JMIR FORMATIVE RESEARCH

Bin et al

Original Paper

User Experience Regarding Digital Primary Health Care in
Santarém, Amazon: Evaluation of Patient Satisfaction and Doctor’s
Feedback
Kaio Jia Bin1, MD, MSc; Patrícia Gabriela Santana Alves1, BSc; Raquel Costa1, MD; Paula Cruz Eiras1, BSc; Luciano
Nader de Araujo1, MD; Antonio José Rodrigues Pereira1, PhD; Carlos Carvalho2, MD, PhD; Ana Maria Malik3, MD,
PhD
1

Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil

2

Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil

3

Fundação Getúlio Vargas Escola de Administração de Empresas de São Paulo, São Paulo, Brazil

Corresponding Author:
Kaio Jia Bin, MD, MSc
Hospital das Clínicas
Faculdade de Medicina
Universidade de São Paulo
R. Dr. Ovídio Pires de Campos, 225 - 3º andarSão Paulo, 05403-110
BrazilPhone: 55 1126616208
Email: kaiobin@gmail.com

Abstract
Background: With the arrival of the pandemic, telemedicine has been widely used to provide medical care and can be used toassist patients in regions far from urban centers that are difficult to access, such as riverside communities in the Brazilian Amazon
region. A telemedicine project connecting São Paulo, a mega-metropolis, to Paysandú, a riverside district in the Amazon, wasbuilt to serve the local population where access to the nearest medical care is 6 hours away by speedboat.
Objective: This study aims to assess the feedback from patients and doctors regarding the use of telemedicine in outpatient care
at Paysandú, a riverside district in the Amazon.
Methods: This is a single-center study following the guidelines “Evaluating digital health products” from Public Health England,with local adaptations for the project and the Brazilian reality, that was conducted between São Paulo and Santarém in Brazil. A
survey was carried out with patients who were treated by a doctor in the city of São Paulo, about 2500 km from the local basic
health unit, between September 27 to December 15, 2021. At the end of each teleconsultation, the attending physician answered
an administrative survey form, and the patient answered a satisfaction survey.
Results: A total of 111 patients completed the satisfaction survey from a total of 220 consultations carried out during the period(95% CI margin error 0.22%). According to the survey, more than 95% of patients were satisfied with the service, 87.4% (n=97)
had previous experience with videoconferencing, and 76.6% (n=85) reported that their demand was fully solved. Additionally,
according to the hired doctor’s feedback, the average duration of the consultations was between 15 and 20 minutes. Of the 220
teleconsultations performed, 90.9% (n=200) of the demands were solved with support from the local health team, and 99.1%(n=218) of the appointments had a problem with audio or video.
Conclusions: This teleconsultation project between São Paulo and Paysandú showed that it is possible to offer medical carefrom more developed locations to communities far from urban centers, as is the case with Paysandú District. Beyond the feasibilityof the infrastructure, acceptance and satisfaction among patients were high. This health care supply model has proven to befunctional and should be expanded nationally or perhaps internationally to regions lacking medical assistance. Escalation of the
project does not seem too difficult once infrastructure issues are solved.
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KEYWORDS
telemedicine; primary health care; user’s experience; Amazon; digital health; pilot; patient; pilot model; pandemic; medical care;assist; urban; community; Brazil; technology; consultation; physician; survey

