An mHealth App for Users with Dexterity Impairments:Accessibility Study
面向行动不便用户的移动医疗应用程序：无障碍研究

Daihua Yu^1*, PhD; Bambang Parmanto^1*, PhD; Brad Dicianno^2*, MD, MS
俞黛华^1*， PhD;Bambang Parmanto^1*，博士;Brad Dicianno^2*，医学博士，理学硕士

1

Health & Rehab Informatics, Department of Health Information Management, University of Pittsburgh, Pittsburgh, PA, United States
健康与康复信息学，健康信息管理系，匹兹堡大学，宾夕法尼亚州，美国

2

Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA, United States *
匹兹堡大学物理医学与康复系， 美国宾夕法尼亚州匹兹堡 *

all authors contributed equally
所有作者的贡献均等

Corresponding Author:
通讯作者：

Bambang Parmanto, PhD
Bambang Parmanto 博士

Health & Rehab Informatics
健康与康复信息学

Department of Health Information Management
卫生信息管理系

University of Pittsburgh
匹兹堡大学

6026 Forbes Tower
福布斯大厦 6026 号

Pittsburgh, PA, 15260
宾夕法尼亚州匹兹堡，15260

United States
美国

Phone: 1 412 383 6649
电话： 1 412 383 6649

Fax: 1 412 383 6655
传真： 1 412 383 6655

Email: parmanto@pitt.edu
电子邮件：parmanto@pitt.edu

Abstract
抽象

Background: A mobile health (mHealth) system called iMHere (interactive mobile health and rehabilitation) was developed to support individuals with chronic conditions and disability in their self-management regimens. The initial design of iMHere, however, lacked sufficient accessibility for users with a myriad of dexterity impairments. The accessibility of self-management apps is essential in ensuring usability.
背景：开发了一种名为 iMHere（交互式移动健康和康复）的移动健康 （mHealth） 系统，以支持患有慢性病和残疾的人进行自我管理。然而，iMHere 的初始设计缺乏足够的可访问性，无法满足具有无数灵巧性障碍的用户。自我管理应用程序的可访问性对于确保可用性至关重要。

Objective: This study aims to increase the usability of the iMHere system for users with dexterity impairments by increasing the app’s accessibility.
目的：本研究旨在通过增加应用程序的可访问性来提高 iMHere 系统对灵巧性障碍用户的可用性。

Methods: We targeted the accessibility redesign by focusing on the physical presentation and the navigability of the iMHere apps. Six participants presenting with dexterity impairments were included in the usability study of the original and redesigned apps.
方法：我们通过关注 iMHere 应用程序的物理呈现和可导航性来针对可访问性重新设计。六名表现出灵巧性障碍的参与者被纳入原始和重新设计的应用程序的可用性研究。

Results: We observed a lower number of touches needed to complete tasks (P=.09) and time to complete individual tasks (P=.06) with the redesigned app than with the original app; a significantly lower time for users to complete all tasks (P=.006); and a significantly lower error rate (P=.01) with the redesigned app than with the original app. In fact, no errors occurred with use of the redesigned app. Participant-reported overall average usability of the redesigned app (P=.007) and usability of individual modules (P<.001) were significantly higher than that of the original app due mostly to better ease of use and learnability, interface quality, and reliability.
结果：我们观察到，与原始应用程序相比，重新设计的应用程序完成任务所需的触摸次数 （P=.09） 和完成单个任务的时间 （P=.06） 更少;用户完成所有任务的时间显著缩短 （P=.006）;错误率显著降低 （P=.01） 与原始应用程序相比。事实上，使用重新设计的应用程序没有发生错误。参与者报告重新设计的应用程序的总体平均可用性 （P=.007） 和单个模块的可用性 （P<.001） 明显高于原始应用程序，这主要是由于更好的易用性和可学习性、界面质量和可靠性。

Conclusions: Improved usability was achieved using a redesigned app. This study offers insight into the importance of personalization in enhancing the accessibility and also identifies strategies for improving usability in app development.
结论：使用重新设计的应用程序实现了更高的可用性。这项研究深入了解了个性化在增强可访问性方面的重要性，并确定了提高应用程序开发可用性的策略。

(JMIR Mhealth Uhealth 2019;7(1):e202) doi:10.2196/mhealth.9931
（JMIR Mhealth Uhealth 2019;7（1）：e202） doi：10.2196/mhealth.9931

KEYWORDS
关键字

accessibility; dexterity impairments; disability; mHealth; self-management; smartphone apps; spina bifida; spinal cord injury;
可及性;灵巧性障碍;残疾;移动健康;自我管理;智能手机应用程序;脊柱裂;脊髓损伤;

wellness; mobile phone
健康;移动电话

Introduction
介绍

Mobile health (mHealth) technologies, an emergent form of treatment support, offer a variety of health services and information through mobile devices such as phones and tablets [1,2]. Using mobile devices to wirelessly link remote and highly mobile populations, mHealth links users directly with health care providers and systems. Mobile apps have become a popular mode for delivering reminders to conduct self-management activities, collect data, and provide treatment support [3], all with the goal of encouraging behavioral changes and improving health care delivery [4-6]. Some specific self-management techniques include frequent communication between patients and clinicians, as well as continuous adherence to, and adjustment of, complex treatment regimens [7].
移动健康 （mHealth） 技术是一种新兴的治疗支持形式，通过手机和平板电脑等移动设备提供各种健康服务和信息 [1， 2]。mHealth 使用移动设备以无线方式连接远程和高度移动的人群，将用户直接与医疗保健提供者和系统连接起来。移动应用程序已成为一种流行的提醒模式，用于进行自我管理活动、收集数据和提供治疗支持 [3]，所有这些都是为了鼓励行为改变和改善医疗保健服务 [4-6]。一些特定的自我管理技术包括患者和临床医生之间的频繁沟通，以及持续坚持和调整复杂的治疗方案[7]。

Improving users’ self-management skills is of critical importance for improving health outcomes and fostering independent living in persons with disabilities (PwDs) [8-10]. This is especially true for individuals with conditions such as spina bifida (SB) and spinal cord injuries (SCI)—a population of 442,000 in the United States—because these individuals are susceptible to secondary complications such as urinary tract infections, constipation, skin breakdown (due to paralysis and loss of sensation), and sepsis [11-13]. These secondary complications are, in part, preventable, but this requires active involvement on the part of patients, caregivers, and clinicians in adherence to self-management regimens. Therefore, developing technologies that promote self-management skills in this population could have a profound impact on health outcomes.
提高使用者的自我管理技能对于改善健康状况和促进残疾人 （PwD） 独立生活至关重要 [8-10]。对于患有脊柱裂 （SB） 和脊髓损伤 （SCI） 等疾病的个体（美国人口为 442,000 人）尤其如此，因为这些个体容易出现继发性并发症，如尿路感染、便秘、皮肤破损（由于瘫痪和感觉丧失）和败血症 [11-13].这些继发性并发症在一定程度上是可以预防的，但这需要患者、照护者和临床医生积极参与，坚持自我管理方案。因此，开发促进这一人群自我管理技能的技术可能会对健康结果产生深远影响。

Investigators at the University of Pittsburgh have developed a novel mHealth system aimed at empowering persons with chronic conditions like SB and SCI and clinicians to be engaged in improving patient health [14]. This mHealth system, iMHere (interactive mobile health and rehabilitation; Figure 1), is a platform consisting of a smartphone app with a suite of modules aimed at managing various medical conditions, a Web-based clinician portal, and a communication system connecting patients with clinicians and caregivers. Some specific modules within the iMHere self-management app target medication management (MyMeds), skin integrity (SkinCare), bowel management (BMQ), bladder self-catheterization (TeleCath), and mental health (Mood).
匹兹堡大学的研究人员开发了一种新型移动医疗系统，旨在使 SB 和 SCI 等慢性病患者和临床医生能够参与改善患者健康状况 [14]。这个移动医疗系统、iMHere（交互式移动健康和康复; 图 1）是一个平台，由一个智能手机应用程序组成，该应用程序带有一套旨在管理各种医疗状况的模块、一个基于 Web 的临床医生门户以及一个连接患者与临床医生和护理人员的通信系统。iMHere 自我管理应用程序中的一些特定模块针对药物管理 （MyMeds）、皮肤完整性 （SkinCare）、肠道管理 （BMQ）、膀胱自我导尿 （TeleCath） 和心理健康 （Mood）。

The first version of iMHere (v1.0) did not offer sufficient accessibility—and, thus, usability—to persons with intellectual disabilities or dexterity impairments. Our prior work [15] revealed that the personalized user interface (UI) design may improve accessibility. In addition, this work generated a list of design requirements for the next iteration of the software. These design requirements were as follows:
iMHere 的第一个版本 （v1.0） 没有为智障人士或灵巧障碍者提供足够的可访问性，因此也没有提供足够的可用性。我们之前的工作 [15] 揭示了个性化用户界面 （UI） 设计可以提高可访问性。此外，这项工作还为软件的下一次迭代生成了一份设计要求清单。这些设计要求如下：

Using simple and common words to ensure the readability and understandability of the text to help users better understand the app by simplifying the cognitive processes needed for completing tasks.
使用简单和常见的词语来确保文本的可读性和可理解性，通过简化完成任务所需的认知过程来帮助用户更好地理解应用程序。

Using shortcuts in navigation to make a given task easier to complete.
在导航中使用快捷方式可使给定任务更易于完成。

Reducing the number of touches to reduce the burden of navigation and text entry.
减少触摸次数以减轻导航和文本输入的负担。

Implementing contrasting colors between the text and background, as well as adding text-shadows, to enhance the contrast and improve readability.
在文本和背景之间实现对比色，并添加文本阴影，以增强对比度并提高可读性。

Providing a short, one-sentence reminder offering directional guidance to prevent mistakes related to task procedures.
提供简短的一句话提醒，提供方向性指导，以防止与任务程序相关的错误。

Using large icons and buttons to improve accessibility, especially for users with dexterity impairments.
使用大图标和按钮来提高辅助功能，尤其是对于行动不便的用户。

