“Glocalization” of Health Information: Considering Design Factors for Mobile Technologies in Malaysia

Abstract

Mobile phones offer promising solutions to basic health-care provisions for developing countries like Malaysia. However, for such technologies to be useful for health and medical intervention, information designers must make information shared via small-screen usable for diverse cultural audiences within a nation. In this entry, we use the international patient experience design framework to propose a heuristic for addressing this situation. This approach can provide insights that can facilitate the “glocalization”—or creating materials to address specific cultural contexts and make health and medical information more usable to diverse populations living in the same country.

Keywords

mobile phone interface design glocalization international patient experience design

Introduction

In developing countries such as Malaysia, the struggle to provide adequate health care to all citizens, across geographical, economic, and culturally diverse realities, is real. Combating diseases such as coronary heart disease, diabetes, HIV/AIDs, and influenza continues to be a problem in Malaysia where the gap of income between the poor and the rich is wide, and the distribution of population is uneven. The challenge becomes finding a mechanism for effectively communicating health-related information to a large and diverse population distributed across a wide-ranging geography. Mobile phones can serve as a central technology that can address this situation. Using them to effectively address health communication needs, however, requires one to understand the complex cultural context in which individuals use these technologies.

The objective of this article is to identify design implications in light of existing health-care practices and needs in the country of Malaysia. In so doing, we propose a heuristic/framework for design practices focusing on patients’ experience, the context of use, along with patients’ needs, preferences, and expectations. To examine such ideas, we review mobile phone use in health-care contexts to make the case for why such technologies can be key to transforming services in challenging locations like Malaysia. We also discuss how “glocalization” (the process of localizing documents or materials to local contexts of use) could be the answer for communicating usable health and medical information across varied settings. In so doing, we overview what aspects of the Malaysian health-care systems can be considered for mobile health technology. To do so, we us international patient experience design (I-PXD) concepts (St.Amant, 2017) to develop a plan for the glocalization of interface designs for Malaysian audiences. Finally, we explore how to apply this heuristic approach to design practice in Malaysia. Through this approach, we offer an overview of a mechanism and method for creating effective health and medical materials Malaysian audiences can effectively access and use via mobile phone.

The Uses of Mobile Phones in Health-Care Intervention

Whether serving people with communicable diseases or providing tools for a simple blood test, mobile technologies could serve as critical tools for solving many health challenges in Malaysia today. Even the simplest phone model can become a powerful piece of equipment (Ventola, 2014), allowing critical information to be shared quickly and easily and reducing travel time to health centers, especially for those in remote areas of the country. As mobile phones become more sophisticated, they could be turned into medical devices, used for monitoring vital signs, in addition to facilitating remote consultations (Hussein, Harun, & Oon, 2016; Watkins, Goudge, Gómez-Olivé, & Griffiths, 2018).

The use of mobile phones and more recently smartphones as tools for health-care and clinical interventions is well-documented (see, e.g., Blaya, Fraser, & Holt, 2010; Ding, 2009; Fjeldsoe, Marshall, & Miller, 2009; Kaplan, 2006; Kumar & Anderson, 2015; Mwangi & Mukanya, 2017). Today, high-income countries such as the United States generally lead in mobile technological innovation and use in health-care and clinical interventions. However, the rates of penetration of such technologies in upper middle-income countries like Malaysia and Thailand, lower middle-income countries like India and the Philippines, and even lower income countries like Tanzania are growing rapidly and, in fact, catching up (Bastawrous & Amstrong, 2013; Chung, Mayes, & White, 2016). In Malaysia today, 25 million of the 30 million or so people are considered Internet users, with the smartphone by far serving as the most common device used to access the Internet (Malaysian Communications and Multimedia Commission, 2017). With advanced computing capabilities, high-resolution cameras, and built-in global positioning systems, mobile phones offer promising solutions to basic health-care provisions for rural and remote areas of Malaysia. These factors can be key in many rural areas where infrastructure issues can cause problems (Minoi, Suhaili, & Yeo, 2014) in contrast to those in the country’s urban capital city, where health clinics are conveniently offered even in shopping malls.

