A qualitative study on the design and development of an mHealth app to facilitate communication with the Deaf community: perspective of community pharmacists

Figures & data

Table 1 Deaf-related terms and definitions

Terms	Definitions
Hard of Hearing (HoH)	Individuals with mild to moderate hearing loss who may communicate using sign language or spoken language, or even both.^Citation53 People with hearing loss are graded as mild, moderate, moderately severe, severe, or profound. People with the latter two are referred to as Deaf, while those graded as mild or moderate are known as HoH.^Citation54
Malaysian sign language (M SL)	Primary language of the Deaf community in Malaysia. It is recognizably different from sign languages used in other countries, and is heavily influenced by Malaysian culture.^Citation34 English and Bahasa Malaysia (the national language) have a different syntax from MSL. MSL sentences do not always follow subject-verb-object word order, making it difficult for a Deaf person to understand written English or Bahasa Malaysia.
Video relay services (V RS)	Uses sign language interpreters (SLIs) to assist communication between a Deaf person who uses a ‘videophone’ to communicate in MSL, and a hearing person who uses a standard telephone; on a computer screen through linked video cameras.^Citation7
Teletypewriters (TTY)	A device used by the Deaf to type their messages using a keyboard through telephone lines. A relay operator then conveys the typed messages using either text or voice format through the telephone.^Citation7
Video remote interpreting (VRI)	Uses video conferencing technology where SLIs are remote or offsite, and communicates with the Deaf person via video in MSL, but with the hearing person in audio.
Videophone (VP)	Deaf people who use a VRS have a phone number designated “VP”. If the person they wish to call also has a VP, they can call the person directly and have a video conversation in MSL. If the person they wish to call uses a voice telephone, the call is routed through a VRS.^Citation7

Note: This table is mirrored from a paper by Steinberg et al.⁷

Table 2 Characteristics of participants

Characteristics	N (%)
Age, years (mean ± SD)	32.08±5.58
Role in pharmacy
Full-time pharmacist	6 (50.0)
Locum pharmacist	6 (50.0)
Number of prescriptions from Deaf or HoH patients filled monthly
Never	8 (66.7)
<5	4 (33.3)
Number of years since graduation (basic degree)
<5	4 (33.3)
5–10	5 (41.7)
>10	3 (25.0)
Type of pharmacy
Chain	4 (33.3)
Independent	8 (66.7)
Qualificationsa
B.Pharm	11 (91.7)
M.Pharm	1 (8.3)
MClinPharmacy	2 (16.7)
Operating system used
Android	7 (58.3)
iOS	5 (41.7)
Frequency of using medical smartphone apps
2–3 times	6 (50.0)
4–5 times	1 (8.3)
>5 times	5 (41.7)

Note:

a Participants were allowed to select more than one response; therefore sum may be more than 100%.

Abbreviation: HoH, hard of hearing.