Implementing colors to indicate the status of medications to let users know whether or not a medication is scheduled.
实施颜色来指示药物状态，让用户知道是否安排了药物。

Separating the modules by color to easily signal which module is in use.
按颜色分隔模块，以便轻松指示正在使用的模块。

Using color-coded body parts on a map of the body to help users correctly specify the location of a skin problem.
在身体地图上使用颜色编码的身体部位，以帮助用户正确指定皮肤问题的位置。

Hiding the unused modules from the iMHere dashboard, selecting text display size, and changing contrast and display theme to make the system more personalized.
在 iMHere 仪表板中隐藏未使用的模块，选择文本显示大小，并更改对比度和显示主题，使系统更加个性化。

In general, users expressed a desire to have a simpler app that is easy to understand and physically use [15,16]. Because an mHealth app is a user’s data point of input, such accessibility is essential for users in performing their self-management-related activities and reporting or communicating with their clinicians.
一般来说，用户表示希望拥有一个更简单、易于理解和实际使用的应用程序 [15， 16]。由于 mHealth 应用程序是用户的数据输入点，因此这种可访问性对于用户执行与自我管理相关的活动以及报告或与临床医生沟通至关重要。

Figure 1. Architecture of the iMHere (interactive mobile health and rehabilitation) system. 图 1. iMHere（交互式移动健康和康复）系统的架构。

Identifying patient needs and preferences with respect to using an iMHere app delineates only one step in the process of creating greater levels of accessibility. We believe that the accessibility of mHealth can be enhanced with user-centered design and implementation. Better accessibility of smartphone apps may benefit some of the 4.04 million adults in the United States with dexterity impairments [17] whose medical problems can be addressed with iMHere.
确定患者在使用 iMHere 应用程序方面的需求和偏好，只是创建更高级别可访问性过程中的一个步骤。我们相信，通过以用户为中心的设计和实施，可以增强移动医疗的可访问性。智能手机应用程序的更好可访问性可能会使美国 404 万敏捷障碍成年人中的一些人受益 [17]，他们的医疗问题可以通过 iMHere 解决。

This study aims to design accessible features in the iMHere self-management app for persons with intellectual disabilities and dexterity impairments. We hypothesized that use of the redesigned app would result in significantly improved usability measures compared with the use of the original app. Results from this study will be used to develop a new version of the software.
本研究旨在为智障和灵巧障碍人士设计 iMHere 自我管理应用程序中的无障碍功能。我们假设，与使用原始应用程序相比，使用重新设计的应用程序将导致可用性指标的显著提高。本研究的结果将用于开发新版本的软件。

Methods
方法

Development Method
开发方法

An earlier evaluation study [15] suggested that possible accessibility issues could be mitigated with better app design and development. We believe that the approach to designing an accessible interface involves working with two primary UI components: physical presentation and navigation (Figure 2). The physical presentation includes the following:
早期的评估研究 [15] 表明，可以通过更好的应用程序设计和开发来缓解可能的可访问性问题。我们认为，设计无障碍界面的方法涉及使用两个主要的 UI 组件：物理表示和导航（图 2）。体格检查包括以下内容：

Presentation of widgets: Focuses on the size and contrast of text and the use of buttons. The size of the widgets (icons) and text and the contrast can be adjusted to users’ preferences.
小组件的表示：侧重于文本的大小和对比度以及按钮的使用。小部件（图标）和文本的大小以及对比度可以根据用户的喜好进行调整。

Visual impact: Focuses on the use of charts, images, and visual cues.
视觉影响：侧重于图表、图像和视觉提示的使用。

Navigation refers to activity flow and layout order in terms of effectiveness. Simple navigation is important for all users, but
导航是指活动流和布局顺序的有效性。简单的导航对所有用户都很重要，但是

especially important for people with dexterity or cognitive impairments. The proposed design approaches the app’s accessibility in terms of navigation from the following aspects:
对于行动不便或认知障碍的人尤其重要。建议的设计从以下几个方面接近应用程序在导航方面的可访问性：

Activity flow: Focuses on the cognitive process, on providing straight-line experiences for a user to complete a task. Good activity flow means the user is able to effectively and efficiently locate the needed information in the smartphone app.
活动流：侧重于认知过程，为用户提供完成任务的直线体验。良好的活动流意味着用户能够在智能手机应用程序中有效且高效地找到所需的信息。

Layout order: Focuses on the presentation of individual screens. Placing related information in close proximity makes it easier for a user to understand the presented information. In addition, having consistent layouts across the modules within the app provides a smooth learning curve for users.
布局顺序：侧重于各个屏幕的显示。将相关信息放在很近的位置，使用户更容易理解所显示的信息。此外，在应用程序内的模块之间具有一致的布局可为用户提供平滑的学习曲线。

Usability Study Method
可用性研究方法

After the development of new accessibility features, a usability study was conducted. Inclusion criteria were as follows: users must have participated in the prior usability study [15], be aged 18-55 years, have dexterity issues in the fingers or hands, have an active condition or past history of skin breakdown from using a wheelchair or having insensate areas of skin, and be taking at least one prescription or nonprescription medication. Exclusion criteria were as follows: users having any problem in vision, hearing, or conversation that completely precluded the use of a mobile phone.
在开发新的辅助功能后，进行了可用性研究。纳入标准如下：用户必须参加过先前的可用性研究 [15]，年龄在 18-55 岁之间，手指或手有灵巧性问题，有活动状况或既往有因使用轮椅或皮肤无感觉区域而皮肤破裂的病史，并且至少服用一种处方药或非处方药。排除标准如下：用户在视力、听力或对话方面有任何问题，完全无法使用手机。

Manufacturers have moved to replace the physical keyboard with virtual or soft keys to reduce the size and weight of smartphone devices. To not leave PwDs behind in the area of smartphone touch screen technologies, this research examined the use of apps on a smartphone with virtual or soft keys (touch screen). Specifically, this research utilized Samsung Galaxy, a lightweight, touch screen-enabled, slate format Android smartphone with no physical keyboard (dimensions: 4.82 in×2.53 in×0.55 in; weight=5.5 oz); this screen size is smaller than the current standard screen size, which is ≥5.5 in.
制造商已经采取行动，用虚拟键或软键取代物理键盘，以减小智能手机设备的尺寸和重量。为了不让 PwD 在智能手机触摸屏技术领域落后，本研究检查了智能手机上使用带有虚拟键或软键（触摸屏）的应用程序。具体来说，这项研究使用了三星 Galaxy，这是一款轻便、支持触摸屏的平板格式 Android 智能手机，没有物理键盘（尺寸：4.82 英寸×2.53 英寸×0.55 英寸;重量 = 5.5 盎司）;此屏幕尺寸小于当前标准屏幕尺寸，即 ≥5.5 英寸。

The Institutional Review Board of the University of Pittsburgh approved this study. All participants were asked to provide informed consent. We enrolled all nine participants (9/9, 100%) from the prior evaluation study [15] were enrolled. All of these individuals could be classified as experienced participants but had abstained from using the iMHere app for >4 months before participating in this study. This abstinence is aimed at minimizing the potential learning effects that could ostensibly carry over from the previous experiences.
匹兹堡大学机构审查委员会批准了这项研究。要求所有参与者提供知情同意。我们招募了先前评估研究 [15] 中的所有 9 名参与者 （9/9， 100%） 均被纳入。所有这些人都可以归类为有经验的参与者，但在参与本研究之前已经 >4 个月不使用 iMHere 应用程序。这种禁欲旨在最大限度地减少表面上可能从以前的经历中延续下来的潜在学习影响。

The Purdue Pegboard Assessment, a popularly utilized diagnostic tool for measuring the movements of a person’s fingers, hands, and arms, was used to measure the baseline for participant dexterity levels [18-22]. We used 4 tests from the Purdue Pegboard Assessment in this study. The assessment comprised 4 tests with 30-second intervals using the right hand, left hand, and both hands, yielding a composite score of “right+left+both hands.” During these tests, participants were asked to pick up pins, collars, or washers from the top of the board and drop them into the peg holes. The score for each test was based on the total number of pins, collars, or washers dropped into the holes correctly. The “right+left+both” hand score was used as the basis for evaluating a participant’s dexterity, with lower “right+left+both” hand scores indicating a higher degree of dexterity impairment.
普渡大学钉板评估是一种广泛使用的诊断工具，用于测量人的手指、手和手臂的运动，用于测量参与者灵巧度水平的基线[18-22]。在本研究中，我们使用了普渡大学钉板评估中的 4 项测试。评估包括 4 项测试，间隔 30 秒，使用右手、左手和双手，得出“右 + 左 + 双手”的综合分数。在这些测试中，参与者被要求从板的顶部捡起别针、项圈或垫圈，并将它们放入钉孔中。每项测试的分数基于正确放入孔中的销钉、套环或垫圈的总数。“右 + 左 + 双手”分数被用作评估参与者灵巧度的基础，“右 + 左 + 双手”分数较低表示灵巧度障碍程度较高。

This study focused on two specific modules within the iMHere self-management app: MyMeds for medication management and Skincare for skin monitoring and reporting of skin breakdown. These two modules were selected not only on the basis of their critical importance to self-management for individuals with chronic conditions like SB and SCI but also for their relative complexity.
本研究侧重于 iMHere 自我管理应用程序中的两个特定模块：用于药物管理的 MyMeds 和用于皮肤监测和皮肤破损报告的 Skincare。选择这两个模块不仅基于它们对 SB 和 SCI 等慢性病患者的自我管理至关重要，还基于它们的相对复杂性。