For mobile phone to be a useful tool for health and medical intervention in a developing, highly diverse country like Malaysia, designers must determine how to make information shared via a small-screen interface usable for diverse audiences of people from different religions, ethnicities, and cultures who speak different languages and have different lifestyles, perceptions, and expectations (Getto & St.Amant, 2015). Unfortunately, there is relatively little information on what constitutes suitable communication design in mobile applications within a specific diverse and developing country such as Malaysia.

With some Malaysians having more access to mobile phones than they might to clean water and sanitation, mobile phones can indeed offer promise for accessing health-care services without the traditional fixed infrastructures. This situation means we need to explore ways to design effective—culturally localized—interfaces for mobile phone use in order to make the information usable and acceptable for users. Factoring explicit cultural characteristics such as language and other culturally sensitive variables represents only the tip of the iceberg in communication design processes (Hoft, 1995 as cited in Sun, 2012, p. 7). Many other factors are often hidden in contexts of use. We argue that answers to such situations might be found in processes called for in glocalization.

Glocalization and Design Practices

The concept of glocalization was introduced by Japanese companies in the 1970s working to customize product design for target regional markets (Dumitrescu & Vinerean, 2010). Expanded by Robertson (1995), the term, a combination of “global” and “localization” refers to the act of merging local elements into globally distributed products or services (Maynard & Tian, 2004). In this article, glocalization is defined as the act of localizing design process and product features of globally available mobile technologies to meet preferences, needs, expectations, and local contexts of users. Advantages of using a glocalized approach to interface design in health-care communication include as follows:

It encourages wider acceptance and adoption of a system or product.

It creates a sustainable solution to local and regional problems in the era of globalization by integrating design approaches that attend to not only users’ culture, experiences, needs, and expectations but also dynamics of local cultural contexts into the design planning, process, and implementation.

It allows for developing products, systems, or applications that are more useful and meaningful to users.

Due to these factors, a growing number of organizations now use glocalization as a regular part of their product development and design processes.

Glocalization of technology applications must also aim to account for more hidden local characteristics in context to bring out the real effects of technology use. By context, we mean the physical and cultural setting in which the application or system is going to be used. Such an approach means user localization in a design process that recognizes not only the user’s culture and experience but also the possibility of making the technology both usable (i.e., achieving a desired objective) and meaningful (i.e., providing different affordances to the user) regardless of culture or locality when desired and for a specific culture or locale when required—all in light of user purpose and context of use.

Considerations for Developing Mobile Health Technologies in Malaysia

Malaysia offers individuals a dual-tiered health-care system: health-care institutions funded by government and taxpayers and those that are privately funded. Both sectors provide excellent specialists and equipment. Yet due to the high number of patients, public institutions struggle with long waits and minimized attention, whereas in the private sector, costs can be too expensive for many Malaysians. In contrast to the United States which, at 17%, spends the most gross domestic product on health care among all countries, Malaysia spends 4.2% (Central Intelligence Agency [CIA], 2018), whereas the United States has 2.5 physicians and 2.9 hospital beds per 1,000 people, Malaysia has about half of that number (1.3 per 1,000 people) and a third fewer hospital beds (1.9 per 1,000 people; CIA, 2018).

The Malaysian government expresses aims to provide access to quality health care for all. However, there is still a shortage of quality health-care centers in remote parts of Malaysia. Moreover, deployment of medical personnel to rural areas remains unpopular among some practitioners who view such posts as less rewarding, with fewer technologies and lower pay (Quek, 2009). As remote regions catch up with connectivity through mobile devices, a high penetration of mobile phone networks in Malaysia can offer great potential for transforming the way health services and information are accessed, delivered, and managed in all parts of the country. Already, more than half of all smartphone owners in Malaysia report using their phone for health information purposes (Salihah, Lua, Ahmad, & Shahril, 2017).

That said, much of the existing mobile innovations are inventions of the West, meaning that current health products and “apps” offer information for targeted types of care tailored through Western approaches less appropriate for Malaysian users, including language used, navigation style, and content not reflecting local values or health-care beliefs and practices. Such problems can exacerbate communication challenges when health-related topics are communicated in different ways within different cultures. This means that a “one-size-fits-all” approach to health communication simply does not exist, and one cannot use the same methods for communicating health and medical information in all cultural contexts, particularly for a diverse country like Malaysia. Rather, health and medical technologies and communication need to be glocalized to be usable and meaningful for individuals in different cultures. This is what I-PXD sets out to accomplish.

