Breastfeeding is essential for children to have a healthy and regular development. The American Association of Pediatrics advises women to breastfeed exclusively for the first six months of the child’s life [1]. Internationally, the World Health Organization also recommends that infants should be exclusively breastfed for the first six months of life, to achieve optimal growth, development, and health [2]. Breast milk provides the best nutritional source for the healthy growth and development of children and it is protective against a variety of diseases [3,4]. Rates of breastfeeding continue below the goals proposed by Healthy People 2020 [5,6].

Among rural women, breastfeeding outcomes seem to be worst compared to women living in urban areas [7]. Research has shown that breastfeeding practices depend on a multitude of factors including knowledge and perception of breastfeeding, socioeconomic status, cultural background, and family relationships [8,9]. Lower prevalence of breastfeeding initiation has been observed among Hispanics living in western states compared to non-Hispanic whites [10]. Many challenges exist to improve breastfeeding practices. Family and friends may provide inaccurate information about breastfeeding, and mothers often perceive social disapproval [11]. Information presented should be tailored, culturally appropriate, and relevant to improve breastfeeding related knowledge, change behaviors, and practices related to breastfeeding initiation and duration [12].

Computer technology can be effectively used to educate patients and improve knowledge and attitudes, leading to healthier behavior [13]. Prior research has shown successful interventions that facilitate behavior modification and health promotion through use of Information and Communication Technologies (ICT) [14]. Health information tailored through use of ICT has proven to be more effective and efficient [15-17]. Computer-based tailoring is a process of creating individualized communication and is an assessment-based approach in which individuals provide personal data related to a given health outcome [18]. Those data are then used to determine the most appropriate information or strategies to meet each individual’s unique need. An important theoretical basis for tailoring comes from the Elaboration Likelihood Model [19], which states that people are more likely to actively and thoughtfully process information if they perceive it to be personally relevant. Messages processed in this way tend to be retained for a longer period of time and are more likely to lead to permanent attitudinal change.

Usability testing is a key component of product evaluation, and focuses on measuring a product’s ability to meet its intended purpose by providing evidence on how real users interact with it [20]. Additional methods of usability testing include expert evaluators to be able to identify problems and determine whether the user conforms to established usability principles in a heuristic evaluation. Expert evaluation can identify errors in a systematic process, and accurately diagnose them within the system design [21]. Usability problems are important to be evaluated such as: (1) revision of instructions and functionality, (2) better introductory instructions, (3) elimination of instructional messages, and (4) simplified representation and improved labeling [21]. Several interactive health care applications often have been hampered by their poor design, making these systems difficult to learn and complicated to use [22]. The systems designed without taking into account the target users can result in poor adoption of these systems. Tailoring the design of the systems helps meet the specific needs of the users and results in increased productivity, reduced errors, reduced need of user training and user support, and improved acceptance [22]. This will allow the users to operate the system effectively rather than struggling with the computer's functions and user interface, enhancing users’ productivity [23]. The implementation of a bilingual computer mediated health education program to disseminate information and improve outcomes among users with low literacy levels has proved to be successful [24]. Usability testing is an important process in the design and implementation of programs to allow for further development and better adoption of technologies in populations. Usability testing can be conducted among target populations, and can help identify key issues before full implementation.

The purpose of this pilot study was to examine the usability of an interactive, bilingual, touch screen enabled standalone and Internet based breastfeeding educational program among Hispanic women living in rural settings and in this case Scottsbluff, Nebraska.

We enrolled a convenience sample of 10 Hispanic rural women at the Regional West Medical Center (RWMC), Scottsbluff, Nebraska during May 2013. Information about this cross-sectional study was made available through the flyers at the RWMC. The optimum number of participants for in-depth interviews is typically 6-10 people with similar backgrounds who participate in the interview for one to two hours, however interview times may vary [25]. Prior literature has suggested that smaller groups of a sample between 6 to 10 participants show greater potential and large enough to gain a variety of perspectives, and small enough not to become disorderly or fragmented [25]. After a brief introduction to the system, study subjects were asked to complete a predefined set of tasks by interacting with the system and the duration of this interaction was around 30 minutes. The study participants used a think aloud protocol involving participants thinking aloud as they used the program, and were asked to say whatever they were looking at, thinking, doing, and feeling. Then, users were assigned 6 tasks including: (1) entering age, (2) moving forward to the next question, (3) ability to pause the program, (4) replay, (5) use of help module, and (6) ability to change the settings. Tasks were chosen based on varied complexity. Information was gathered about the time taken to complete the task, task completion (yes or no), number of attempts taken to complete the task, and whether or not assistance was sought during the completion of the task. Notes and test sessions were audiotaped of everything that users said. Usability scores were recorded among the 10 study participants, where vast amounts of usability problems and issues can be identified with only a small number of test subjects, as few as 8 to 10 participants [26]. The UNMC Institutional Review Board (IRB protocol#430-12-EP) approved the study.