A 1-week field trial was completed, in which participants were asked to use the two modules in their daily lives. Afterwards, a laboratory-setting evaluation and in-depth interview were conducted. A “think-aloud” protocol [23] requires participants to verbalize their thoughts as they attempt to complete the tasks, thereby allowing investigators to identify further usability or accessibility issues that need to be addressed. The “think-aloud” method required participants to describe, in words, what they see, think, do, and feel while performing the tasks needed to navigate through the two modules. The following tasks were included in the laboratory test:
完成了一项为期 1 周的现场试验，要求参与者在日常生活中使用这两个模块。之后，进行了实验室设置评估和深入访谈。“发声思考”方案 [23] 要求参与者在尝试完成任务时用语言表达他们的想法，从而使研究人员能够确定需要解决的进一步可用性或可访问性问题。“出声思考”方法要求参与者用文字描述他们在执行浏览这两个模块所需的任务时的所见、所想、所做和所感。实验室测试包括以下任务：

Task 1: Scheduling a new medication alert; this includes searching for and finding the correct medication as well as setting up a medication schedule.
任务 1：安排新的药物警报;这包括搜索和查找正确的药物以及设置用药时间表。

Task 2: Modifying a medication reminder, which includes changing the alert time for a medication.
任务 2：修改药物提醒，包括更改药物的提醒时间。

Task 3: Responding to a medication alert, which includes indicating whether the participant took a particular medication.
任务 3：响应药物警报，包括表明参与者是否服用了特定药物。

Task 4: Scheduling an alert to remind oneself to check the skin for any issues or problems.
任务 4：安排警报以提醒自己检查皮肤是否有任何问题或问题。

Task 5: Responding to a skincare reminder, which involves taking a picture and describing any dermatological issues through a series of survey questions.
任务 5：回应护肤提醒，包括拍照并通过一系列调查问题描述任何皮肤病问题。

Task 6: Setting personalized configurations for UI presentations, including choosing a preferred list of modules, modifying the reading size of text, and choosing the size of onscreen buttons.
任务 6：为 UI 演示文稿设置个性化配置，包括选择首选的模块列表、修改文本的阅读大小以及选择屏幕按钮的大小。

The researcher first explained the tasks to the participant until he or she understood the details of each activity (approximately 15 min). Once the participant was well informed of his or her expectations in performing the tasks, a quantitative evaluation was performed, and the following usability measures were collected:
研究人员首先向参与者解释任务，直到他或她理解每项活动的细节（大约 15 分钟）。一旦参与者充分了解他或她对执行任务的期望，就会进行定量评估，并收集以下可用性指标：

Importance ranking: Participants were asked to rate the new accessibility features on a scale from 1 to 10 (1=most important feature; 10=the least important feature).
重要性排名：参与者被要求以 1 到 10 的等级对新的辅助功能进行评分（1 = 最重要的功能;10 = 最不重要的功能）。

User effort: The minimum number of times the participant needed to touch the screen to complete all tasks.
用户工作量：参与者完成所有任务所需触摸屏幕的最少次数。

Individual task time: Average time to complete a specific task.
单个任务时间：完成特定任务的平均时间。

Overall task time: Average time to complete all tasks.
总任务时间：完成所有任务的平均时间。

Error rate: The number of errors or mistakes committed during all tasks.
错误率：所有任务期间提交的错误数。

Usability: Participants were asked to complete a modified version of the Telehealth Usability Questionnaire (TUQ) [24,25]. The TUQ is a qualitative survey covering the following factors—usefulness, ease of use and learnability, interface quality, interaction quality, reliability, and satisfaction and future use [24,25]. In assessing these factors, the TUQ utilizes a 7-point Likert scale (with a value of 1 as least usable and 7 as most usable). An overall average score and individual factor scores were calculated.
可用性：参与者被要求完成修改版的远程医疗可用性问卷 （TUQ） [24， 25]。TUQ 是一项定性调查，涵盖以下因素——有用性、易用性和可学习性、界面质量、交互质量、可靠性以及满意度和未来使用 [24： 25]。在评估这些因素时，TUQ 使用 7 点李克特量表（值为 1 表示最不可用，7 表示最可用）。计算总体平均分和个体因素得分。

An in-depth interview was subsequently conducted to gather participant feedback and impressions regarding the iMHere app.
随后进行了深入访谈，以收集参与者对 iMHere 应用程序的反馈和印象。

Statistical Analysis
统计分析

All the data collected from this study were uploaded to SPSS (IBM Corp. Released 2016, IBM Statistics for Windows, Version 24.0, Armonk, NY: IBM Corp) for statistical analysis. The sum and average task completion times were utilized to measure participants’ performance levels. Error rate was calculated as the number of errors or mistakes divided by the total of steps taken to complete tasks. SDs were calculated to reveal any possible dispersion patterns. The results from the previous evaluation study of the originally designed iMHere app [15] were used here for comparison.
从这项研究中收集的所有数据都上传到 SPSS（IBM Corp. Released 2016，IBM Statistics for Windows，Version 24.0，Armonk，NY：IBM Corp）进行统计分析。任务完成时间的总和和平均用于衡量参与者的表现水平。错误率的计算方法是错误或失误的数量除以完成任务所采取的总步骤数。计算 SD 以揭示任何可能的色散模式。这里使用最初设计的 iMHere 应用程序 [15] 的先前评估研究的结果进行比较。

Because our sample size was smaller than 50, Shapiro-Wilk test was used to determine whether the data were normally distributed. As all data were normally distributed, paired t tests were utilized to evaluate differences between the original and new app with regard to usability measures. Statistical significance was set at P<.05.
因为我们的样本量小于 50，所以使用 Shapiro-Wilk 检验来确定数据是否呈正态分布。由于所有数据都是正态分布的，因此使用配对 t 检验来评估原始应用程序和新应用程序在可用性测量方面的差异。统计学显著性设置为 P<.05。

Backgrounds of Participants
参与者背景

Of the 9 participants from the earlier evaluation study [15], 3 were lost due to follow-up issues (ie, changed phone number or had relocated). Overall, 6 participants completed this study. Of all participants, 5 had SB and 1 had SCI. All participants with SB had some degree of cognitive impairment related to shunted hydrocephalus.
在早期评估研究的 9 名参与者中 [15]，有 3 名因随访问题（即更改电话号码或搬迁）而丢失。总体而言，6 名参与者完成了这项研究。在所有参与者中，5 例患有 SB，1 例患有 SCI。所有 SB 参与者都有一定程度的与分流脑积水相关的认知障碍。

All 6 participants were right-hand dominant and all met the inclusion and exclusion criteria. All individuals with SB had spinal lesion levels at the low thoracic or lumbosacral levels. The participant with SCI had a cervical lesion level.
所有 6 名参与者均为右手主导，均符合纳入和排除标准。所有 SB 患者的脊柱病变水平均处于较低的胸椎或腰骶水平。SCI 参与者的宫颈病变水平。

As shown in Table 1, all participants’ “right+left+both” hand scores were below −2 SD from the mean score of general factory workers (46.76−2 SD=38.68) [26]. Participants 1, 5, 6, and 7 tried picking up pins using both hands and dropping the pins in the holes at the same time to speed up their performance. This led to scores for the “both-hand test” that were around the mean of general factory workers at 16.01. Participant 8 had experienced a traumatic SCI (C5) resulting in minimal movement of the arms, a slight movement of the thumb and index figure, and an inability to hold or pick up objects. In addition, participant 8 was unable to perform the pegboard assessment test, but could access a smartphone either using the side of the fifth digit or a stylus mounted to a custom orthosis.
如表1所示，所有参与者的“右+左+双手”得分均低于一般工厂工人的平均得分（46.76−2 SD=38.68）的−2 SD[26]。参与者 1、5、6 和 7 尝试用双手捡起瓶子，同时将瓶子放入孔中，以加快他们的表现。这导致“双手测试”的分数大约是一般工厂工人的平均分数 16.01。参与者 8 经历了创伤性 SCI （C5），导致手臂运动轻微，拇指和食指略微移动，无法握住或拿起物体。此外，参与者 8 无法进行钉板评估测试，但可以使用第五个数字的一侧或安装在定制矫形器上的手写笔访问智能手机。

Development Results
开发成果

Table 2 shows the number of individuals assigning high (1-3, very important), medium (4-7, important but not essential), and low (8-10, less important) ranks for each newly developed accessibility feature.
表 2 显示了为每个新开发的辅助功能分配高（1-3，非常重要）、中（4-7，重要但不是必需的）和低（8-10，不太重要）等级的人数。

Table 1. Background of participants (P).
表 1. 参与者背景 （P）。

Age (in years) 36 27 25 20 33 22
年龄 （岁）362725203322

Highest education Graduate High school High school High school Undergraduate Graduate
最高学历研究生高中高中高中本科毕业生

Gender Female Male Male Male Female Male
性别女男男男女男

Regular phone versus smartphone Regular Regular Smartphone Smartphone Smartphone Smartphone
普通手机与智能手机普通智能手机智能手机智能手机 智能手机

Physical keypad versus touch screen Physical Physical Touch Touch Touch Touch
物理键盘与触摸屏物理触摸物理触摸触摸

Mobile phone experience (in years) 0-2 >5 >5 >5 >5 >5
手机使用经验（年）0-2>5>5>5>5>5

Daily use (in minutes) >60 >60 >60 >60 >60 >60
每日使用量（分钟）>60>60>60>60>60%3E60%

Pegboard score right+left+both 33.00 27.00 23.67 36.33 37.00 0.00
钉板得分 右 + 左 + 两者33.0027.0023.6736.3337.000.00

Table 2. Importance ranking.
表 2. 重要性排名。

# Features Number of individuals assigning ranks
#特点分配等级的人数

 Ranks 1-3 Ranks 4-7 Ranks 8-10
第 1-3 名第 4-7 名第 8-10 名

Customized app list 2 2 2
自定义应用列表222

Customized text display size 2 1 3
自定义文本显示大小213

Customized theme 0 2 4
自定义主题024

Customized button size 2 3 1
自定义按钮大小231

Customized keyboard 2 2 2
定制键盘22 2

Ability to take a picture of a pill or med bottle 2 4 0
能够拍摄药丸或药瓶的照片240

Color-coding 1 2 3
颜色编码123

Text guide 2 4 0
文本指南240

Voice guide 4 1 1
语音导览411

Short cut for navigation 2 2 2
导航捷径222

Figure 3. Screenshots of the use of color-coding at the app level. (Source: Created by the authors).
图 3. 在应用程序级别使用颜色编码的屏幕截图。（来源： 由作者创建）.