Introduction
Until 2020, the last alert for a pandemic had been declared by
the World Health Organization more than 10 years earlier,referring to the global spread of the H1N1 virus in 2009 [1]. In
2020, the level of contamination by a new type of coronavirus
with great infective potential became global, leading to a new
World Health Organization statement warning about the
COVID-19 pandemic on March 11 [2].
In early 2020, the Brazilian Ministry of Health had alreadydeclared an Emergency in Public Health of National Importance[3], leading to a series of responses from the state and local
health systems to fight the disease. These responses modified
daily activities for the entire population. With the need for social
distancing, different levels of care sought alternatives tomaintain regular activities for their populations, encouraging
the incorporation of new technologies into services and boosting
existing initiatives. In this context, services mediated bytechnology gained prominence, including telehealth ortelemedicine actions to support diagnosis, therapy, and healtheducation, especially where distance is a critical factor [4].
Telemedicine and telehealth actions have already been
incorporated by other health systems in the world as is the caseof Canada, which, given the geography and often adverse
climate, was one of the first countries to use IT tools, especiallystarting in the 1990s, to provide medical care and promote
distance education [5]. In the United Kingdom, the National
Health Service has also adopted telemedicine since the 1990s
and considers it a method that combines the use of computers
and telecommunication technology with medical expertise to
send and receive information that helps a medical diagnosis andthat assists services in caring for people who are far away [6].
In Brazil, the use of telemedicine was controversial until
Ordinance N.467 of March 20, 2020, edited by the Ministry of
Health, that allowed the use of telemedicine actions covering
health care and teleconsultations during the pandemic due tothe need to reduce the circulation of people exposed to the newvirus [7], especially in health services.
Despite telemedicine being considered a recent advancementin Brazil when compared to its diffusion in high-income
countries such as England, Canada, and the United States, it isan opportunity to increase equity in the access and delivery of
medical care, regardless of the geographic location andsocioeconomic status of users of the health system [8]. Several
Brazilian national and local government initiatives are currently
underway. One of them is the Telessaude Brasil Program thatstarted in 2019 with the aim of improving and expanding thehealth services network, mainly strengthening thecommunication of primary care with other levels of health care
[9].
Another Brazilian government initiative is the University
Telemedicine Network Project (Rede Universitária deTelemedicina) by the Ministry of Health and the Ministry of
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Technology and Innovation, which aims to support thetelemedicine infrastructure in universities and teaching hospitals
countrywide to promote greater collaboration, communication,
health care, and teaching [10].
Within the current pandemic context, the need to strengthen
primary health care was explicit; in addition to the scope of
prevention, promotion, and health education innate to thedifferent levels of care, primary care also proved to be an
important resource in combating COVID-19 [11].
To preserve primary health care’s routine activities, it isnecessary to readjust and to incorporate new procedures,
including the use of information and communication
technologies to carry out teleconsultations [11].
Teleheath enables the system to avoid treatment discontinuityor the worsening of patients with chronic conditions, in addition
to meeting lower risk demands, which do not requireface-to-face interaction, for example, the renewal ofprescriptions for continuous use [11].
A qualitative systematic review published in 2020, whichanalyzed the results of 43 studies in different countries on theperception of health professionals working with telemedicine
programs in primary health care, showed that the innovation
has improved the relationship between practitioners and theirpatients as well as enabled the delivery of care in regionsdifficult to access. A counterpoint described in the same study
is the difficulty of maintaining this type of care when it depends
on the availability of individual equipment—cell phones, tablets,
computers—by the target population [12].
In view of this evidence, a solution that promotes remoteprimary health care delivery through teleconsultations that is
not conditional on the availability of technological resources
for personal use by each user of the system is needed, allowing
for interaction between people physically located kilometers
away and providing quality care capable of meeting the demandsof a region lacking health professionals [13].
Social distancing as a measure of sanitary control leveraged thedevelopment of telemedicine, turning it into an important healthcare tool for individuals who, historically, have little access tohealth services [14].
Given the incorporation of new technologies and new modesof care delivery to users of the health system, it is important toadopt methodologies that assess new work processes. It should
not only consider the results and impacts but also enablemeasurement of satisfaction with the new modalities of careamong users. Issues such as access to the service anddoctor-patient relationship are fundamental aspects of the healthcare model when it comes to user satisfaction [15].
In Brazil, a continental country, some cities are among the mostdeveloped in the world, like the city of São Paulo. On the other
hand, some of them, with a very low Human Development
Index, can only be accessed by boat in the middle of the Amazon
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region like the district of Paysandú. For these hard-to-reachsmall towns, even access to primary care provided by a primarycare physician is often scarce. In Society 5.0, where humans
are supposed to be the center and technology the servant,geographical barriers should be broken using telemedicine.
Based on the Scrum methodology already used previously [16],a telemedicine project was carried out between the city of São
Paulo and Paysandú, a riverside district of the city of Santarém
in the Amazon region of Brazil, between September 27 andDecember 15, 2021. At the end of each consultation, a surveyof patient satisfaction and physician impressions were collected
over 220 performed teleconsultations.
This study aims to assess the feedback from patients and doctors
regarding the use of telemedicine in outpatient care at Paysandú,a riverside district in the Amazon.