Results showed the mean age of the study participants to be 28 years (SD 3.6), the majority of them had 12 or more years of education (90%, 9/10), half of them were married (50%, 5/10), 60% (6/10) had breastfed less than 6 months. The majority of the participants received a low income with one (10%, 1/10) participant’s annual incomes less than $10,000, one (10%, 1/10) between $10,000-19,000, two (20%, 2/10) between $20,000-29,000, two (20%, 2/10) between $30,000-39,000, three (30%, 3/10) between $40,000-49,000, and one (10%, 1/10) was greater than $50,000. The majority of the study participants had either no prior history of taking prenatal classes (90%, 9/10) or did not intend to take any prenatal classes in the future (80%, 8/10) (Table 2).

Overall, the interactive, touch screen computer-based breastfeeding program had high acceptance. There were 100% (10/10) of the study participants that found the program very easy to use, 60% (6/10) of them found it very interesting, and more than half of them (80%, 8/10) would use it quite often for receiving breastfeeding educational support. More than half of them would always want to use the program in the future (60%, 6/10). Figure 4 shows the distribution of the program acceptance.

Despite the clear benefits of breastfeeding to mother and infant, breastfeeding rates continue to remain below the recommendation levels in the United States, most notably among low income mothers living in rural settings. Modifiable factors such as maternal attitudes and self-efficacy demonstrate a positive relationship with continued breastfeeding. The promotion of breastfeeding is of utmost importance because of its role in many health related outcomes. There are many challenges that prevent Hispanic women from breastfeeding, these include embarrassment, pain, inconvenience, lack of breastfeeding support, and not being able to consume alcohol or smoke cigarettes [33,34]. These barriers need to be addressed in a culturally sensitive manner that focuses on how women can overcome them. The delivery of health information is challenging for non-English speaking populations due to well-known language, low literacy, and cultural barriers.

Research has translated the average SUS score to be easily interpreted by others where products that scored in the 90s are exceptional, products that score in the 80s are good, and products that score in the 70s were acceptable, and below 70 is concerned to have usability issues that cause concerns [35]. Results of this study among 10 low-income Hispanic women living in a rural setting suggest that an interactive, computer-based breastfeeding educational program is highly acceptable with an average SUS score of 90. The interactive program included a series of breastfeeding educational modules in English and Spanish. Each module was broken down into submodules and each submodule was further broken down into a series of short educational messages. The educational messages were enhanced using various formats of multimedia in the form of text, audio, and images.

The majority of the participants had familiarity with the use of computers and had access to the Internet, however only 60% (6/10) of them used the Internet to find breastfeeding related information. Most of the participants did not find the breastfeeding related information on the Internet useful. Results of our study showed that all the participants were able to complete all the tasks unassisted during the use of the program. All the participants agreed that use of images and audio enhanced their understanding about the various breastfeeding educational modules. However, study participants believed that labeling of the buttons, highlighting keywords, and use of videos can further make the program interactive and useful. The system demonstrated high usability scores, reflecting its usefulness among rural Hispanic women. The usability testing of the program has helped to take into account the preferences of the target group.

Prior research suggests that technology is a promising way to change a person’s health behavior. Usability factors are a major obstacle to health information technology (IT) adoption. Lack of attention to health IT evaluation may result in an inability to achieve system efficiency, effectiveness, and satisfaction. Consequences may include frustrated users, decreased efficiency coupled with increased cost, disruptions in workflow, and increases in health care errors [36]. It is essential to be attentive to health IT usability, keeping in mind its intended users, task to be performed, and environment. Further, the usability evaluation should not only be done through use of questionnaires that provide subjective information, but should also include objective assessments through task analysis. A longitudinal study is needed to explore the acceptance of the program after the program is used for a longer duration. Future studies are planned to determine the usability among a large longitudinal study. A longitudinal study will help identify further usability challenges and program acceptance among populations with varied characteristics.

Results of our study showed high acceptance with no assistance needed by the 10 Hispanic women living in rural settings. The study participants were able to navigate through the program with ease and obtain relevant breastfeeding related health information specific to meet their needs. An interactive, touch screen breastfeeding educational program using multimedia can help overcome these barriers by delivering health education among Hispanic rural women. The results add to the growing literature demonstrating the use of touch screen technology for health education in Hispanic populations living in rural settings. Delivering interactive breastfeeding educational material in a culturally relevant manner can help facilitate change in the knowledge, attitude, and practices related to breastfeeding.