Customized app list: This feature provides the ability for a user to hide or show a selected module from the home screen. Overall, 67% (4/6) participants thought that the first feature was important to hide the TeleCath and BMQs apps because they did not need to catheterize the bladder (TeleCath) or perform bowel management (BMQs).
自定义应用程序列表：此功能使用户能够从主屏幕隐藏或显示所选模块。总体而言，67% （4/6） 的参与者认为隐藏 TeleCath 和 BMQs 应用程序的第一个功能很重要，因为他们不需要为膀胱插管 （TeleCath） 或进行肠道管理 （BMQ）。

Size of display text: A user can specify his or her minimal and comfortable reading size. This display size is then used as the foundation for all other configuration parameters for text display in iMHere modules. Overall, 50% (3/6) participants thought that using customized text size was important; participants 1, 3, and 8 ranked this feature 2, 3, and 4, respectively.
显示文本的大小：用户可以指定他或她的最小和舒适的阅读大小。然后，此显示大小将用作 iMHere 模块中文本显示的所有其他配置参数的基础。总体而言，50% （3/6） 的参与者认为使用自定义文本大小很重要;参与者 1 、 3 和 8 分别对此功能进行排名 2 、 3 和 4 。

Customized theme: The feature allows the user to select his or her preferred background and text color. Although all participants reported liking this feature, 67% (4/6) participants, that is, participants 1, 4, 7, and 8, thought it to be unnecessary for improving the accessibility of the modules. These participants ranked this feature as 10, 10, 9, and 8, respectively.
自定义主题： 该功能允许用户选择他或她喜欢的背景和文本颜色。尽管所有参与者都表示喜欢此功能，但 67% （4/6） 的参与者，即参与者 1、4、7 和 8，认为它对于提高模块的可访问性是不必要的。这些参与者将此功能分别排在 10 、 10 、 9 和 8 之间。

Customizedbutton size: The system asks the user to press his or her index finger on the screen to record his or her fingertip size. This touch size was used as the minimum target size for buttons or icons in the accessible design. Overall, 83% (5/6) participants thought this feature was important. Participants 4 and 8—notably individuals who presented with a higher degree of dexterity impairments—ranked it as the second most important accessibility feature.
自定义按钮大小：系统要求用户在屏幕上按他或她的食指以记录他或她的指尖大小。此触摸大小用作辅助设计中按钮或图标的最小目标大小。总体而言，83% （5/6） 的参与者认为此功能很重要。参与者 4 和 8 — 特别是表现出较高程度灵活性障碍的个体 — 将其列为第二重要的辅助功能。

Customized keyboard: A customized keypad with softer keys, larger key sizes, and preconfigured characters was designed to reduce the number of required touches on the smartphone screen. When using the customized keypad to enter “2 tablets,” of a medication, for instance, the users would touch “2” and “tablet.” This 2-touch entry can be contrasted with the 8-touch entry necessitated by using a traditional keypad for text entry. Overall, 67% (4/6) participants identified this feature as important for them. In particular, participant 8 (with severe dexterity impairments) ranked the customizable keyboard as the most important feature.
定制键盘：定制的键盘具有更柔软的键、更大的键尺寸和预配置的字符，旨在减少智能手机屏幕上所需的触摸次数。例如，当使用自定义键盘输入药物的“2 片”时，用户会触摸“2”和“片剂”。这种 2 点触控输入可以与使用传统键盘进行文本输入所需的 8 点触控输入形成对比。总体而言，67% （4/6） 的参与者认为此功能对他们很重要。特别是，参与者 8（有严重的灵巧性障碍）将可自定义键盘列为最重要的功能。

Ability to take a picture of a pill or bottle: This feature provides the ability for a user to take a photo of a pill or medication bottle and upload it into his or her medication schedule. With this feature, a user can “double verify” the medication is correct by comparing it with a picture before taking his or her prescribed dose. Overall, 33% (2/6) participants ranked this feature as one of the most important.
能够拍摄药丸或药瓶的照片：此功能使用户能够拍摄药丸或药瓶的照片并将其上传到他或她的服药计划中。使用此功能，用户可以在服用处方剂量之前将其与图片进行比较，从而“双重验证”药物是否正确。总体而言，33% （2/6） 的参与者将此功能列为最重要的功能之一。

Color-coding: As suggested by participants in the earlier evaluation study [15], color-coding was utilized in the new design to help a user navigate within the modules. For example, the title for the SkinCare module has been highlighted in red, and all screens under the SkinCare module now have a red bar to remind the user which module is being used (Figure 3). Participant 5 indicated that this feature was very important for him, as it provided a way to remember which module he was using. This participant ranked the color-coding feature as 3. Participants 3 and 6 thought this feature was important but might not be essential. Participant 7 thought this feature might be beneficial to users with intellectual disabilities.
颜色编码：正如早期评估研究 [15] 中的参与者所建议的那样，新设计中使用了颜色编码来帮助用户在模块中导航。例如，SkinCare 模块的标题以红色突出显示，SkinCare 模块下的所有屏幕现在都有一个红色条，提醒用户正在使用哪个模块（图 3）。参与者 5 表示此功能对他来说非常重要，因为它提供了一种记住他正在使用的模块的方法。该参与者将颜色编码特征排为 3。参与者 3 和 6 认为此功能很重要，但可能不是必需的。参与者 7 认为此功能可能对智障用户有益。

Text guidance: Text containing self-training instructional notes is displayed on the screen and highlighted in a particular color (such as orange in Figure 2). Participants 3 and 4 ranked the text guidance as a very important feature to them, ranking this feature as 2 and 3, respectively. The remainder thought the text guidance was important but not essential, providing respective rankings of 4 and 6.
文本指导：包含自我训练说明的文本显示在屏幕上，并以特定颜色突出显示（如图 2 中的橙色）。参与者 3 和 4 将文本指南列为对他们来说非常重要的功能，分别将此功能排在 2 和 3 之间。其余的人认为文本指南很重要，但不是必需的，分别提供了 4 和 6 的排名。

Voice guidance: Using text-to-speech technology, users can listen to text guidance as audio output. Participants 4, 5, 7,
语音提示：使用文本转语音技术，用户可以将文本提示作为音频输出收听。参与者 4， 5， 7，

and 8 (ie, 4/6, 67%, participants) thought this voice guidance ability was important, ranking it as 3, 1, 1, and 3, respectively.
8 人 （即 4/6,67% 参与者） 认为这种语音指导能力很重要，分别排在 3、1、1 和 3 位。

Navigational short cut: The newly designed app allows for personalization on the level of navigation. For example, the system checks the database for personalized settings first (Figure 4). If no personalized settings are found, the system will then lead the new user to set his or her preferences before going to the home screen (a list of modules). Overall, 33% (2/6) participants indicated that the ability to create shortcuts in navigation was very important to them. Participants 1 and 5 ranked this feature as 1 and 3, respectively, while participants 5 and 8 thought this feature was important but not essential, ranking it as 4 and 7, respectively.
导航快捷方式：新设计的应用程序允许在导航级别进行个性化。例如，系统首先检查数据库中的个性化设置（图 4）。如果未找到个性化设置，系统将引导新用户在进入主屏幕（模块列表）之前设置他或她的首选项。总体而言，33% （2/6） 的参与者表示，在导航中创建快捷方式的能力对他们来说非常重要。参与者 1 和 5 将此功能分别排在 1 和 3 分，而参与者 5 和 8 认为此功能很重要但不是必需的，分别排在 4 和 7 分。

Usability Study Results
可用性研究结果

Table 3 displays user effort results. Overall, user effort to complete all tasks was reduced by an average of about 25% in the redesigned modules. A lower average number of touches was needed for completing tasks with the redesigned modules (mean 7.20, SD 4.82) than with the original modules (mean 10.80, SD 8.04), but this difference was not statistically significant (t₄=2.25; P=.09).
表 3 显示了用户努力结果。总体而言，在重新设计的模块中，用户完成所有任务的工作量平均减少了约 25%。使用重新设计的模块完成任务所需的平均接触次数（平均值 7.20，SD 4.82）低于原始模块（平均值 10.80，SD 8.04），但这种差异在统计学上不显著（t₄=2.25; P=.09）。

Table 4 shows individual task time results. The average time to complete individual tasks was reduced by just over 50% in the redesigned modules. Participants spent the most time on tasks that required scheduling a medication or reporting a new skin problem. Particularly, task 3, responding to a medication alert, showed only a small improvement in completion time (7.7%).
表 4 显示了单个任务时间的结果。在重新设计的模块中，完成单个任务的平均时间减少了 50% 多一点。参与者在需要安排药物或报告新皮肤问题的任务上花费的时间最多。特别是，任务 3 响应药物警报，完成时间仅略有改善 （7.7%）。

This small increase may be attributed to the fact that this task involved only a single click on the alert screen for both the original and redesigned modules. The average time to complete individual tasks was higher using the original modules (mean 91.72, SD 81.79, seconds) than using the redesigned modules (mean 37.54, SD 36.32, seconds), but this difference was not statistically significant (
这种小幅增长可能归因于以下事实：此任务仅涉及在原始模块和重新设计的模块的警报屏幕上单击一次。使用原始模块完成单个任务的平均时间（平均值 91.72，SD 81.79，秒）高于使用重新设计的模块（平均值 37.54，SD 36.32，秒），但这种差异没有统计学意义（t₄=2.64; P=.06).