Methods

the purpose of its improvement or implementation, which do
not aim to obtain generalizable knowledge but only data thatcan be used by that service for its improvement, do not require
ethical analysis by the research ethics committee system(Comitês de Ética em Pesquisa/Conep), as it does not have direct
patient involvement or handle personal data [20,21].
In this study, a satisfaction survey was carried out among
patients, and an opinion survey was given to physicians. All
responses were collected anonymously, without identifying or
sensitive data.
All the data collected were used to evaluate the performance ofthe pilot project carried out between September and December
2021 to identify possible points for improvement, such as
internet connectivity and patient satisfaction.

Main Research Question
What is the satisfaction of patients regarding teleconsultation
between São Paulo and Paysandú?

Study TypeA single-center study following the guidelines “Evaluating
digital health products” from Public Health England [17], withlocal adaptations for the project and the Brazilian reality, wasconducted between São Paulo and Santarém in Brazil.
A descriptive study of the “analysis of routinely collected data”[18] using administrative and “user feedback study” [19] datacollected by a satisfaction survey was conducted by the
management team.

Ethics Approval
This user experience study was approved by the ethics
committee of Hospital das Clínicas, Faculdade de Medicina,
Universidade de São Paul Comissão de Ética para Análise deProjetos de Pesquisa) without the need for ethical analysis by
the research ethics committee system (Comitês de Ética em
Pesquisa/Conep). According to the guidelines of Brazilian
National Health Council resolution No. 466/12 and No. 510/16,
studies that only have the objective of assessing a service forStudy Setting
From September 27 to December 15, 2021, a study was carriedout linking a basic health unit in the city of Santarém and auniversity hospital in the city of São Paulo, separated by about
2500 km. The basic health unit is located in Paysandú District,a riverside city in the city of Santarem, state of Pará, Brazil.
The local team consists of 1 nurse and 2 nursing technicians.
For remote medical care, Hospital das Clínicas, Faculdade de
Medicina, Universidade de São Paulo, a tertiary university
hospital, hired a primary care physician for 20 hours per week
(5 hours per day, 4 days per week on Monday, Tuesday,
Wednesday, and Friday afternoons), totaling 39 days with 195
hours scheduled for appointments and 220 hours performing
teleconsultations (Table 1).
Disregarding holidays, local vaccination campaigns, andjustified absences of the hired doctor when there were no remoteappointments during the project, there were 220 performed
consultations (Table 1).

Table 1. Total planned days, total planned hours, and total performed consultation per week during the project.
Week

Total planned days (N=39), n

Total planned hours (N=195), n

Performed consultation (N=220), n

Week 13

15

10

Week 24

20

0Week 32

10

8

Week 44

20

32

Week 54

20

22

Week 63

15

10

Week 74

20

20

Week 83

15

27

Week 93

15

19

Week 103

1528

Week 113

15

21

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Telemedicine Performance

Study Design

To assess the performance of telemedicine, at the end of eachconsultation, the doctor fills out a multiple-choice survey basedon their personal opinion through a Google Form on theadministrative aspects of care.

The data from Google Forms were extracted to Excel version
2010 (Microsoft Corporation), where they were analyzed.

To simplify the administrative analysis, the consultation
performed was classified according to the following criteria by
the doctor:

From the 220 performed appointments, 160 were previously
scheduled and 60 were scheduled on the same day of theconsultation (Table 2).

••

Investigation: presents acute complaints to be analyzed;
follow up with tests for diagnostic confirmation andre-evaluation
Orientation: guidelines regarding procedures, contraceptive
methods, and prescription renewal

Patient’s Satisfaction Survey
At the end of each medical consultation, a health agent asked
whether the patient was interested in participating in asatisfaction survey anonymously. If the patient agreed toparticipate in the survey, a self-explanatory printed satisfaction
survey in Brazilian Portuguese with multiple-choice questions
using a Likert scale was given to the patients, with the following
response options:
•
•
•
•
•

I totally agree
I partially agree
Indifferent
I partially disagree
I totally disagree

The questions used in the satisfaction survey (translated from
Portuguese):
1.