Table 3 Common themes identified and example responses

Theme	Sub-theme	Examples
1. Suggestions for app design	Information on medications and diseases	“The video [should come] with subtitles also. Maybe they can choose – do they want to see it in video or in text because sometimes in-text […] it is more comprehensive […]. For those who can read, for those who are literate or can read, they can really read in detail. I think it’s more clear rather than showing the sign language, but for those who cannot read then it’s better to have sign language.”
	Scheduling and reminder service	“So actually by having the app, let’s say they are able to have the app, they can just […] type in what’s the problem, things like that. […] so then, if we get the information earlier, then from those questions, […] when the patient is right in front of you, you can ask […] you have this problem, you can actually ask more and then, you’ll be ready by then [with] what kind of actions you need to do or are supposed to do.”
	Notifications	“Like something pops up into your phone […] you have to collect your medications. I think that might be good. Or maybe […] it has something different from [a] message. Instead of just words or what, it could come up like maybe [a] picture or maybe […] like in a video like someone telling the patient [what they need to do] […]”
	Grab & Go service	“You [should] list down in the app, what are the items that can be under ‘Grab & Go’. Like certain medications, you cannot [list], like Tramadol. It’s controlled so you cannot ‘Grab & Go’ […] certain items you can, which is quite safe […] like vitamins […] where it won’t cause any untoward side effects […] [‘Grab & Go’] should not be for hypertensive and diabetic medications […] ‘Grab & Go’ would be more for like OTCs […] cough and cold, those sort of things.” “[…] I have experiences where [drug] addicts come for Benadryl^® (diphenhydramine) only. So we recognize them and we refuse to sell. We just tell them off […] we just told them that we do not have it. But […] they got pissed off, they scolded us. But because we can recognize them so we can refuse to sell […]. It’s hard to control if you buy through the app. Let’s say for today, they use this phone under this identity […] a different identity. It’s usually a big group of them also.”
2. Perceived benefits of the app	Facilitates communication with Deaf and HoH patients	“We had a patient [who came] to the discharge pharmacy who was Deaf and dumb. He was illiterate and so, I had a difficult time communicating with him. He got diabetic medications earlier on. Instructions were written on the envelope and I think the dispenser who dispensed to him told him like one tablet once a day you know, but I think [the dispenser] couldn’t tell him before or after meals. So he came back again and we didn’t know what he wanted […] and he got so frustrated, he showed us a picture of a policeman like saying ‘I’m going to complain’. So, he just couldn’t [communicate] – and he got so frustrated, he walked a few yards from the discharge pharmacy and yelled you know, because he was so frustrated. He just yelled and yelled and yelled. You know, like crying out. He was so so frustrated.”
	Time-saving	“[…] you can find that they want […] you to keep confirming the dose. You know like to take one tablet three times a day. Yeah, I had to like repeat it to them a few times and they in turn showed me like ‘1’, ‘3’ times a day (showing hand gestures). You know, like that sort of thing. So it’s not so […] smooth sailing as if you had been dealing with an able-bodied person.”
	Relationship-building and boost for business	“Yes, they will [appreciate it because they feel like they are being cared for]. They will appreciate it because you know […] they do not come out that much because of society and all that. When they find, okay someone is showing them some sort of care, it’s good I think.”
3. Potential challenges related to the app	Current health practice in Malaysia	“It all depends on the pharmacy itself. If the pharmacy or pharmacists care, they will […] have their own proper record in their own computer, [and] how they want to record it is up to them or how to follow-up is up to them. It all depends on them, some of them just want to do business so it’s a totally different story.” “[…] I mean this app is ideal for those countries that have already established dispensing separation like maybe, Australia or somewhere. But in Malaysia, I keep thinking of people misusing and abusing this system.”
	App charges	“I have an experience with an app […] which I have used for my eye drops because I have to use it 5–10 times a day. So, it helps to remind me as and when I need to use the eye drops. My initial experience with the app was okay until recently because it’s been almost one month, it says my trial version is ending. So if you are providing for those who are not so financially well, I think we should give it for free. If we can provide that [it would be good] because there are a lot of in-app purchases. You know, taking into consideration that they are illiterate and not so well to do, if we really want to help them, perhaps we can think about this.”
	Privacy and security	“Security issues. Let’s say we upload it to the Cloud, it could be hacked. That could be hacked. So if I were the customer, I may be worried if my information may be disclosed or exposed. For example, if I buy Viagra^® then […] right? Okay, let’s say you’re not uploading, the server is not the Cloud, are we keeping it in the phone? If you keep it in the phone and anything happens to the phone then […] all information will be gone.” “Or maybe when patients key in their details, they can choose [that] they want to […] disclose this particular information to this particular shop. Maybe they want to link it, maybe they want the same information going to this shop and that shop, and so only these two can view their particulars.”
	Manpower and knowledge requirement	“It’s good, just that it depends on whether the pharmacy has that ability or manpower. If you put the feature there, and at the end [of the day] the pharmacy does not have the manpower to provide that [service]. People will be disappointed. [They may ask], ‘Why did you put that?’”
	Attitude of patients	“You can see that most of the customers that walk into the pharmacy, you can see they have no patience […] and they cannot wait for you. They are in a hurry […]”
	Patient perception	“I think when you design the app, you have to think from two points. For example, I went to a clinic and it was a newly opened clinic, and it was the first time I was seeing the doctor and she gave me some consultation. It was just a sore throat and she told me ‘Oh you do not need antibiotics for now.’ And so she discharged [me with] some medications. Then, a few days later, her nurses actually called me to ask about my condition. So, I was very shocked because there are several GP’s I’ve visited and none of them have given me this type of service. So that would prompt me to think, ‘are you really that caring towards me or are you doing it for the profit?’ So I think when you are designing the aps, you need to think of this because the pop-up reminders would make me felt like as if you [only] want business from me, or it’s time to refill so it’s time to come to the pharmacy to get your medicine. That’s what I felt.”

Abbreviations: GP, general practitioner; OTC, over the counter.

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