Table 5 shows the average time in seconds for each participant to complete all 5 tasks and TUQ scores. A significantly lower average time for users to complete all 5 tasks was observed with the use of the redesigned modules (mean 35.33, SD 10.83, seconds) than with the use of the original modules (mean 81.70, SD 29.51, seconds; t₅=−4.52; P=.006). Significantly higher overall average TUQ scores were observed with the use of the redesigned modules (mean 6.85, SD 0.16) than with the use of the original modules (mean 6.08, SD 0.42; t₅=4.39; P=.007).
表 5 显示了每个参与者完成所有 5 项任务和 TUQ 分数的平均时间（以秒为单位）。使用重新设计的模块（平均 35.33，SD 10.83，秒）观察到用户完成所有 5 项任务的平均时间明显低于使用原始模块（平均 81.70，SD 29.51，秒; t₅=−4.52; P=.006）。使用重新设计的模块（平均值 6.85，SD 0.16）观察到的总体平均 TUQ 分数明显高于使用原始模块（平均值 6.08，SD 0.42; t₅=4.39; P=.007）。

As shown in Table 6, the error rate using the redesigned modules (mean 0, SD 0) was significantly lower than that using the original modules (mean 8.51, SD 5.55; t₅=3.76; P=.01). In fact, no participants made errors using the redesigned modules.
如表 6 所示，使用重新设计的模块的错误率（平均值 0，SD 0）明显低于使用原始模块的错误率（平均值 8.51，SD 5.55; t₅=3.76; P=.01）。事实上，没有参与者在使用重新设计的模块时犯错误。

When comparing the average subscale scores for the 6 individual domains of the TUQ with the subscale scores in the earlier evaluation study [15], usability improved significantly from the original app (mean 5.86, SD 0.40) to the redesigned app (mean 6.80, SD 0.19; t₅=−8.81; P<.001). As shown in Figure 5, pronounced improvements were noted for the factors “ease of use and learnability,” “interface quality,” and “reliability” (>15% improvements).
将 TUQ 的 6 个单独领域的平均子量表分数与早期评估研究 [15] 中的子量表分数进行比较时，从原始应用程序（平均值 5.86，SD 0.40）到重新设计的应用程序（平均值 6.80，SD 0.19; t₅=−8.81; P<.001）。如图 5 所示，在“易用性和可学习性”、“界面质量”和“可靠性”等方面都有明显的改进（>15% 的改进）。

Table 6. Comparison of the error rates. 表 6. 错误率的比较。 P01 7.17 0.00 P03 0.00 0.00 P04 16.08 0.00 P05 5.75 0.00 P055 5.750.00 P07 10.00 0.00 P08 12.08 0.00 Average 8.51 0.00 平均8.510.00 Figure 5. Telehealth Usability Questionnaire factors, scores, and percent increase. 图 5. 远程医疗可用性问卷因素、分数和百分比增长。

Discussion
讨论

Principal Findings
主要发现

A smartphone is an ideal tool for implementing self-management programs for PwDs [27], but it does pose accessibility challenges. The size of the screen and the mobile device itself is the main obstacle to accessibility [28-30]. The small screen becomes easily cluttered when a designer wishes to fill the space with attractive text, images, and widgets [30]. This small size of the screen leads to an issue with usability [31] because it is difficult for users to read [32]. The small target or touch size, low contrast, and inappropriate text size presented on a small screen might be problematic for users with visual or dexterity problems to access [33-35]. In addition, unnecessary options and functions create difficulties for users with intellectual disabilities to understand the process, as well as to recall procedures [32].
智能手机是为残障人士实施自我管理计划的理想工具 [27]，但它确实带来了可访问性挑战。屏幕的大小和移动设备本身是可访问性的主要障碍 [28-30]。当设计师希望用有吸引力的文本、图像和小部件填充空间时，小屏幕很容易变得杂乱无章 [30]。这种小尺寸的屏幕会导致可用性问题 [31]，因为用户难以阅读 [32]。小屏幕上呈现的小目标或触摸大小、低对比度和不适当的文本大小可能会给视觉或灵巧性问题的用户带来访问问题 [33-35]。此外，不必要的选项和功能给智障用户带来了理解过程以及调用程序的困难[32]。

Some of the abovementioned accessibility issues can be mitigated with design and development of a better UI. The results of this study and our prior studies [15,16] reveal strategies important to improving accessibility of smartphone apps. These strategies are presented in Figure 6, organized according to the different stages of human information processing. The text underlined in Figure 6 indicates the accessibility strategies that are important for general users; the other text indicates important features for persons with dexterity impairments.
上述一些辅助功能问题可以通过设计和开发更好的 UI 来缓解。这项研究的结果和我们之前的研究 [15， 16] 揭示了提高智能手机应用程序可访问性的重要策略。这些策略如图 6 所示，根据人类信息处理的不同阶段进行组织。图 6 中带下划线的文本 表示对一般用户很重要的可访问性策略;另一个文本表示对灵巧性障碍者的重要功能。

Some features such as the customized app list, reading size, theme, and button size made the system simpler and more conducive to personal use. Particularly, the small target size of icons or buttons presented a problem for users with dexterity impairments due to the decreased strength and sensation in their fingers.
自定义应用程序列表、阅读大小、主题和按钮大小等一些功能使系统更简单，更有利于个人使用。特别是，图标或按钮的目标尺寸较小，由于手指的力量和感觉下降，给灵巧性障碍的用户带来了问题。

The redesign implemented in this study was based on the findings that the size of buttons has a significant impact on usability. Chen et al found that users without disabilities plateaued with a minimal button size of 20 mm and users with disabilities plateaued at 30 mm [36]. Colle and Hiszem found that 20 mm² buttons resulted in optimal user performance for younger participants [37], while Jin et al suggested a button size of 19.05 mm for elderly users [38]. Monterey Technologies Inc recommends the button size to be at least 19.05 mm [39]. In addition, Apple recommends a minimum target size of 44 pixels wide and 44 pixels long (by 11.64 mm) [40]. Notably, all these prior studies assumed a fixed button size.
本研究中实施的重新设计是基于按钮大小对可用性有重大影响的发现。Chen 等人发现，非残疾用户的最小按钮尺寸稳定在 20 毫米，而残疾用户稳定在 30 毫米 [36]。Colle 和 Hiszem 发现，20 mm² 的按钮为年轻参与者带来了最佳的用户性能 [37]，而 Jin 等人建议老年用户使用 19.05 mm 的按钮尺寸 [38]。Monterey Technologies Inc 建议按钮尺寸至少为 19.05 毫米 [39]。此外，Apple 建议的最小目标尺寸为 44 像素宽和 44 像素长（x 11.64 毫米）[40]。值得注意的是，所有这些先前的研究都假设了固定的按钮大小。

We introduced the ability to measure the finger or touch size of a user via the smartphone as well as the ability to leverage that measurement toward creating an optimum target button or icon size. This feature is especially beneficial for users with a higher degree of dexterity impairment.
我们引入了通过智能手机测量用户手指或触摸大小的功能，以及利用该测量来创建最佳目标按钮或图标大小的功能。此功能对灵巧程度较高的用户特别有益。

In addition to the abovementioned features, participants also found the following strategies implemented in the redesigned apps to be helpful:
除了上述功能外，参与者还发现在重新设计的应用程序中实施的以下策略很有帮助：

Multiple-choice questions in place of text entry: All participants found that making a selection was easier than entering long lines of text. Text entry, however, should always be an option in the list; if a user selects “other” he or she can then operate the text function and answer the given prompt in more detail.
用多项选择题代替文本输入：所有参与者都发现，进行选择比输入长行文本更容易。但是，文本输入应始终是列表中的一个选项;如果用户选择 “其他”，则他或她可以作文本功能并更详细地回答给定的提示。

The volume button has been appropriated as the camera button: Except for participant 8, who was unable to hold a smartphone, all other participants liked being able to use the volume control button to take a picture, especially when taking photographs of a skin wound located in a difficult to reach area.
音量按钮已被用作相机按钮：除了参与者 8 无法手持智能手机外，所有其他参与者都喜欢能够使用音量控制按钮拍照，尤其是在拍摄位于难以触及区域的皮肤伤口时。

A self-directed questionnaire has been utilized to simplify the cognitive procedures of tasks: Compared with the regular format, the redesigned modules show only one question at a time. The system automatically proceeds to the next question after a user makes a selection. In this study, 4 of 6 participants indicated that the process flow in the self-directed questionnaire was easier to understand and follow as a result of offering more guidance and fewer functions per screen.
自我指导的问卷已被用于简化任务的认知程序：与常规格式相比，重新设计的模块一次只显示一个问题。用户做出选择后，系统会自动继续下一个问题。在这项研究中，4 名参与者中有 6 名表示，由于提供更多指导和每个屏幕的功能更少，自主问卷中的流程更容易理解和遵循。

Most notably, the average time to complete tasks in this study was reduced by about 60% in the redesigned modules. Usability of the redesigned apps as measured by TUQ showed a significant increase. Pronounced improvements were particularly noted for the factors “ease of use and learnability,” “interface quality,” and “reliability.” Finally, the redesigned modules were able to eliminate all errors that occurred during use of the original modules.
最值得注意的是，在重新设计的模块中，完成本研究中任务的平均时间减少了约 60%。通过 TUQ 衡量的重新设计的应用程序的可用性显示出显着提高。特别值得注意的是，在“易用性和可学习性”、“界面质量”和“可靠性”等方面的改进。最后，重新设计的模块能够消除使用原始模块期间发生的所有错误。

A surprising finding of this study was the degree of dexterity impairment identified in participants with SB. All participants had spinal lesion levels in the low thoracic or lumbosacral areas, which means that there was no paralysis of the arms or hands. Impairments in fine motor control in SB are thought to be due to the abnormal organization of the cerebral cortex [41,42]. All participants with SB, however, had pronounced impairments in dexterity, measured as >2 SDs below normative values. Little is known about the extent of fine motor control problems in SB and how it affects the use of mHealth technologies.
这项研究的一个令人惊讶的发现是在 SB 参与者中发现的灵巧度受损程度。所有参与者的下胸或腰骶区域的脊柱病变水平，这意味着手臂或手没有麻痹。SB 的精细运动控制障碍被认为是由于大脑皮层组织异常 [41， 42]。然而，所有患有 SB 的参与者都有明显的灵巧性障碍，测量为低于正常值的 >2 SD s。关于 SB 中精细运动控制问题的程度以及它如何影响移动医疗技术的使用，人们知之甚少。

