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The contextual inquiry

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 Chapter 8

The Contextual Inquiry

Hanneke Kip, Nienke Beerlage-de Jong & Jobke Wentzel

Introduction

As was already explained in Chapter 1, eHealth has a lot of potential benefits for health,
healthcare, and wellbeing. However, in order to reach that potential, a good fit between the
technology, its users, other stakeholders, and their context is extremely important. To achieve
this, a participatory development approach is required, during which developers should at all
times keep an eye on the context. Participatory development entails a structural cooperation of
eHealth developers with potential end-users and other stakeholders during its development. A
proper eHealth development process should thus be iterative. The CeHRes Roadmap prescribes
that a thorough contextual inquiry should be the first step in eHealth development, since its
results serve as valuable input and information for all further phases of development (see Chapter
7).

In this chapter, the relevance of the contextual inquiry is explained. A non-exhaustive overview
of relevant research methods is provided and illustrated by cases from practice. After completing
this chapter, you will be able to:

• explain why and in what way the contextual inquiry is essential for the eHealth
development process.
• provide concrete examples from practice to illustrate the relevance of conducting a good
contextual inquiry for the development of good eHealth development.
• name and explain the relevance of multiple research methods that are used in the
contextual inquiry.
• explain the identification, analysis and added value of stakeholders during the contextual
inquiry, and connect this to the entire eHealth development process.
• connect the contextual inquiry to holistic development, using the terms user, context and
technology.

Contextual Inquiry: The First Step in Any eHealth Project

What is the aim of the contextual inquiry?

A contextual inquiry entails the activities that are undertaken to get a good grasp of the
problems, how technology can contribute to resolving these issues, and who might benefit from
the technology. The contextual inquiry was introduced as a phenomenological research method
that makes use of many qualitative methods in design (Whiteside, Bennett, & Holtzblatt, 1988).
It is part of contextual design, which aims to aggregate data from stakeholders in the context
where they are living and working, and applying these findings into a final product (Beyer &
Holtzblatt, 1998). Consequently, the goal of the contextual inquiry in eHealth development is to
get a thorough understanding of the prospective users, other important stakeholders and their
environment. Together they make up the context in which the technology can be used.
Consequently, there has to be a thorough understanding of the potential end-user’s day-to-day
environment. This requires, for example, insight into their daily tasks, activities, or procedures
(Beerlage-de Jong, van Gemert-Pijnen, Wentzel, Hendrix, & Siemons, 2017). An in-depth
contextual inquiry is necessary to achieve a fit between the technology, its users, other
stakeholders and their context. If this is achieved, chances are very high that the technology that
is developed is going to be used and implemented sustainably (Van Gemert-Pijnen et al., 2011).

Because multiple perspectives ensure a broader view on the context, the development team
should consist of multiple groups of people, like researchers, policy makers, designers and
potential end-users (see Chapter 7). In the contextual inquiry, the team learns about the context
by combining information from both science and practice. eHealth developers have to be familiar
with important literature on their topic in order to know the scientific context, but they must also
account for the perspectives of important stakeholders and learn about their environment by
means of multiple methods (Beerlage-de Jong et al., 2017).

The specific research questions that should be answered in a contextual inquiry depend on the
type of project. To illustrate this a bit further, the following questions can be central during the
contextual inquiry:

• who are the stakeholders that are relevant for the project and its development? Which
stakeholders are the most important?
• what does the current situation look like? What is going well? What could be improved?
• what problem has to be addressed? Who has a problem? What does the problem entail
and what are its causes according to stakeholders and literature?
• what kind of behaviour has to be changed? What are the causes of this behaviour
according to people and literature?
• what rules, regulations and ethical concerns are applicable to the context the technology
has to be used in?
• what kind of eHealth technologies are already being used in the context, and what are the
experiences of users and other stakeholders?

What is the added value of the contextual inquiry?

Not conducting a contextual inquiry, or even conducting it too superficially, can lead to a
mismatch between the technology, context and users. Several fictional (but reality-inspired)
examples to illustrate this are provided below.

Example: Technology in a nursing home

Imagine a technology that aims to assist nurses in caring for their diabetic, elderly patients. The
technology prescribes when and what kind of actions need to be undertaken for each individual
patient. These nurses are working in a retirement home where elderly are living in separate
apartments. The technology is designed to run on a personal computer (PC), meaning that the
nurses constantly have to run back and forth between their office and the patients’ apartments,
which costs a lot of unnecessary time and energy. A computer based technology probably
wouldn’t have been chosen if the developers would have had a good idea about the work
processes of the nurses before coming up with the solution, since it doesn’t fit the work patterns
of the nurses. It might have been better to develop an app for tablet or smartphone that the nurses
can carry with them.

Example: An app for depression

Another example emphasizes the importance of a thorough stakeholder analysis. An app was
developed that aimed to assist depressive people treated by a therapist in writing about negative
and positive experiences. The developers acknowledged the importance of accounting for the
perspective of, according to them, the most important stakeholders: the patients. They
continuously asked for their perspective, input and feedback on the technology. However, they
did not include the therapists in the process, which resulted in a lot of resistance on their side.
The therapists didn’t agree with the way some of the exercises were described and missed
important information on depression. Consequently, they did not advise the app to any of their
clients. If the developers had conducted a comprehensive stakeholder identification and analysis,
they would have found out about the important role of the psychologists in time.