Using I-PXD to Glocalize Interface Designs for Malaysian Audiences

The fundamental goal of the I-PXD heuristic/framework is to “create a usable health and medical materials according to patient expectations of care-related contexts in other nations and cultures” (St.Amant, 2017, p. 64). This process involves addressing questions related to contexts in which patients will perform a given care-related activity:

In what specific location/context will patient in this culture or nation perform a given care-related activity?

What care materials are in the setting?

Who is present in that setting?

What ancillary aspects are available and accessible in this setting?

What are the environmental conditions under which individuals will perform this task?

What is the size of the physical space in which individuals will perform this process?

How quickly and easily can individuals access outside information in this location? What mechanisms are available to facilitate such external access?

How much time do individuals usually have to perform a given process in this setting (St.Amant, 2017, p. 65).

In the following subsections, we address these questions in terms of the five core I-PXD considerations (pp. 66–68) for health-care design. These are

Accessibility: How individuals in a given location access information.

Manageability: How effectively individuals can perform a task or use an item based on their experiences and backgrounds.

Comprehensibility: How well and effectively individuals understand what they must do or are being asked to do in order to use something.

Sustainability: How often individuals are expected to perform an activity or use an item and how effectively individuals can meet such expectations based on local conditions.

Acceptability: How appropriate, credible, and acceptable individuals consider the design and use of items based upon cultural norms and expectations.

Each consideration examines an aspect of what constitutes a “usable” design based upon the environment where individuals use items and the cultural conventions governing design and use. By identifying and addressing such factors, individuals can better meet the local realities and cultural expectations affecting how materials are used by a cultural audience. We employed this framework to identify different needs individuals must meet when designing interfaces used to disseminating health-care information in Malaysia.

Accessibility

Of the five considerations of the I-PXD approach, accessibility is likely to prove most challenging for designing interfaces to disseminate and communicate health-care information in Malaysia. With a population of roughly 32 million people, Malaysia is a multicultural, multiracial, and multilingual country made up of two distinct regions. West Malaysia accounts for 40% of the country’s area but 80% of the country’s population. It is completely separated from East Malaysia by the South China Sea. Additional unique challenges are based on geographical features across Malaysia. For example, the nation is comprised of many small islands, rainforests, plains, and mountain ranges along with corresponding climate variations among highland, lowland, and coastal areas. Such factors can have important implications in terms of how local conditions can affect use and usability. For instance, in parts of Malaysia, “lush vegetation and incessant rain” can interrupt Internet signals needed to maintain access to the Internet itself (Nordrum, 2016).

Fortunately, access to the Internet and availability of information are currently a priority for the Malaysian government. In the past 5 years, the government, with aims to bring the country to higher positioning in economic status, has focused attention on Internet access through such systems as a Wireless Village Program which targets rural communities through a community center with stations offering access to Internet and technologies (Sahharon, Omar, Bolong, Shaffril, & D’Silva, 2014). This and other such programs are helping some residents, yet such efforts leave the country still facing connectivity challenges, including those relating to terrain and weather (Sahharon et al., 2014). In the case of health-care information design and dissemination, irregular connections suggest creating materials that can be uploaded to—as well as downloaded and stored on—one’s mobile device. Ideally, such approaches would mean when Internet access is available, mobile devices can be updated automatically by the health-care provider/institution as well as manually by the user or practitioner. Such a platform can then make information accessible, though not always completely updated, regardless of Internet accessibility.