Limitations and Future Studies
局限性和未来研究

Only a limited number of participants were involved in this study of the redesigned iMHere modules. The development and usability study follow the iterative design [43], which consists of a cycle process of prototyping, testing, analyzing, and refining a system. This study is at the later stage of the iterative cycle that follows previous studies [15,16]. By limiting the evaluation to participants from the earlier studies, we were able to probe deeper into the usability of the fundamental structure of the mHealth apps and to find majority of the usability problems [43].
只有有限数量的参与者参与了这项重新设计的 iMHere 模块的研究。开发和可用性研究遵循迭代设计 [43]，它包括原型设计、测试、分析和完善系统的循环过程。这项研究处于先前研究之后的迭代周期的后期阶段 [15， 16]。通过将评估限制在早期研究的参与者中，我们能够更深入地探索移动医疗应用程序基本结构的可用性，并发现大多数可用性问题 [43]。

The results of this study should be viewed with the nature of participants’ impairments in mind. The next study should include more participants with varying levels of dexterity impairments— as well as a wider range in the diagnoses underlying these impairments—to better assess the overall acceptance and preference of the redesigned modules. In addition, more studies into the various degrees of dexterity impairments in individuals with SB, and the effect(s) of these impairments on the use of mHealth technologies, are warranted. Furthermore, future studies are warranted on the usability of the iMHere clinician portal and caregiver app—work that is conducted in parallel with studies performed on the patient app.
应牢记参与者损伤的性质来看待本研究的结果。下一项研究应包括更多具有不同灵巧性障碍程度的参与者——以及这些障碍背后的诊断范围更广——以更好地评估重新设计的模块的整体接受度和偏好。此外，有必要对 SB 个体不同程度的灵活性障碍以及这些障碍对移动健康技术使用的影响进行更多研究。此外，未来需要对 iMHere 临床医生门户和护理人员应用程序的可用性进行研究——这项工作与在患者应用程序上进行的研究同时进行。

Conclusion
结论

The accessibility standards and guidelines such as the Web Content Accessibility Guidelines 1.0 [44] and 2.0 [45] are mainly aimed at improving the general accessibility of the Web, not specifically of smartphone apps. The cross-platform technology for developing smartphone apps, which is based on Web technology, is increasingly popular. We plan to implement the strategies and accessibility principles in this study to the cross-platform app development environments that is based on Web technology in our future studies.
可访问性标准和指南，如 Web 内容可访问性指南 1.0 [44] 和 2.0 [45] 主要旨在提高 Web 的一般可访问性，而不是专门针对智能手机应用程序的可访问性。基于 Web 技术开发智能手机应用程序的跨平台技术越来越受欢迎。我们计划在未来的研究中将本研究中的策略和可访问性原则实施到基于 Web 技术的跨平台应用程序开发环境中。

This study proposes a design and developmental model to approach accessibility through two primary elements of UI: physical presentation and navigation. A usability study showed that the effectiveness and efficiency of, and user satisfaction with, the redesigned modules significantly improved after implementing accessibility strategies into the UI design. As the results suggested, the meaningful presentation and navigation flow also helped us achieve a smoother activity flow during task completion. By extending the concept of personalization to navigation and task flow, the efficiency of users’ performance could be significantly improved.
本研究提出了一种设计和开发模型，通过 UI 的两个主要元素（物理表示和导航）来实现可访问性。一项可用性研究表明，在 UI 设计中实施辅助功能策略后，重新设计的模块的有效性、效率和用户满意度显著提高。正如结果所示，有意义的演示和导航流程还帮助我们在任务完成期间实现了更顺畅的活动流程。通过将个性化的概念扩展到导航和任务流，可以显著提高用户的性能效率。

The aforementioned accessibility strategies and features could be used for other developers to design and develop smartphone apps. This paper focuses on the general principles of accessible mHealth design. Most of the UI elements can be implemented as an accessibility personalization setting of an mHealth app. We plan to implement accessibility personalization feature in our future mHealth developments.
上述辅助功能策略和功能可供其他开发人员设计和开发智能手机应用程序。本文重点介绍无障碍 mHealth 设计的一般原则。大多数 UI 元素都可以作为 mHealth 应用程序的辅助功能个性化设置实现。我们计划在未来的 mHealth 开发中实施无障碍个性化功能。

Acknowledgments
确认

This research was supported in part by the National Institute on Disability, Independent Living, and Rehabilitation Research grant #90RE5018 (Rehabilitation Engineering Research Center From Cloud to Smartphone: Empowering and Accessible Information and Communication Technologies and grant #90DP0064 Disability and Rehabilitation Research Project Promoting Independence & Self-management using mHealth), by the National Institutes of Health grant #1R21HD071810, and by a grant from the Craig H. Neilsen Foundation.
这项研究部分得到了国家残疾、独立生活和康复研究所资助 #90RE5018（从云端到智能手机的康复工程研究中心：赋权和可访问的信息和通信技术，以及 #90DP0064 残疾和康复研究项目促进独立和自我管理使用移动健康）、美国国立卫生研究院资助 #1R21HD071810 和Craig H的资助。 尼尔森基金会。

Conflicts of Interest
利益冲突

DY, BP, and BD are inventors of the iMHere mHealth system.
DY、BP 和 BD 是 iMHere 移动医疗系统的发明者。

References
引用

Cipresso P, Serino S, Villani D, Repetto C, Albani G, Mauro A, et al. Is your phone so smart to affect your state? An exploratory study based on psychophysiological measures. Neurocomputing 2012 May 01;84:23-30 [FREE Full text] [Medline: 25904163]
Cipresso P、Serino S、Villani D、Repetto C、Albani G、Mauro A 等人。您的手机是否如此智能，以至于会影响您的状态？一项基于心理生理学测量的探索性研究。神经计算 2012 年 5 月 1 日;84：23-30 [免费全文] [Medline： 25904163]

UN Foundation-Vodafone Foundation. 2009. mHealth for Development: The Opportunity of Mobile Technology for Healthcare in the Developing World URL: http://www.globalproblems-globalsolutions-files.org/unf_website/assets/ publications/technology/mhealth/mHealth_for_Development_full.pdf[accessed 2018-11-15] [WebCite Cache ID 73xljThEz]
联合国基金会-沃达丰基金会。2009. 移动医疗促进发展：移动技术在发展中国家医疗保健的机遇 URL：http://www.globalproblems-globalsolutions-files.org/unf_website/assets/ publications/technology/mhealth/mHealth_for_Development_full.pdf[访问时间 2018-11-15] [WebCite 缓存 ID 73xljThEz]

Kosaraju A, Barrigan CR, Poropatich RK, Casscells SW. Use of mobile phones as a tool for United States health diplomacy abroad. Telemed J E Health 2010 Mar;16(2):218-222. [doi: 10.1089/tmj.2009.0095] [Medline: 20156128]
Kosaraju A， Barrigan CR， Poropatich RK， Casscells SW. 使用手机作为美国海外卫生外交的工具。Telemed J E Health 2010 年 3 月;16(2):218-222.[doi： 10.1089/tmj.2009.0095] [医疗热线：20156128]

Asangansi I, Braa K. The emergence of mobile-supported national health information systems in developing countries. Stud Health Technol Inform 2010;160(Pt 1):540-544. [Medline: 20841745]
Asangansi I， Braa K.发展中国家出现移动支持的国家卫生信息系统。Stud Health Technol Inform 2010 年;160（第 1 部分）：540-544。[Medline： 20841745]

Boyer EW, Smelson D, Fletcher R, Ziedonis D, Picard RW. Wireless Technologies, Ubiquitous Computing and Mobile Health: Application to Drug Abuse Treatment and Compliance with HIV Therapies. J Med Toxicol 2010 Jun;6(2):212-216 [FREE Full text] [doi: 10.1007/s13181-010-0080-z] [Medline: 20623215]
博耶 EW、斯梅尔森 D、弗莱彻 R、齐多尼斯 D、皮卡德 RW。无线技术、无处不在的计算和移动健康：药物滥用治疗和 HIV 疗法依从性的应用。J Med Toxicol 2010 年 6 月;6（2）：212-216 [免费全文] [doi： 10.1007/s13181-010-0080-z] [Medline： 20623215]

Han D, Lee M, Park S. THE-MUSS: Mobile u-health service system. Comput Methods Programs Biomed 2010 Feb;97(2):178-188. [doi: 10.1016/j.cmpb.2009.08.004] [Medline: 19762108]
Han D， Lee M， Park S. THE-MUSS：移动 u-health 服务系统。计算方法程序 Biomed 2010 年 2 月;97(2):178-188.[doi： 10.1016/j.cmpb.2009.08.004] [Medline： 19762108]

Hays R, Kraft G, Stolov W. Chronic Disease and Disability : A Contemporary Rehabilitation Approach to the Practice of Medicine. New York: Demos Medical Publishing; 1994.
Hays R， Kraft G， Stolov W. 慢性病和残疾：医学实践的当代康复方法。纽约：Demos Medical Publishing;1994.