Waiting time to get an appointment with the doctor was
satisfactory.
2. Duration of medical care was satisfactory.
3. Doctor was respectful, kind, and considerate during theconsultation.
4. Doctor’s explanation of care/treatment plan was clear andunderstandable.
5. You feel confident with the care/treatment plan
recommended by the doctor.
6. You feel that your privacy was respected throughout theservice.
7. Your demand was appropriately met by the doctor.
8. You are already familiar with video calls via cell phone orcomputer.
9. Local team provided you with the necessary guidance before
remote medical care.
10. Local team provided you with the support needed during
the video call.
11. Audio quality during the video call was satisfactory.
12. Image quality during video call was satisfactory.
13. You feel comfortable receiving medical care by video call.
14. Remote care provided by the doctor was as good as
face-to-face care.
15. Remote medical care has made it easier for me to see ahealth care provider.

Results

Of the 220 performed teleconsultations, 70.9% (n=156) were avisit with a clinical investigation, 90.1% (n=200) took between
15 and 20 minutes, 80.9% (n=178) were first visits, 70% (n=154)
received medical discharge, and only 2.7% (n=6) needed local
specialist medical care support; none required local generalist
medical care (Table 3).
Regarding the question “Was it possible to solve the patient's
demands?” the hired doctor answered that in 90.1% (n=200) ofvisits, it was possible to solve the patient’s demands with thesupport of the local team (Table 4).
About “connectivity issues?”, the doctor answered that, in 75.5%(n=166) of the visits, there were issues with audio and video;
only 2 visits were performed without any connectivity issue
related to audio or video (Table 5).
The satisfaction survey received a total of 111 answers of the
220 total performed consultations; at a 95% CI, the margin oferror was 0.22% (Table 6).
About the remote medical care, according to satisfaction survey
responses, more than 96% of patients agreed that:
•
•
•
•
•
•
•

About the connectivity of the remote medical care, 87.4% (n=97)
of patients agreed that they were already familiar with using
video calls via cell phone or computer, and more than 95%
agreed that:•••

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Audio quality during the video call was satisfactory,
Image quality during the video call was satisfactory, andLocal team provided the support needed during the video
call.

Regarding the patient, more than 97% of them agreed that they:••

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Waiting time to get an appointment with the doctor was
satisfactory;
Duration of medical visit was satisfactory;
Doctor was respectful, kind, and attentive during theconsultation;
Doctor’s explanation of care/treatment plan was clear andunderstandable;
Remote care provided by the doctor was as good as
face-to-face care;
Remote medical care has made it easier for you to see ahealth care provider; andLocal team provided you with the necessary guidance before
remote medical care.

Felt confident with the care/treatment plan recommended
by the doctor,
Felt that privacy was respected throughout the consultation,
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Felt comfortable receiving medical care by video calling.

A total of 76.6% (n=85) of patients agreed that their demands
were appropriately met by the doctor. Table 7 presents the

Bin et aldetailed distribution of answers by question regarding
satisfaction survey.

Table 2. Total service performance by type of attendance.
When the appointment was scheduled

Consultation (N=220), n (%)

Previous scheduled

160 (72.7)

Scheduled at same day

60 (27.3)

Table 3. Administrative information collected after medical teleconsultation.
Consultation (N=220), n (%)
Was it an investigation or an orientation?
Investigation

156 (70.9)

Orientation

64 (29.1)

What was the duration of the consultation? (minutes)
10-15

6 (2.7)15-20

200 (90.9)>20

14 (6.4)

Was it first visit or return?
First visit

178 (80.9)

Return visit

42 (19.1)

Did it require a return visit or led to medical discharge?
Medical discharge

154 (70.0)

Return for re-evaluation

30 (13.6)

Return with complementary exams

36 (16.4)

Did it require local medical care?
Forwarding to local specialist

6 (2.7)

Forwarding to local generalist

0 (0.0)None

214 (97.3)

Table 4. Was it possible to meet the patient’s demands?
Was it possible to meet the patient’s demands?

Consultation (N=220), n (%)

Yes, without local team support

6 (2.7)

Yes, with local team support

200 (90.9)

Partially, with local team support

14 (6.4)

No, needed an external medical care

0 (0.0)

Table 5. Were there any connectivity issues?
Were there any connectivity issues?