Still, a concern for mobile technologies used across Malaysia for health-care purposes is that when phone service and the Internet is out of reach, as it is at times in more rural or mountainous areas, the ability to interact with a health-care professional directly and immediately would be lost. Connectivity is particularly important in emergencies, more so in the geographic regions where health-care facilities are rare or difficult to reach. As health care in general moves to mobile technologies, as it is with recent telemedicine and mobile health efforts (Abidi, Goh, & Yusoff, 1998), industries and governments alike will be called on for infrastructures supporting mobile access. As Zhu and Protti (2009) remind us, “a national health information management/information technology strategy is crucially important for a country in planning and implementing healthcare priorities” (p. 122). Malaysia’s Ministry of Health, along with counterparts across the globe, can serve to advocate for more widespread connectivity with an eye to improving health care for all.

We need to note that current connectivity efforts such as the Wireless Village Program do not come without cultural or other complications when we consider access. Not only do we need to take into account the I-PXD suggestion to consider the size of the physical space in which individuals will perform a health-related action, but we need to consider user privacy, an important issue for Malaysians (Belkhamza & Niasin, 2017). A recent survey by the Malaysian Communications and Multimedia Commission (2016) found that, 92% of Malaysian users expressed concerns about privacy when using the Internet. Preferences for confidentiality could, for instance, impact rural users accessing the Internet in small and crowded public places set up through the Wireless Village Program, areas that might currently offer their only option for Internet access. We expect that such issues will come into play even more as interactive apps that request input of personal health or family history data become more popular.

Yet another accessibility issue when using mobile technologies for disseminating and communicating health-care information in Malaysia concerns the small-screen interface of mobile technologies. Disseminating health-related information in any context is challenging and doing so within constraints of a mobile phone screen can complicate matters. Kim, Young, Neimeyer, Baker, and Barfield (2008) remind us of several challenges in delivering health-related information in general. First, of course, it is difficult to convey medical information to the general public in a way that ensures necessary and sufficient comprehension. Transforming such information for mobile delivery typically implies minimizing the amount of text while considering use of other forms of delivery, including graphics, audio, and simple animation. Based on studies of Malaysian website designs on user preferences (see, e.g., Callahan, 2005), we imagine that animated images that depict local characters and health activities, for instance, would be welcome, bandwidth allowing, in delivery of health-care information for many Malaysian contexts.

However, in contexts of care where access to technology and even electricity is unpredictable, we suggest that medical materials can be designed to be viewed and used on screen only with no expectation they can be printed to be used later or without options like live video streaming. This also means that the amount of information that appears on the screen must be configured to fit the size of the screen. Text use should be task focused, simple with limited images to allow for easy access in low-bandwidth environments. We need to note that all of such concerns and suggestions highlighted here, and in the four subsequent I-PXD areas mentioned next, call for testing, an issue we take up in the sections on usability later.

Manageability

A second primary objective advocated in the I-PXD approach concerns the ability of users to perform required processes (manageability). This concern addresses not just whether a person can understand and use health-care information offered via mobile technology but whether required materials or resources will be available for doing so. In Malaysia, while urban dwellers might enjoy modern medical care with sophisticated medical technologies common to countries such as the United States, the rural areas do not necessarily have such luxuries. Designers creating health-care products or information even for a single, small country such as Malaysia will therefore want to consider the diversity of medical equipment and other technologies available.

Manageability therefore requires considering alternative tools, devices, materials, and units of measurement that are more familiar and likely to be found readily, with many more implications for user content than for interface design. Should bandwidth eventually allow for images or even simple animation, innovative practices with common materials could be displayed in addition to being mentioned through textual information, all with precautions and safety in mind. Notably, safety and legalities are clear concerns of manageability. For this reason, we are not advocating a “do try this at home” approach so much as suggesting that health-care interfaces include safe and legal options for less serious situations, those that do not require a trained health-care professional.

Comprehensibility

In addition to manageability, the I-PXD approach suggests focus on comprehensibility or how well an audience understands something. At nearly 95%, the adult literacy rate is higher than that of the United States (United Nations Children’s Fund, 2015), as is the rate of currently enrolled Malaysian primary school children (United Nations Children’s Fund, 2017). Also related to comprehension, of course, can be the language(s) being used in an interface. Although there are 134 living languages in Malaysia (CIA, 2018), the official language, Bahasa Malaysia, is the primary language of the Malay and indigenous people who account for 69% of the population (Department of Statistics Malaysia, 2017). This language is also the compulsory language of school instruction (Hassan, 1987). Mandarin is the most widely spoken language among the Malaysian Chinese, who account for 23% of the population, while Tamil is the most commonly spoken language among Indian Malaysians, about 7% of the population (Department of Statistics Malaysia, 2017). Interestingly, while the use of the national Malaysian language was thought to be an important requirement for the adoption of mobile technology in Malaysia, Ariffin and Dyson (2015) found that when offered languages prevalent in Malaysia in mobile applications, all who took part in their study chose English as the mode of communication over even the official Bahasa Malaysia language.