Lorig KR, Holman H. Self-management education: history, definition, outcomes, and mechanisms. Ann Behav Med 2003 Aug;26(1):1-7. [doi: 10.1207/S15324796ABM2601_01] [Medline: 12867348]
Lorig KR， Holman H. 自我管理教育：历史、定义、结果和机制。Ann Behav Med 2003 年 8 月;26(1):1-7.[doi： 10.1207/S15324796ABM2601_01] [Medline： 12867348]

Clark NM. Management of chronic disease by patients. Annual Review Public Health 2003;24:289-313. [doi:
克拉克 NM。患者对慢性病的管理。公共卫生年鉴 2003;24：289-313。[doi：

10.1146/annurev.publhealth.24.100901.141021] [Medline: 12415147]
10.1146/annurev.publhealth.24.100901.141021] [医疗热线：12415147]

Fairman AD, Dicianno BE, Datt N, Garver A, Parmanto B, McCue M. Outcomes of Clinicians, Caregivers, Family Members and Adults with Spina Bifida Regarding Receptivity to use of the iMHere mHealth Solution to Promote Wellness. Int J Telerehabil 2013;5(1):3-16 [FREE Full text] [doi: 10.5195/ijt.2013.6116] [Medline: 25945209]
Fairman AD， Dicianno BE， Datt N， Garver A， Parmanto B， McCue M. 脊柱裂临床医生、护理人员、家庭成员和成人脊柱裂患者对使用 iMHere 移动健康解决方案促进健康的接受度的结果。国际康复杂志 2013;5（1）：3-16 [免费全文] [doi： 10.5195/ijt.2013.6116] [Medline： 25945209]

National Institute of Health. 2018 Jul 06. Spina Bifida Fact Sheet URL: https://www.ninds.nih.gov/Disorders/ Patient-Caregiver-Education/Fact-Sheets/Spina-Bifida-Fact-Sheet [WebCite Cache ID 6fWLfUlKb]
美国国立卫生研究院。2018 年 7 月 6 日。脊柱裂情况说明书 URL：https://www.ninds.nih.gov/Disorders/ Patient-caregiver-education/Fact-sheets/Spina-Bifida-Fact-Sheet[WebCite Cache ID 6fWLfUlKb]

National Spinal Cord Injury Statistical Center (NSCISC). 2015. Spinal Cord Injury (SCI) Facts and Figures at a Glance URL: https://www.nscisc.uab.edu/Public/Facts%202015%20Aug.pdf[accessed 2016-02-23] [WebCite Cache ID 6fWMQja9n]
国家脊髓损伤统计中心 （NSCISC）。2015. 脊髓损伤 （SCI） 事实和数据一览 URL：https://www.nscisc.uab.edu/Public/Facts%202015%20Aug.pdf[访问时间 2016-02-23] [WebCite 缓存 ID 6fWMQja9n]

Dicianno BE, Kurowski BG, Yang JMJ, Chancellor MB, Bejjani GK, Fairman AD, et al. Rehabilitation and medical management of the adult with spina bifida. Am J Phys Med Rehabil 2008 Dec;87(12):1027-1050. [doi:
Dicianno BE、Kurowski BG、Yang JMJ、校长 MB、Bejjani GK、Fairman AD 等。成人脊柱裂的康复和医疗管理。Am J Phys Med Rehabil 2008 年 12 月;87(12):1027-1050.[doi：

10.1097/PHM.0b013e31818de070] [Medline: 18923330]
10.1097/PHM.0b013e31818de070] [Medline： 18923330]

Parmanto B, Pramana G, Yu DX, Fairman AD, Dicianno BE, McCue MP. iMHere: A Novel mHealth System for Supporting Self-Care in Management of Complex and Chronic Conditions. JMIR Mhealth Uhealth 2013 Jul 11;1(2):e10 [FREE Full text] [doi: 10.2196/mhealth.2391] [Medline: 25100682]
Parmanto B、Pramana G、Yu DX、Fairman AD、Dicianno BE、McCue MP。iMHere：一种新型移动医疗系统，用于支持自我保健以管理复杂和慢性疾病。JMIR Mhealth Uhealth 2013 年 7 月 11 日;1（2）：e10 [免费全文] [doi： 10.2196/mhealth.2391] [Medline： 25100682]

Yu DX, Parmanto B, Dicianno BE, Watzlaf VJ, Seelman KD. Accessibility needs and challenges of a mHealth system for patients with dexterity impairments. Disability and Rehabilitation Assistive Technology 2017 Dec;12(1):56-64. [doi:
Yu DX、Parmanto B、Dicianno BE、Watzlaf VJ、Seelman KD。移动医疗系统对行动不便患者的可访问性需求和挑战。残疾与康复辅助技术 2017 年 12 月;12(1):56-64.[doi：

10.3109/17483107.2015.1063171] [Medline: 26153097]
10.3109/17483107.2015.1063171] [Medline： 26153097]

Yu DX, Parmanto B, Dicianno BE, Pramana G. Accessibility of mHealth Self-Care Apps for Individuals with Spina Bifida. Perspectives in Health Information Management 2015;12:1-19 [FREE Full text] [Medline: 26755902]
Yu DX、Parmanto B、Dicianno BE、Pramana G. 脊柱裂患者移动健康自我保健应用程序的可访问性。健康信息管理观点 2015;12：1-19 [免费全文] [Medline： 26755902]

Adams PF, Martinez ME, Vickerie JL. Summary health statistics for the U.S. population: National Health Interview Survey, 2009. Vital Health Stat 10 2010 Dec(248):1-115 [FREE Full text] [Medline: 21696068]
亚当斯 PF，马丁内斯 ME，维克里 JL。美国人口健康统计摘要：全国健康访谈调查，2009 年。Vital Health Stat 10 2010 年 12 月（248）：1-115 [免费全文] [Medline： 21696068]

Desrosiers J, Hébert R, Bravo G, Dutil E. The Purdue Pegboard Test: normative data for people aged 60 and over. Disabil Rehabil 1995 Jul;17(5):217-224. [Medline: 7626768]
Desrosiers J， Hébert R， Bravo G， Dutil E.普渡钉板测试：60 岁及以上人群的规范数据。Disabil Rehabil 1995 年 7 月;17(5):217-224.[Medline： 7626768]

Ozçelik IB, Purisa H, Sezer I, Mersa B, Kabakaş F, Tuncer S, et al. [Evaluation of long-term results in mutilating hand injuries]. Ulus Travma Acil Cerrahi Derg 2009 Mar;15(2):164-170 [FREE Full text] [Medline: 19353320]
Ozçelik IB， Purisa H， Sezer I， Mersa B， Kabakaş F， Tuncer S， et al. [残缺性手损伤长期结果的评估]。Ulus travma acil Cerrahi Derg 2009 年 3 月;15（2）：164-170 [免费全文] [Medline： 19353320]

Delp HL, Newton RA. Effects of brief cold exposure on finger dexterity and sensibility in subjects with Raynaud's phenomenon. Phys Ther 1986 Apr;66(4):503-507. [Medline: 3960975]
Delp HL，牛顿 RA。短暂的寒冷暴露对雷诺现象受试者手指灵活性和敏感性的影响。Phys Ther 1986 年 4 月;66(4):503-507.[Medline： 3960975]

Wilson BC, Iacoviello JM, Wilson JJ, Risucci D. Purdue Pegboard performance of normal preschool children. J Clin Neuropsychol 1982 May;4(1):19-26. [Medline: 7096583]
Wilson BC、Iacoviello JM、Wilson JJ、Risucci D. Purdue 正常学龄前儿童的钉板表现。J Clin Neuropsychol 1982 年 5 月;4(1):19-26.[Medline： 7096583]

Smoot B, Wong J, Cooper B, Wanek L, Topp K, Byl N, et al. Upper extremity impairments in women with or without lymphedema following breast cancer treatment. J Cancer Surviv 2010 Jun;4(2):167-178 [FREE Full text] [doi:
Smoot B， Wong J， Cooper B， Wanek L， Topp K， Byl N， et al. 乳腺癌治疗后患有或不患有淋巴水肿的女性的上肢损伤。J Cancer Surviv 2010 年 6 月;4（2）：167-178 [免费全文] [doi：

10.1007/s11764-010-0118-x] [Medline: 20373044]
10.1007/s11764-010-0118-x] [Medline： 20373044]

Lewis C. Using the“ thinking-aloud” method in Cognitive Interface Design (Technical Report). IBM TJ Watson Research Center 1982.
Lewis C. 在认知界面设计中使用“发声思考”方法（技术报告）。IBM TJ Watson 研究中心 1982 年。

Parmanto B, Saptono A, Pramana G, Pulantara W, Schein RM, Schmeler MR, et al. VISYTER: versatile and integrated system for telerehabilitation. Telemed J E Health 2010 Nov;16(9):939-944. [doi: 10.1089/tmj.2010.0033] [Medline: 21034239]
Parmanto B、Saptono A、Pramana G、Pulantara W、Schein RM、Schmeler MR 等人。VISYTER：用于远程康复的多功能集成系统。Telemed J E Health 2010 年 11 月;16(9):939-944.[doi： 10.1089/tmj.2010.0033] [医疗热线：21034239]

Schutte J, Gales S, Filippone A, Saptono A, Parmanto B, McCue M. Evaluation of a telerehabilitation system for community-based rehabilitation. Int J Telerehabil 2012;4(1):15-24 [FREE Full text] [doi: 10.5195/ijt.2012.6092] [Medline: 25945193]
Schutte J， Gales S， Filippone A， Saptono A， Parmanto B， McCue M. 社区康复远程康复系统的评估。国际康复杂志 2012;4（1）：15-24 [免费全文] [doi： 10.5195/ijt.2012.6092] [Medline： 25945193]

Lafayette Instrument Evaluation. 2002. Purdue Pegboard Test URL: http://lafayetteevaluation.com/products/purdue-pegboard [accessed 2018-01-25] [WebCite Cache ID 6wk8LNNPu]
Lafayette Instrument 评估。2002. 普渡钉板测试 URL：http://lafayetteevaluation.com/products/purdue-pegboard [2018-01-25 访问] [WebCite 缓存 ID 6wk8LNNPu]

Holman H. Chronic disease--the need for a new clinical education. JAMA 2004 Sep 01;292(9):1057-1059. [doi:
Holman H. 慢性病--需要新的临床教育。美国医学会 2004 年 9 月 1 日;292(9):1057-1059.[doi：

10.1001/jama.292.9.1057] [Medline: 15339897]
10.1001/jama.292.9.1057] [Medline： 15339897]

Brewster S, Cryer PG. Maximising screen-space on mobile computing devices. In: CHI'99 extended abstracts on Human factors in computing systems. New York: ACM; 1999:224-225.
Brewster S， Cryer PG. 最大化移动计算设备上的屏幕空间。在：CHI'99 扩展了关于计算系统中的人为因素的摘要。纽约：ACM;1999:224-225.

