Factors that impact on the usability of computerised cognitive behavioural therapy (CCBT): mixed methods studies
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Computerised Cognitive Behavioural Therapy (CCBT) has been recommended for patients in the National Health Service (NHS) Primary Care across the United Kingdom for management of mild to moderate anxiety and depression. This approach also promises financial savings, and may fill the gap between demand and supply of face-to-face therapy. Studies have shown that CCBT is feasible and effective. However, dropout rates can be as high as 86%, but the reasons remain unclear and the information available is limited. This thesis explores factors that may impact on the usability and user experience of this computer-mediated therapy. Espousing the “real world” research philosophy and widely used methods in the Human-Computer Interaction (HCI) field for usability evaluations, four studies using a mixed-methods design were conducted. Study I was an online usability survey, which investigated if usability evaluations had been conducted for CCBT applications. Two versions of questionnaires were sent to four CCBT software developers and ten authors of randomised controlled trials. The categories and responses of the questionnaires gathered from five respondents were reviewed and summarised. The findings suggested that usability evaluations for CCBT were still in their infancy when compared to other healthcare interventions to which HCI approaches have been widely applied. Study II was a usability Heuristic Evaluation (HE) conducted with four expert evaluators to assess two different CCBT applications’ interfaces (MoodGYM and Living Life to the Full) against the self-designed usability heuristics for their compliance. The findings revealed numerous usability issues. Major problems related to navigation and inconsistency of the interfaces were identified. These could be rectified to enhance the user experience. Study III focused on other factors besides usability that might have an influence on the effective use of CCBT. Perceptions of service providers who were involved in both decision-making about CCBT availability and supporting its use were gathered. Nine service providers at different NHS organisations were interviewed. The interviews were analysed using techniques from Grounded Theory (GT). The findings suggested that the practitioners’ attitudes towards CCBT might have affected its service delivery. Four categories from the data analysis were identified: (1) shaping behaviour, (2) implementing and delivering, (3) making an appropriate referral, and (4) technology/CCBT packages - advancing with time. A conceptual model was also generated, “building support around CCBT”: a road-map that could address some of these issues. Study IV examined patients’ perceptions and acceptance of a CCBT application (Beating the Blues), its usability and the user experience, and also whether the user characteristics (e.g. computer experience (CE) and computer self-efficacy (CSE)) had any influence on patients’ use of this technology. A mixed-methods approach was utilised with a sample of 33 participants. Face-to-face and email interviews were conducted. Feedback was also gathered from a usability questionnaire and think-aloud protocol with seven participants selected from the sample. The data were analysed using Thematic and Saliency Analysis to uncover themes. Descriptive statistics were used to describe data from questionnaires. Two overarching themes from the interviews were identified: (1) access to CCBT services, and (2) perceptions and attitudes towards CCBT. Both themes revealed issues which might have significantly impacted on patients’ engagement with CCBT. Numerous flaws were also discovered in the application’s design and functionality (e.g. navigation, aesthetics, relevance of content, and inflexibility). However, the results from CE and CSE questionnaires suggested that participants were confident in using this technology. The four studies provided an in-depth understanding of factors that affect the usability and user experience of CCBT and possible reasons for the high attrition rates. The implications of this research point to the need for health policymakers to focus on the current implementation issues and on how best to deploy this treatment therapy to patients. Further development of CCBT is pivotal to its success, in particular, expanding contexts of use and increasing usability evaluations. Keeping users interested and engaged will improve treatment efficiency, completion rates and will achieve better clinical outcomes.