This preference for the English language as a preferred mode of online communication tells us that in online settings, language, or other cultural factors may not be as predictable as we might have thought. This finding may align with what some see as a globally new online culture. Verhulsdonck (2015) suggests that many, though not all, mobile technologies currently target populations already familiar with earlier design features and affordances. Still, while English has spread as an accepted language for online delivery of health-care and other information in Malaysia that may not be the case in rural and remote areas. To ensure comprehensibility of health information for users in rural and remote areas, we suggest testing whether the national language or translation options for the local language is preferred.

Sustainability

A related I-PXD objective is sustainability of processes, activities, or uses. This consideration encompasses the extent to which materials, human resources, and information are available at the point of need. Such factors include availability of materials or resources (e.g., a health-care professional) and if an item is intended for (and can actually meet requirements for) a one-time single use or for multiple uses or applications across time. Addressing sustainability means designing content that takes into account frequency of use and frequency of health-care professional assistance being available. We add that this objective can also include, with respect to mobile technology, the sustainability of the health-care information itself as well as the important ability for the information to be updated as new information becomes available.

Acceptability

Acceptability, a final consideration of the I-PXD approach, concerns the extent to which the information, tools, procedures, or resources fit cultural norms, practices, and expectations. Many factors, of course, play a role in the look, feel, content, and options considered acceptable to given users of an online site such as those available through mobile technology. In a study exploring Malaysian cultural expectations for online interfaces, Tong and Robertson (2008) found that while the governmental websites they studied were more likely to present a “Malay monoculture” (p. 76) such as use of Malay language only and Malay theme for overall design of website, corporate Malaysian websites consider multicultural facets in ways that we would see as relevant for disseminating medical information in mobile technologies in order “to capture … interest across … society without causing exclusion or ethnic preference [even] while still appealing to the idea of national unity, a sense of community, and collaboration” (p. 77).

In contrast, some interfaces and applications are therefore precisely localized, targeting specific users with specific expectations. One such health-related technology being developed for Malaysians is a Cancer Dietary app called “CanDi,” designed for cancer patients and focused specifically on Malaysian “food choices, preferences and ingredients” (Salihah et al., 2017, p. 33). This app includes Malaysian recipes offering nutrition-rich foods targeted for cancer patients; the app also takes into account common Malaysian caregiving practices (Salihah et al., 2017).

Finally, in addition to the primary questions emphasized by the I-PXD approach as highlighted earlier, an additional question to consider is not just where a Malaysian goes for health-care services but also what cultural factors impact such decisions. While this may seem an odd concern, the answer matters when designing and developing health-care applications for Malaysian audiences. Where Malaysians go for health-care services, the treatment choices they are offered, along with the health decisions they make can be highly influenced by their cultural beliefs and practices (Ariff & Beng, 2006). Many Malaysians, especially Chinese Malaysians, do not believe that modern or Western medicine is sufficiently holistic (Lim, 2002). It is therefore not uncommon for them to combine traditional with medicine and Western medicine, particularly people for whom accessing a medical clinic is more of a geographical challenge. Use of holistic, homeopathic approaches is very important to know given that traditional or homeopathic medications can have side effects or even catastrophic drug interactions when used together (Lim, 2002). Here, we suggest that content for health-care treatment should be designed synergistically with existing cultural beliefs and practices in order to maximize effectiveness of health-care interventions.