Brewster S. The design of sonically-enhanced widgets. Interacting with Computers 1998 Dec 1;11(2):211-235. [doi:
布鲁斯特 S.声音增强的小部件的设计。与计算机交互 1998 年 12 月 1 日;11(2):211-235.[doi：

10.1016/S0953-5438(98)00028-9]
10.1016/S0953-5438（98）00028-9]

Brewster S. Overcoming the Lack of Screen Space on Mobile Computers. Personal and Ubiquitous Computing 2002 May 1;6(3):188-205. [doi: 10.1007/s007790200019] [Medline: 26811110]
布鲁斯特 S. 克服移动计算机上屏幕空间不足的问题。个人和无处不在的计算 2002 年 5 月 1 日;6(3):188-205.[doi： 10.1007/s007790200019] [Medline： 26811110]

O’Neill E, Kaenampornpan M, Kostakos V, Warr A, Woodgate D. Can we do without GUIs? Gesture and speech interaction with a patient information system. Pers Ubiquit Comput 2005 Nov 10;10(5):269-283. [doi: 10.1007/s00779-005-0048-1]
O'Neill E， Kaenampornpan M， Kostakos V， Warr A， Woodgate D.我们可以没有 GUI 吗？与患者信息系统的手势和语音交互。Pers Ubiquit Comput 2005 年 11 月 10 日;10(5):269-283.[doi： 10.1007/s00779-005-0048-1]

Kurniawan S, Mahmud M, Nugroho Y. A study of the use of mobile phones by older persons. In: CHI '06 Extended Abstracts on Human Factors in Computing Systems. Montreal, Quebec, Canada: ACM; Apr 22, 2006.
Kurniawan S、Mahmud M、Nugroho Y。一项关于老年人使用移动电话的研究。收录于：CHI '06 关于计算系统中人为因素的扩展摘要。加拿大魁北克省蒙特利尔市：ACM;2006 年 4 月 22 日。

Abascal J, Civit A. A Mobile Communication for Older People: New Opportunities for Autonomous Life. The 6th ERCIM Workshop 2000;27:57-66.
阿巴斯卡尔 J，西维特 A。老年人的移动通信：自主生活的新机遇。第 6 届 ERCIM 研讨会 2000;27：57-66。

Kane SK, Bigham JP, Wobbrock JO. Slide Rule: Making mobile touch screens accessible to blind people using multi-touch interaction techniques. New York: ACM; 2008 Presented at: Proceedings of the 10th International ACM SIGACCESS Conference on Computers and Accessibility; October 13-15, 2008; Halifax, Nova Scotia, Canada p. 73-80. [doi:
凯恩 SK、比格姆 JP、沃布洛克 JO。计算尺：使用多点触控交互技术，让盲人能够使用移动触摸屏。纽约：ACM;2008 年发表于：第 10 届国际 ACM SIGACCESS 计算机和可访问性会议论文集;2008 年 10 月 13 日至 15 日;加拿大新斯科舍省哈利法克斯，第 73-80 页。[doi：

10.1145/1414471.1414487]

Kane SK, Jayant C, Wobbrock JO, Ladner RE. Freedom to roam: a study of mobile device adoption and accessibility for people with visual and motor disabikities. 2009 Oct 25 Presented at: Proceedings of the 11th international ACM SIGACCESS conference on Computers and accessibility; October 25-28, 2009; Pittsburgh, PA. [doi: 10.1145/1639642.1639663]
凯恩 SK、贾扬特 C、沃布洛克 JO、拉德纳 RE。自由漫游：视力和运动障碍人士的移动设备采用率和可访问性研究。2009 年 10 月 25 日 发表于：第 11 届国际 ACM SIGACCESS 计算机和可访问性会议论文集;2009 年 10 月 25 日至 28 日;宾夕法尼亚州匹兹堡。[doi： 10.1145/1639642.1639663]

Chen KB, Savage AB, Chourasia AO, Wiegmann DA, Sesto ME. Touch screen performance by individuals with and without motor control disabilities. Appl Ergon 2013 Mar;44(2):297-302 [FREE Full text] [doi: 10.1016/j.apergo.2012.08.004] [Medline: 23021630]
Chen KB， Savage AB， Chourasia AO， Wiegmann DA， Sesto ME.有和没有运动控制障碍的人的触摸屏性能。Appl Ergon 2013 年 3 月;44（2）：297-302 [免费全文] [doi： 10.1016/j.apergo.2012.08.004] [Medline： 23021630]

Colle H, Hiszem K. Standing at a kiosk: effects of key size and spacing on touch screen numeric keypad performance and user preference. Ergonomics 2004 Oct 22;47(13):1406-1423. [doi: 10.1080/00140130410001724228] [Medline: 15513716]
Colle H， Hiszem K. 站在自助服务终端上：按键大小和间距对触摸屏数字键盘性能和用户偏好的影响。人体工程学 2004 年 10 月 22 日;47(13):1406-1423.[doi： 10.1080/00140130410001724228] [Medline： 15513716]

Jin ZX, Plocher T, Kiff L. Touuch screen user interfaces for older adults: button size and spacing. In: Universal Access in Human Computer Interaction Coping with Diversity. New York: Springer; 2007:933-941.
Jin ZX、Plocher T、Kiff L. Touuch 老年人屏幕用户界面：按钮大小和间距。在：人机交互中的普遍访问应对多样性。纽约：施普林格;2007:933-941.

Monterey TINC. Resource Guide for Accessible Design of Consumer Electronics. Washington, DC 1996:1996.
蒙特雷锡厂消费电子产品无障碍设计资源指南。华盛顿特区 1996：1996。

Apple Developer. 2014. Human Interface Guidelines URL: https://developer.apple.com/ios/human-interface-guidelines/ overview/themes/ [accessed 2018-01-29] [WebCite Cache ID 6wpH6oU4h]
Apple 开发人员。2014. 人机界面指南 URL：https://developer.apple.com/ios/human-interface-guidelines/ overview/themes/[2018 年 1 月 29 日访问] [WebCite 缓存 ID 6wpH6oU4h]

Treble A, Juranek J, Stuebing KK, Dennis M, Fletcher JM. Functional significance of atypical cortical organization in spina bifida myelomeningocele: relations of cortical thickness and gyrification with IQ and fine motor dexterity. Cereb Cortex
高音 A、Juranek J、Stuebing KK、Dennis M、Fletcher JM。脊柱裂脊髓脊膜膨出非典型皮质组织的功能意义：皮质厚度和回旋化与 IQ 和精细运动灵活性的关系。大脑皮层

2013 Oct;23(10):2357-2369 [FREE Full text] [doi: 10.1093/cercor/bhs226] [Medline: 22875857]
2013 年 10 月;23（10）：2357-2369 [免费全文] [doi： 10.1093/cercor/bhs226] [Medline： 22875857]

Ware AL, Kulesz PA, Williams VJ, Juranek J, Cirino PT, Fletcher JM. Gray matter integrity within regions of the dorsolateral prefrontal cortical-subcortical network predicts executive function and fine motor dexterity in spina bifida. Neuropsychology 2016 Dec;30(4):492-501 [FREE Full text] [doi: 10.1037/neu0000266] [Medline: 26752120]
Ware AL、Kulesz PA、Williams VJ、Juranek J、Cirino PT、Fletcher JM。背外侧前额叶皮质-皮质下网络区域内的灰质完整性可预测脊柱裂的执行功能和精细运动灵活性。神经心理学 2016 年 12 月;30（4）：492-501 [免费全文] [doi： 10.1037/neu0000266] [Medline： 26752120]

Nielsen J. Nielsen Norman Group. 2018 Jun 19. Why You Only Need to Test with 5 Users URL: https://www.nngroup.com/ articles/why-you-only-need-to-test-with-5-users/ [accessed 2018-06-19] [WebCite Cache ID 70IT9rNx5]
尼尔森 J. 尼尔森诺曼集团。2018 年 6 月 19 日。为什么只需要使用 5 个用户进行测试 URL：https://www.nngroup.com/ 篇文章/why-you-only-need-to-test-with-5-users/[访问时间 2018-06-19] [WebCite 缓存 ID 70IT9rNx5]

Chisholm W, Vanderheiden G, Jacobs I. World Wide Web Consortium (W3C). 1999 May 05. Web Content Accessibility Guidelines 1.0 URL: https://www.w3.org/TR/1999/WAI-WEBCONTENT-19990505/ [accessed 2018-06-19] [WebCite Cache ID 70ITS4tgg]
Chisholm W， Vanderheiden G， Jacobs I. 万维网联盟 （W3C）。1999 年 5 月 5 日。Web 内容可访问性指南 1.0 URL：https://www.w3.org/TR/1999/WAI-WEBCONTENT-19990505/[2018 年 6 月 19 日访问] [WebCite 缓存 ID 70ITS4tgg]

Caldwell B, Cooper M, Reid LG, Vanderheiden G. World Wide Web Consortium (W3C). 2008 Dec 11. Web Content Accessibility Guidelines (WCAG) 2.0 URL: https://www.w3.org/TR/WCAG20/ [accessed 2018-06-19] [WebCite Cache ID 70ITgsLeA]
Caldwell B， Cooper M， Reid LG， Vanderheiden G. 万维网联盟 （W3C）。2008 年 12 月 11 日。Web 内容可访问性指南 （WCAG） 2.0 URL：https://www.w3.org/TR/WCAG20/[2018-06-19 访问] [WebCite 缓存 ID 70ITgsLeA]

Abbreviations
缩写

iMHere: interactive mobile health and rehabilitation
iMHere：交互式移动健康和康复

mHealth: mobile health
mHealth：移动医疗

PwDs: persons with disabilities
残疾人士：残疾人士

SB: spina bifida
SB： 脊柱裂

SCI: spinal cord injuries
SCI：脊髓损伤

TUQ: Telehealth Usability Questionnaire
TUQ：远程医疗可用性问卷

UI: user interface
UI：用户界面

©Daihua Yu, Bambang Parmanto, Brad Dicianno. Originally published in JMIR Mhealth and Uhealth (http://mhealth.jmir.org), 08.01.2019. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), 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 http://mhealth.jmir.org/, as well as this copyright and license information must be included.
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