Describe Current Situation

One of the first exploratory activities that is conducted during the contextual inquiry phase is desk research. Within eHealth development, desk research is the non-systematic collection of material that helps the development team to learn as much as possible about the context (Wentzel, Beerlage-de Jong, & van Gemert-Pijnen, 2014). Examples of relevant materials are scientific and non-scientific literature, policy documents, videos, or readily available reports such as the outcomes of employee satisfaction surveys. Desk research can be conducted in several ways, e.g. by means of using search engines, going through relevant websites, asking stakeholders for material, or using the archive of an organization. A prerequisite is that all the collected material should already exist; no systematic data collection or primary research activities are carried out. Since desk research is an exploratory activity and not a systematic research method, the aim is not to publish scientific articles on the results, but to get acquainted with the context.

Desk research can be used as a first step in the development process in all kinds of settings. An example is the development of a technology in forensic psychiatry, which is the psychological treatment of offenders with the primary goal of preventing recidivism. Desk research can help in answering several questions, like:

• what official rules and regulations are relevant when implementing a technology in forensic practice and working with forensic psychiatric patients for research purposes?
• what e-mental health technologies are already being used by Dutch forensic psychiatric institutions?
• what treatment protocols exist for forensic psychiatry? What kind of psychological tests are being used in the treatment of forensic psychiatric patients?
• what organizations are involved in initiatives related to e-mental health in forensic psychiatry?

These types of results are used throughout the entire development process to make sure that, for example, the technology complements the current practice, doesn’t overlap with existing technologies, or is consistent with rules and regulations.

In a diary study, participants are asked to keep a diary of certain daily life events that are of interest to the researcher (Bolger, Davis, & Rafaeli, 2003). By letting the participants register these events on a regular basis (daily, weekly, whenever the event occurs, etc.), the researcher gets an idea of the frequency and context of the event. Such registrations by the participant can be done via, for example, a predefined paper-based diary, online or mobile applications, or by telephone calls. Diary study is a method that is a form of Ecological Momentary Assessment (EMA), which is characterized by the collection of data in the real world, a focus on individual’s current or recent states, and multiple assessments [2].

Sometimes it can be very difficult for people to recall how specific events occurred, who were involved, how exactly they were feeling at that moment, or how often something occurred. A diary study enables the participant to record the event before he/she forgets about it. In addition, when it is difficult for participants to open up about a certain event or behave differently when being observed because of shame or social desirability, a (anonymous) diary study can be a good alternative. Drawbacks of diary studies are the needed participant compliance with keeping the diary and subjectivity. However, prompts can be used to remind the participants. Furthermore, diary studies can in some cases require a substantive amount of instructions for the participants.

Diary studies can render a broad range of information: either more factual data (what, where, how often, for how long) or subjective experiences. For example, people can be asked to daily record in a diary how they feel after a knee surgery. This would render insights into the recovery and possible motivational issues during this period. Researchers may use such information to develop supporting interventions for post-operative care. In other cases, diaries can give insight into the frequency or gravity of a problem or occurrence of event, for example, the intensity and supportiveness of social contact during the daily life of cancer treatment.

[1] Bolger, N., Davis, A., & Rafaeli, E. (2003). Diary methods: capturing life as it is lived. Annual Review of Psychology, 54, 579-616.

[2] Trull, T.J., & Ebner-Priemer, U.W. (2009). Using experience sampling methods/ecological momentary assessment (ESM/EMA) in clinical assessment and clinical research: Introduction to the special section. Psychological Assessment, 21(4), 457–462.

Focus groups are a useful method for the development of technology as well [1]. Focus group research can be defined as ‘a way of collecting qualitative data, which—essentially— involves engaging a small number of people in an informal group discussion (or discussions), ‘focused’ around a particular topic or set of issues’ [2]. In the contextual inquiry, one type or a cross-section of key stakeholders can be brought together within this discussion group format [3]. The level of structure can range from unstructured, with the researcher announcing the topic to be discussed and allowing the participants to respond freely, to semi structured, with the researcher using a predetermined scheme to cover questions and topics presented in some order [4].

Focus groups are accompanied by many advantages. The interaction that takes place between the participants often allows for the spontaneous discussion of topics, bouncing ideas off each other, comparing attitudes and sharing experiences [2]. The interaction between participants can lead to new information that wouldn’t have been discovered when using individual methods like interviews, and one can explore a variety of different opinions and visions, that wouldn’t become apparent in methods like questionnaires. Focus groups can also be conducted online and anonymously (e.g., using a chat platform), which has been found to be a feasible and valid method for collecting sensitive data [5]. Some drawbacks might be greater planning and recruitment efforts to assemble groups and the disproportionate influence of dominant participants [3].