Testing Usability of the Interface in the Target Culture

So far, we have shared what we see as key factors critical for designers to consider when developing apps, interfaces, and other aspects for information delivery through mobile technologies in Malaysia. Here, we focus more specifically on strategies for user-testing mobile health communication delivery through interfaces. In addition to the factors mentioned earlier with respect to the I-PXD approach, issues to explore include basics such as types of mobile phone hardware and software available if not common (for instance, in Malaysia, the Android smartphone and its features are currently the most popular and familiar; Salihah et al., 2017), and general expectations and needs of Malaysian populations, including cultural preferences with respect to content web page organization (links, layout, use of images, or animation).

U.S. governmental guidelines for usability recommend prioritizing user performance over user preferences (U.S. Department of Health & Human Services, 2017). For medical concerns, user performance is of particular importance, leading us to suggest that even when glocalizing, usability studies focus most on user interaction, navigability, format, and so on. However, considering cultural distinctions related to aesthetics, Tractinsky (1997) called for continued attention to “how people [across cultures] experience and judge information systems” (p. 121) since preferences, cultural or otherwise, can very well impede performance.

To assess the effectiveness of health-related interface in the contexts of care as we propose earlier, usability evaluation is required. Like others before us (see, e.g., Kushniruk, Borycki, Kuwata, & Kannry, 2011), we recommend that usability testing be diversified to include laboratory testing, real-world health-care contexts (e.g., hospitals, clinics) as well as contexts where health-related activities are conducted by patients (e.g., at home or in a community center). The goal is to identify issues users experience while rather than after a system is designed.

One such usability testing approach employed in health-care settings by researchers such as St.Amant (2017) is the talk-aloud protocol, which asks users to verbalize what they are doing and why while using a given mobile technology or app. A disadvantage of the talk-aloud procedure among Malaysians is a potential refusal to express what they experience as negative in order to save face and preserve the dignity of the tester or designer (Yeo, Barbour, & Apperley, 1997). To prevent this social–cultural effect, those conducting tests can minimize their role and emphasize the purpose to improve the given interface to optimize all future user experiences. Testers should also try to remain minimally visible while the mobile device audio-records user verbalization and records the screen the user is interacting with.

A second usability testing approach that we consider useful in Malaysian contexts is the scenario-based method (Rosson & Carroll, 2009). An advantage of the scenario-based method is that it can easily be understood by anyone, as it focuses on tasks rather than the technology itself. Because the scenario-based test describes a sequence of events and actions related to usage contexts, it can capture other design possibilities that were not thought of in the initiation process of the design.

Another testing method that could be helpful for testing in Malaysia is the contextual inquiry method. Adapted from the fields of psychology, anthropology, and sociology, contextual inquiry is a qualitative data gathering and analysis method requiring that evaluators go to actual settings and observe while users engage with the product (Raven & Flanders, 1996). Data gathered are then shared and compared among product development team members. What is beneficial about the contextual inquiry method is that it is built upon three core principles: (a) it is focused on understanding the context of use where the product is used, (b) the user is considered a partner in the design process, and (c) it is constructed upon the foundation that usability design processes as well as assessment methods must have a clear focus (Ghasemifard, Shamsi, Kenari, & Ahmadi, 2015). This is particularly useful for a design approach centered in the context of use and the user.

Yet another possibility is an actual experiment to test functionality or bring to light hidden factors impeding use among Malaysians. Such tests can include a comparison model testing people using standard procedures for a given task as opposed to using, for instance, the new interface on a mobile phone. Time, error rates, satisfaction, and more can all be tracked in such a study. In addition, given our interests in working toward the objectives of I-PXD, later we address more specific suggestions for exploring usability with respect to these factors.

The I-PXD Approach to Assessing Usable Design

The aforementioned approach helps identify certain design aspects that can affect the usability of online health and medical materials accessed via mobile phones by individuals in Malaysia. The next step in the process involves using I-PXD considerations to review and contextualize the results. We present this I-PXD-focused assessment in the subsections that follow.

Usability Testing and Accessibility

In conducting user tests to address accessibility in Malaysia, we want to reiterate what the I-PXD approach recommends with respect to contexts of use (i.e., where something is actually used). As mentioned, context can include the physical space (e.g., whether it is public, private, spacious); the materials present; the people present; connectivity and bandwidth issues, to name a few. Such recommendations suggest that usability studies in Malaysia take into account varied, primary contexts: for both East and West Malaysia, public and private health institutions, rural and urban areas, varied geographical contexts (plains, mountains, rainforests, and islands), and affluent as well as low-income areas. Key here is that the usability studies take place in context, where people will engage health-care communications or information through mobile technologies, whether in their homes, a public setting, or a health institution.

