervention strategies (feature outlines):
| Intervention functions | COM-B Component | Behaviour change techniques | Intervention strategies |
| Education, Environmental restructuring | Automatic motivation | Prompts | App reminders and notifications |
| Training | Physical capability | Rehearsal | Video training to teach and learn exercises |
| Enablement | Problem solving | Removing physical barriers that restrict exercise in a space at home |
In apps, we would normally discuss features rather than intervention strategies. We used the terms interchangeably for this exercise. Video training is an intervention strategy and can quite clearly be considered a feature. We also discovered that peer support can be a useful tool for influence patient behaviour and keeping them motivated, especially for chronic or long term health conditions.
Hypotheses we tested against
Look and feel
1
We believe a modern, professional looking app will put stroke survivors at ease, establish instant trust in the service and make it more desirable for them to use the app on a daily basis
Peer support
2
We believe a peer support network would be a valuable addition to the app for stroke survivors, and it’s purpose would be clearly understood
Video guidance
3
We believe that video guidance will be an easy to use, easy to understand pattern for users of the app, and would be an engaging method to encourage repeat use
Design & Test
Design activities leading up to user testing
Sprint 1
The first sprint was to design the overall framework of the app and would culminate in a pilot study performed with staff internally at Team. In this study, we were looking to eliminate obvious usability issues or areas of confusion. We avoided asking attitudinal questions about features as these participants were not the intended target audience. I tackled the bulk of the design work in this sprint, covering the app structure and a first pass at the UI, while also planning and performing the user research.
Sprint 2
The second sprint was to iterate the designs based on pilot study feedback and create a more refined UI style. As our hypotheses were based around this being a consumer-level, attractive app, it made sense to focus on these elements. My colleague tackled the UI updates for this sprint while I tackled recruitment and setting up a more formal user test involving real stroke survivors.
Key design decision
We quickly decided that a timeline style of layout would be beneficial for the app home screen as the user would be performing sequential tasks each day. Based on experience designing and using other apps within the medical and wellness spaces, this pattern seemed like a sensible solution.
Realistic app-access for in-person testing
In the test scenario, accessing the app was performed by scanning a QR code that led to a Figma link. This was intended to simulate a patient scanning a letter they’d received with a unique code in order to securely access their rehabilitation plan. Rather than a traditional account setup experience, we believed this would alleviate frustrations in this regard for patients, especially those with cognitive or motor control issues who may have a challenge typing passwords.
Remote testing
We then performed a remote study using UserTesting.com with a small number of participants from the UK and USA. I worked with the Human Factors Team to set this up, revising the prototype, assisting with writing the protocol, and liaising with UserTesting.com about trial setup. This was a team learning exercise and had the secondary benefit of selling in the UserTesting.com proposition at Team, a company which has historically relied on in-person user/patient studies. Having used UserTesting extensively in the past I was keen to test this tool in a medical capacity.
Results from user testing
Participant parameters
- In-person, moderated study, n=5, average age of participants 65 years.
- Remote, unmoderated study, n=5, average age of participants 54 years.
Results
- Participants were overall delighted by the app. The look and feel helped them to trust the service offering and they remarked that it felt high quality.
- 7 out of 10 participants expressed interest in the peer group function, indicating it would help them with their recovery.
- 3 participants did not favour the peer group function, stating that they would prefer to manage their rehabilitation alone and were not very social otherwise
- 4 participants expressed that should they be joining a peer group, they would want the peers to have similar challenges to them and be similar in age or outlook.
- The exercise videos were positively received by all participants as an easy way to learn / be reminded of exercises.
QR code access was well understood. Several participants remarked that this functionality was much more familiar since COVID. One participant was expecting a specific QR code scanning app, but understood the printed instructions to simply user her camera. Notably, regarding native camera views (not part of the app we designed) usability on iOS for tapping the QR link was poorer compared to Android with participants needing to be instructed. Motor control issues are common in stroke survivors, and tapping a small link in the centre of a camera view on iOS was not easy. The interactive tap area on Android was larger and easier to interact with.
Project outcome
We created an app that was welcomed with delight by stroke survivors
We contacted the Stroke Association with a view to building this app for stroke survivors. While they did not have current funding available for the app, they were keen to discuss the project and provided valuable clinical guidance on defining the product as a fully workable clinical service.