Focus groups can be used for several activities of the contextual inquiry, for example identifying stakeholders and their roles, describing a current situation, finding out about points of improvement, describing relevant behaviour, or uncovering attitudes and other predictors of behaviour [6]. Some examples of research that made use of focus groups in order to learn more about the context are:

• finding out about current uses, preferences, facilitators and barriers to using existing electronic health resources by veterans [7].
• investigating the current use of internet among adults in order to gain insight into attitudes, reasons, and current ways of internet use [8].
• the identification of sensitive topics among young people with cancer [5].

[1] Avis, J.L., van Mierlo, T., Fournier, R., & Ball, G.D. (2015). Lessons Learned From Using Focus Groups to Refine Digital Interventions. JMIR Research Protocols, 4(3): e95.

[2] Wilkinson, S. (2003). Focus groups. In J.A. Smith (Ed.), Qualitative psychology: A practical guide to research methods (pp. 184-204). London: Sage.

[3] Maguire, M., & Bevan, N. (2002). User requirements analysis: A review of supporting methods. In J. Hammond, T. Gross, and J. Wesson (Eds. ), Proceedings of IFIP 17th World Computer Congress - TC13 Stream on Usability: Gaining a Competitive Edge (pp. 133-148). Deventer, The Netherlands: Kluwer B.V.

[4] Krueger, R.A., & Casey, M.A. (2001). Designing and conducting focus group interviews. In R.A. Krueger, M.A. Casey, J. Donner, S. Kirsch & J N. Maack (Eds.), Social analysis: Selected tools and techniques (pp. 4-23). Washington, DC: Social Development Family of the World Bank.

[5] Wettergren, L., Eriksson, E.L., Nilsson, J., Jervaeus, A., & Lampic, C. (2016). Online Focus Group Discussion is a Valid and Feasible Mode When Investigating Sensitive Topics Among Young Persons With a Cancer Experience. JMIR Research Protocols, 5(2): e86. doi:10.2196/resprot.5616

[6] Velsen, L. van, Wentzel, J., & van Gemert-Pijnen, J.E. (2013). Designing eHealth that Matters via a Multidisciplinary Requirements Development Approach. JMIR Research Protocols, 2(1): e21.

[7] Haun, J.N. , Nazi, K.M. , Chavez, M., Lind, J.D., Antinori, N., Gosline, R.M., & Martin, T.L. (2015). A participatory approach to designing and enhancing integrated health information technology systems for veterans: Protocol. JMIR Research Protocols, 4(1): e28.

[8] Donnelly, L.S., Shaw, R.L., & van den Akker, O.B.A. (2008). eHealth as a challenge to ‘expert’ power: a focus group study of internet use for health information and management. Journal of the Royal Society of Medicine, 101(10), 501-506.

The most common aim of an interview is obtaining answers to questions of an individual participant [1]. An interview can range from highly structured, to semi-structured and completely structured.

Within the contextual inquiry, interviews can be conducted with individual stakeholders, like possible users, experts or project managers. Interviews can have several goals, for example to uncover opinions, behaviour, causes of behaviour, to describe a problem, or to identify roles and tasks within a specific context [2]. The main difference with focus groups is that an interview focuses on the perspective of the individual. Some examples of the use of interviews during the contextual inquiry are:

• conducting semi-structured, in-depth interviews to find out about knowledge on, experience with, and attitude and behaviour regarding ticks and Lyme disease [3]
• questioning several kinds of stakeholders working in public health about their personal experience with social media and the context of public health [4].
• conducting interviews with students, their parents and teachers to explore the problem of cyberbullying, by asking about views and understanding of cyberbullying, experiences, and attitudes [5].

[1] Dooley, D. (2001). Social Research Methods (4th Edition). New Jersey : Prentice-Hall.

[2] Velsen, L. van, Wentzel, J., & van Gemert-Pijnen, J.E. (2013). Designing eHealth that Matters via a Multidisciplinary Requirements Development Approach. JMIR Research Protocols, 2(1): e21.

[3] Velsen, L. van, Beaujean, D.J., Wentzel, J., van Steenbergen, J.E., & van Gemert-Pijnen, J.E. (2015). Developing requirements for a mobile app to support citizens in dealing with ticks and tick bites via end-user profiling. Health Informatics Journal, 21(1), 24-35.

[4] Hart, M., Stetten, N., & Castaneda, G. (2016). Considerations for public health organizations attempting to implement a social media presence: A qualitative study. JMIR Public Health Surveillance, 2(1): e6.