Within these varied settings, usability specialists will want to note variations in mobile phone ownership, connectivity, tools (artifacts, technologies, and human or professional resources) likely to be present during use, as well as any impacts of seasonal variations. These can include rough monsoon seasons experienced more heavily on the east coast of Malaysia. Understanding such contexts will help designers realize how, when, and where to make their mobile tools usable when Internet connections are unpredictable.

Context with respect to accessibility also includes the mobile phone interface possessing a small amount of “real estate” that therefore must be optimized. How can medical or health-related information or apps convey what is needed most efficiently and effectively for Malaysian users on that small screen? What balance of text and image is optimal for a literate population that may not be so literate when it comes to medical or health-related information? What minimal bandwidth requirements should be available for use of animation, sound, or video? What portability requirements will be optimal in Malaysia between phone and other technologies? Notably, Malaysians are far less likely to own a laptop, desktop, or tablet than they are a phone. What are the implications for relying heavily or exclusively on the mobile phone alone, with and without Internet connectivity as well as with and without service, as can occur in some regions more than others?

A primary method we recommend for exploring accessibility of mobile technologies for health-care purposes is observation. Although this method can be costly time- and resources-wise, observing users in various contexts will allow usability specialists firsthand insights into challenges likely to be encountered in specifically varied contexts, whether in a home in a remote region, in a car in the mountains, in a community “wireless village” space, in public, or private health institutions. Moreover, as Edwell (2017) explains, observation in specific, physical contexts allows us to note how “the built environment makes rhetorical claims on audiences, observing how audiences engage or manipulate the emplaced rhetoric, and [importantly] considering how such rhetoric might be practiced differently” (p. 160). We agree with Edwell’s (2017) argument that “when the target of rhetorical inquiry is material and spatial, the researcher needs to be ‘on the ground’ at the site” (p. 167).

Another method to assess accessibility could be conducting user tests with Malaysians of varied ages, educational backgrounds, and knowledge of particular language. Studies could involve tasks and practices common to health-related practices (e.g., search for and use of health-care information; interactions with health-care professionals). They could also help address questions such as: Is our assumption correct that high literacy rates in Malaysia will help facilitate online health-care-related practices through mobile technologies there? Will user-test results support prior research on Malaysia users holding preferences for English language rather than their first language when it comes to health-care practices? What characteristics work best for apps when connectivity is spotty at best? The resulting answers can help develop approaches and create materials that better address local and cultural needs in terms of access.

Usability Testing and Manageability

Usability specialists will want to ask similar questions with respect to manageability. Core questions to address here would include the following: To what extent can the target Malaysian users understand, use, or manage their health-care needs and practices via mobile phone? What resources are available in the various contexts, and what required resources would need to be added to supplement health-care communication, information, and interaction through their mobile phones? The resulting answers can assist in developing technologies a wide range of individuals can use, based upon their understanding of the technology and topics being addressed.

Usability and Comprehensibility

Aspects important to usability of mobile technologies in Malaysia include high literacy rates. Do these vary, however, by any of the contexts mentioned previously? For example, are the mountainous or rainforest areas more likely to have people with lower literacy rates or income? What implications for design can be determined based on intersectional factors such as remote regions; less familiarity with the English, Malay Bahasa languages; and so on? Ideally, the designs of materials and technologies would make them seem almost reflexively easy to use as individuals seem to readily understand what they do and how to use them.

Usability Testing and Sustainability

Sustainable in mobile technologies can include whether one can return to the information previously consulted, use that information again and again, and get that information updated in the background (which unfortunately can only occur when one has connectivity). Sustainable in mobile technologies might also include whether an app, once purchased or downloaded, remains available or whether there is an annual fee.