Consultations (N=220), n (%)

Problems with audio and video

166 (75.5)

Problems with audio

44 (20.0)

Problems with video

8 (3.6)None

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Table 6. Participation in satisfaction survey and margin of error.
Participation in satisfaction survey

Value

Total performed consultation, n

220

Total participation in satisfaction survey, n111

CI (%)

95.0

Margin of error (%)

0.22

Table 7. Detailed distribution of answers (N=111) by question of the satisfaction survey.
I totally
agree, n

I partially Indifferent, I partiallyagree, nndisagree, n

I totally
disagree, nNo reply,
n

Agree
(%)

Disagree(%)

Waiting time to get an appointment with the doctor
was satisfactory

74

34

0

1

1

1

97

2

Duration of medical care was satisfactory

87

23

0

0

0

1

99

0

Doctor was respectful, kind, and attentive during the 89
consultation

19

0

1

0

2

97

1

Doctor’s explanation of care/treatment plan was clear 87
and understandable

22

0

0

1

1

98

1

Remote care provided by the doctor was as good as
face-to-face care

85

22

2

1

0

1

96

1

Remote medical care has made it easier for you to
see a health care provider

83

24

0

1

0

3

96

1

Local team provided you with the necessary guidance 84
before remote medical care

23

1

1

1

1

96

2

You are already familiar with using video calls via
cell phone or computer

70

27

2

2

2

8

87

4

Audio quality during the video call was satisfactory 78

29

0

0

1

3

96

1

Image quality during video call was satisfactory

84

21

2

0

3

1

95

3

Local team provided you with the support needed
during the video call

89

20

0

1

0

1

98

1

You feel confident with the care/treatment plan rec- 83
ommended by the doctor

27

0

0

0

1

99

0

You feel that your privacy was respected throughout 90
the consultation

18

0

0

1

2

97

1

You feel comfortable receiving medical care by video 89
calling

20

1

1

0

0

98

1

Your demand was appropriately met by the doctor

9

0

0

0

26

77

0

76

Discussion
Principal Findings
A pilot project of telemedicine was built to connect a
metropolitan city, rich in human resources and infrastructure,
to a riverside city in the middle of the Amazon region, where
the only possible physical access is by boat and the internet isprovided by satellite. Before this pilot project, the local
population of the district Paysandú received one medical visit
a month from the city of Santarém, with 30 appointments
scheduled for 1 day. When there is an unscheduled spontaneous
demand, a 6-hour boat ride downtown is needed.
The pilot project provided the local population with one
web-based physician 4 times per week; during the 12-weekperiod, 220 consultations were offered (an average of 73
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consultations every 4 weeks). Considering the infrastructure
connectivity shortcomings, there was no need for the doctor of
the city of Santarém to travel to the district of Paysandú forlocal consultations. To reduce subjective bias, only one clinicalphysician was hired to evaluate the conditions provided fortelemedicine, like other studies involving technologies [22].
As described by Combi et al [23], implementing telemedicine
in low-income countries has more challenges than in
high-income countries. So, there are several relevant findings
from the feedback from the hired clinical physician.
First, the web-based doctor did not need the support from a
local doctor, which means that a permanent telemedicine
program is possible in this region. Second, only 0.9% (n=2) of
the teleconsultations had no connectivity issues, a recurring
problem in remote regions such as Amazonas [23]. Even withJMIR Form Res 2023 | vol. 7 | e39034 | p. 6
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signal problems, the presence of the doctor at a distance is usefulfor the local population, as will be discussed below. Third,
90.1% (n=200) of teleconsultations needed a local support teamand relevant information regarding setting up a health care unit
in remote regions, requiring the presence of a local health agent.
In addition to being effective, the telemedicine service also
needs to be well accepted by patients [24,25], even withconnection problems in more than 99% of teleconsultations.
More than 95% of the survey participants were satisfied withthe received health care, especially in relation with the doctor,
the infrastructure (even with the existing connectivity problems),
and the support of the local team. This percentage was probably
directly influenced by the high percentage of patients who werefamiliar with the use of telemedicine [23]. However, it isnoteworthy that 76.6% (n=85) of patients responded that they
had their needs answered by the doctor during theteleconsultation (Table 7) using only a videoconference camera,
which indicates that telemedicine helps substantially, but it still
does not replace face-to-face care in full, and barriers still need
to be overcome [26].