[5] Mishna, F., McInroy, L.B., Lacombe-Duncan, A., Bhole, P., van Wert, M., Schwan, K., . . . Johnston, D. (2016). Prevalence, motivations, and social, mental health and health consequences of cyberbullying among school-aged children and youth: Protocol of a longitudinal and multi-perspective mixed method study. JMIR Research Protocols, 5(2): e83.

Log data typically consists of the registration of an event, e.g., logging in, entering a room, sending a message, performing a certain action, and a ‘timestamp’. The analysis of log data of a technology (website, app, etc.) enables researchers to look into the ways users have used a system by studying the logged transaction data. Log data can also consist of data on the behaviour of users in a certain context, logged by technologies such as sensors, GPS, etc. In this way, log data enable researchers to learn more about the current situation. There are two ways in which log data can be used during the contextual inquiry: system and behaviour log data. Log data can also be used for evaluation.

With system log data, researchers can check how often, in what way and when people visited a website or an app, have used a feature, or logged into the system. Behaviour log data tracks measurable behaviour, such as sleep, location or exercising, of the participants. This can include the routes of healthcare workers through a hospital, the amount of persons entering a certain room, or specific behaviours such as the frequency of use of alcohol dispensers for hand hygiene. If sensors or GPS devices are in use, the information can be logged automatically. This way, researchers gain insight into the current behaviour patterns of intended users and can consequently use this information to make sure an eHealth intervention fits the prospective users’ current patterns.

The use log data on technology use and behaviour can provide researchers with insight into:

• the frequency of an event (use of a system, behaviour)
• who the users of an existing system are
• how often certain features of a system or a physical area are used, or what content is accessed
• how people access the system or website: type of device and operating system used, referral pages or links that were used and/or search words that have led people to a website
• an idea of how users interact with the system: time spent, amount of messages sent, etc
• how people move throughout a certain area or system; which routes they take 

For a contextual inquiry log data can be very useful, since it provides a lot of information about the current situation. In some cases, technologies are already being used and their use logged in a specific context. This existing information can be used to determine what should be accounted for when developing a new intervention in the same context, or if an existing technology should be adapted and if so, in what way [1]. Behaviour log data can be used to identify points of improvements in current behaviours, or to make sure that a new technology fits with the current situation.

[1] Van Gemert-Pijnen, J. E., Kelders, S. M., & Bohlmeijer, E. T. (2014). Understanding the usage of content in a mental health intervention for depression: An analysis of log data. Journal of Medical Internet Research, 16(1): e27.

In observations, also called field research, the researcher observes an event of interest while it occurs. The researcher may even participate in the event or activity that is under study. In such cases, we speak of participatory observation. Conversely, the researcher can also assume a fully covert and distant role and purely observe.

Via observation, the researcher observes the situation or event directly or mediated via technology (e.g., video). This is especially useful in situations that are highly complex and therefore make it difficult for subjects to adequately report on it themselves. Also, observations may provide more reliable data than self-reports when social desirability or shame may influence subjects’ accurate reporting of the situation. Lastly, observations can provide insight in pieces of information that are so obvious and routine to the people involved in the situation under study that it would not occur to them to report on it, even though such information can be crucial to the researcher.

Via observations, initial insight can be gained in a certain context or situation. The results can be quantified. For example, how often do physicians disinfect their hands during rounds, are there differences in frequency/accuracy of disinfection between physicians or situations? Observations can help the development team to identify points of improvement, or assist in making sure that the eHealth technology fits seamlessly with the current behaviour of the end-users.

When gaining insight in the current status quo of scientific literature in a certain field, several methods are available, such as meta-analysis, systematic review, and a scoping review. All of these are based on a thorough and systematic search of literature. However, with a scoping review, a broad field of study, where research questions are relatively unspecific and various kinds of study designs are used, can be addressed within a relatively short amount of time [1]. Thus, a scoping review can help to quickly explore a field, without excluding studies based on their quality.

The results of a scoping review consist of an overview of the literature that is available in a field, which provides the development team with relevant knowledge on the context in which they will be developing an eHealth technology. The exact nature of the results depends on many factors, such as the aims of the study and the field. Scoping reviews in very new or quickly evolving fields (such as eHealth) and with exploratory aims may yield narrative results, offering a more qualitative description of the literature. Fields that have already been more established and more focused aims can yield results that are more quantitative and focused on effectiveness.

[1] Arksey, H. & O'Malley, L. (2005). Scoping studies: towards a methodological framework. International Journal of Social Research Methodology, 8(1), 19-32.