More important with respect to sustainability could be exploring what occurs after a user has engaged with health-care communication, interaction, or application through mobile technologies. To track this, we recommend survey or follow-up interviews as valid methods. Usability specialists looking at use of a specific health-related app could follow-up with users to learn what features of the app allowed them to access what they needed, how if at all they used the information gained, what more they might need from an app for their given circumstance, and more. In “‘No Single Path’: Desire Lines and Divergent Pathologies in Health and Medicine,” for instance, Gouge (2017) reminds us that “unpredictability is a part of the experience and treatment of an illness” (p. 118), as is the use of mobile technologies for health-related purposes. In other words, users may or may not use the health-related materials offered through mobile technologies as intended, and it will be important to learn how and why they do—or do not—so.

Usability Testing and Acceptability

Issues to consider for designing mobile technologies for health-care purposes in Malaysia can include identifying whether irrelevant or inappropriate information is present (e.g., with particularly Western lenses or approaches). They can also encompass whether additional information is required for specific tendencies of Malaysians in specific areas. (Such a situation would be the case for Malay individuals who consult with or visit traditional healers as a first step in their health care or for those persons who rely heavily on homeopathic approaches.)

At the same time, we would like to use a word of caution not to essentialize by nation or even region of Malaysia or make assumptions about such aspects as prominent “races” or ethnicities within Malaysia. Happe (2017), for instance, cautions against “racial profiling in medical care” and calls for “rhetoric and health care communication that is problem-driven rather than identity-driven” (p. 88). The point here is not to ignore explicit differences (such as the names used for various instruments or illnesses) but to avoid making assumptions based on profiles of given groups, whether by race, religion, or region.

Conclusion

With advanced computing capabilities, mobile phones offer promising solutions to basic health-care provisions for the health-care industries both in advanced and developing countries. Smartphones could allow medical professionals to solve problems quickly and coordinate care with other medical professionals easily; mobile technology can offer patients tools for self-management of diseases, health education, and remote monitoring (Van Velsen, Beaujean, & van Gemert-Pijnen, 2013). The large question that we need to answer is how mobile technology can be designed to meet the needs of diverse cultural groups and still be meaningful to users in such a diverse country as Malaysia.

In this article, we have explored factors to consider for testing in the design and use of interfaces offering health-care activities through mobile devices, in this case, for Malaysian users. Although Malaysia is already a “mobile-oriented society” (p. 10), as we have learned from Verhulsdonck (2015), when it comes to mobile technologies, design “needs to be flexible enough to accommodate” what is learned about specific or local user contexts and constraints “while at the same time employing elements that can be recognized and reused by individuals globally” (p. 141).

In the case of Malaysia, we see potential for research that will identify user familiarity with “standard” mobile features for a more global “online culture,” those that are established as well as constrained by evolving and improving hardware features along with connectivity capacities. Such a situation is in contrast to mobile design features that more explicitly reflect local needs and expectations for—as well as uses of—health-care information. Where mobile interface design for specific cultures is concerned, we suggest that information designers explore experiences of local target users to determine what works best for them in given contexts.

Future researchers in mobile health information delivery might also consider exploring the glocalization approaches advocated throughout this article. Such work could have the potential, as Bhavnani, Narula, and Sengupta (2016) remind us, to allow us to “identify new methods for patient engagement that results in beneficial and measurable behavioral changes” based on the “interplay” not just of digital devices and “digital patients” but also other stakeholders involved in health information solutions (pp. 1437–1438). The I-PXD framework is but one approach allowing for glocalization to be implemented. Overall, along with St.Amant (2015) and Sun (2012), we advocate seeking richer, contextual user-informed practices from inception of a design to a deliverable health-care product, urging a view of design as ongoing and products as evolutionary, continually informed and improved by capturing response from actual as well as potential “glocal” users of mobile, health-related information in Malaysia and beyond.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Evelyn H. Saru is a final year PhD student working on her dissertation at University of Texas El Paso. Her research interests include rhetoric of health and medicine, technical communication, professional communication, and intercultural/cross-cultural rhetoric.

Patti Wojahn serves as a professor and department head of Interdisciplinary Studies at New Mexico State University. Her research interests include human-computer interaction, collaborative processes, interdisciplinary collaboration, and professional communication.

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