Limitations
To avoid bias from different doctors in the performance of theconsultations, all appointments were performed by a single hired
doctor, which had the limitation of medical impressions beingfrom a single source.
Additionally, because there was only one doctor in the study,
the high rate of satisfaction may be due to the role played by
the hired doctor; on the other hand, the high rate of satisfaction
also suggests that a good doctor-patient relationship increases

Bin et alpatient satisfaction even with medical care at a distance andscarce resources.
No evaluation was made comparing this visit with the previous
monthly medical care visit, so it is not possible to assess whether
telemedicine was better accepted in relation to previous medicalcare.
As this was a user experience study based on satisfaction andopinion, no clinical data were collected or evaluated; so, there
is no way to assess the clinical effectiveness of telemedicine,
only its acceptance by the involved users.

Conclusion
This teleconsultation project between São Paulo and Paysandú
showed that it is possible to offer medical care from moredeveloped locations to communities far from urban centers.
Beyond the feasibility of the infrastructure, acceptance andsatisfaction among patients was high. This remote health caremodel proves to be functional and should be expanded nationallyor perhaps internationally to regions lacking medical care.
Escalation of the project does not seem too difficult once
infrastructure issues are solved.
Having the possibility of offering medical care withprofessionals at a distance, it is possible to design a future where
members of a small community can go to urban centers in searchof medical education and, after completing their graduation,
serve their home population through telemedicine.
In addition to the possibility of using remote monitoring devices,such as smart watches [27], the potential for improving thequality of health care for populations in need of medical careis promising.

Acknowledgments
The authors would like to thank Fundação Faculdade de Medicina for funding all equipment and subsidies; Fernanda Christianede Azevedo, Sarah do Valle Studart, and Yohana Rodrigues Andrade, students of the Advanced Study Program in Hospital
Administration and Health Systems at Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo who participatedduring the design phase of the project; and Claudia Mayu Konoma, Rosemeire Bononi Pires, and Rosemeire Keiko Hangai, staff
members of the Advanced Study Program in Hospital Administration and Health Systems at Hospital das Clínicas, Faculdade
de Medicina, Universidade de São Paulo, for all the support offered.

Authors' Contributions
KJB contributed toward the conceptualization, data curation, formal analysis, funding acquisition, investigation, methodology,
project administration, resources, software, supervision, validation, visualization, writing the original draft, and review and editing.
PGSA contributed toward the data curation, formal analysis, investigation, methodology, project administration, supervision,validation, visualization, and writing the original draft. PCE contributed toward the data curation, formal analysis, investigation,
methodology, project administration, supervision, validation, visualization, and writing the original draft. LNdA contributed
toward data curation, formal analysis, investigation, methodology, project administration, supervision, validation, visualization,
and writing the original draft. RC contributed toward investigation, methodology, visualization, and writing the original draft.
AJRP contributed toward the conceptualization, funding acquisition, methodology, project administration, resources, and validation.
CC contributed toward the conceptualization, validation, and supervision. AMM contributed toward the conceptualization,
supervision, validation, and review and editing.

Conflicts of Interest
None declared.

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Edited by A Mavragani; submitted 26.04.22; peer-reviewed by S El kefi, N Plastow; comments to author 02.09.22; revised version
received 05.10.22; accepted 05.11.22; published 11.01.23
Please cite as:
Bin KJ, Santana Alves PG, Costa R, Eiras PC, Nader de Araujo L, Pereira AJR, Carvalho C, Malik AM
User Experience Regarding Digital Primary Health Care in Santarém, Amazon: Evaluation of Patient Satisfaction and Doctor’s
Feedback
JMIR Form Res 2023;7:e39034
URL: https://formative.jmir.org/2023/1/e39034
doi: 10.2196/39034
PMID:©Kaio Jia Bin, Patrícia Gabriela Santana Alves, Raquel Costa, Paula Cruz Eiras, Luciano Nader de Araujo, Antonio José Rodrigues
Pereira, Carlos Carvalho, Ana Maria Malik. Originally published in JMIR Formative Research (https://formative.jmir.org),
11.01.2023. This is an open-access article distributed under the terms of the Creative Commons Attribution License(https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium,provided the original work, first published in JMIR Formative Research, is properly cited. The complete bibliographic information,a link to the original publication on https://formative.jmir.org, as well as this copyright and license information must be included.

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