Activities in the contextual inquiry

The what and why of the contextual inquiry have been explained, but it is important to address
the how as well. What activities should be undertaken to conduct a thorough and systematic
contextual inquiry? There is no one clear answer to this question, since there are many ways to
do this. However, it is always advisable to use multiple methods to collect information since this
enables the eHealth developers to paint a good, comprehensive picture of the context. These
methods can have very different characteristics, ranging from explorative and qualitative
methods that can provide a broad view on a certain topic or situation, to more fact-checking and
quantitative approaches that can assess how ‘big’ or widespread a problem or situation is.
Combining methods decreases the chances of overlooking important information.

Methods for the Contextual Inquiry

In the contextual inquiry, multiple methods are combined to provide an overview of the context
that is as complete as possible. Each individual method has to render useful input for the rest of
the development process. This input has to guide decisions that have to be made in upcoming
phases, for example about the goals of the technology, its platform, and the implementation
strategy. The list of methods discussed in this section (see Table 1) is not exhaustive, but
provides oversight of possible methods that can be used in the contextual inquiry. The order in
which they are discussed by no means implies an order in which they should be applied; this
chapter is not a blueprint for a contextual inquiry. The methods can be used subsequently, but
can also be applied simultaneously, and other type of methods can be used as well.

Table 1. A list of methods discussed in this chapter.

Method
Stakeholder identification The identification of stakeholders; people who are affected by an
eHealth technology.
Stakeholder analysis The analysis of the interdependencies, responsibilities and stakes
of involved stakeholders.
Desk research The non-systematic collection of material that helps the
development team to learn as much as possible about the context.
Scoping review The gaining of insight in the current status quo of scientific
literature in a certain broad field of study by means of a
systematic search of literature.
Focus group The collection of qualitative data by involving a small number of
stakeholders in a group discussion, ‘focused’ around a particular
topic or set of issues.
Interviews The asking of questions in a structured, semi-structured or
unstructured way to obtain answers from an individual.
Observations (field The observation of an event of interest while it occurs by a
research) researcher, direct or mediated via technology.
Diary study The keeping of a diary of certain events on a regular basis by
research participants.
Log data analysis The use of data that logs certain behaviour on a system or in
daily life to analyse patterns.

Stakeholder identification and analysis

A pivotal part of any contextual inquiry is a thorough stakeholder identification and analysis.
After all, for an eHealth technology to be successful, it must fit the various goals and work- and
think processes of the people that will be in any way in contact with it. To achieve this,
researchers and technology developers need to have a clear view on who the relevant
stakeholders are and what their stakes are; hence, a stakeholder analysis is required.

But who or what are stakeholders? A widely known and accepted definition says that a
stakeholder is ‘any group or individual who can affect or is affected by [eHealth technology]’
(Freeman, 2010, p46). Thus, stakeholders are not only the (potential) end-users of the
technology. For example, policy makers may have a clear say in whether an eHealth technology
fits their organization’s vision, and whether it will be implemented. ICT experts may have clear
ideas about what is needed for them to be able to maintain the eHealth technology, or what the
possibilities of a technology are. This can make policy makers, ICT experts and many others,
like doctors, therapists or funders, stakeholders as well.

First, all possible stakeholders must be identified. After that, their interdependencies (e.g.
manager vs. employee), responsibilities, and stakes are evaluated in a stakeholder analysis. This
section describes some of the research questions that should be answered in these stages and
examples of several commonly-used methods.

Stakeholder identification
First, it is determined who the relevant stakeholders are, during the stakeholder identification
(Van Velsen, Wentzel, & Van Gemert-Pijnen, 2013; Van Woezik, Braakman-Jansen, Kulyk,
Siemons, & van Gemert-Pijnen, 2016). Many of the methods that can be used in this stage are
described elsewhere in this chapter. For example, a scoping review of scientific literature is a
suitable way to gain quick insight in the stakeholders that might be present. Such a list is often
used as a starting point, from which to further progress towards insight in who the stakeholders
for your specific case are. For instance by asking known experts in the field to identify who they
perceive as being stakeholders, which is called expert recommendations. Besides the experts, the
stakeholders themselves may also have clear ideas about who other stakeholders are, which is
referred to as snowball sampling.

The end result of stakeholder identification is a (long) list or visualized map (see for an example
Figure 1) of stakeholders that is generated based on literature, e.g. via a scoping review, and
practice, e.g. via expert recommendations or snowball sampling). In many situations, a lot of
stakeholders are at play. However, it is often impossible or even undesirable to involve them all
in the development process. Therefore, the next step is to determine who the key stakeholders are
and what their stakes are by means of a stakeholder analysis.

Figure 1. An example of a stakeholder map (Van Limburg, 2016)

Stakeholder analysis

Some stakeholders may have a greater influence on or may be more influenced by the
technology than others, for example end-users, or decision makers in an organization. Such
stakeholders are referred to as ‘key stakeholders’. To find the key stakeholders among your list
of all stakeholders, different frameworks have been developed (e.g. Bryson, 2004; Mitchell,
Agle, & Wood, 1997). One of the most widely used frameworks is that of Mitchell et al. (1997).
In this approach, stakeholders can be mapped based on their power, legitimacy, and urgency.
Their power reflects the amount of influence their opinions will have. Legitimacy of a
stakeholder reflects whether a stakeholder should be involved; it shows what stakeholders are the
ones who ‘really count’ and are relevant (Mitchell et al., 1997; Van Woezik et al., 2016). A
stakeholder’s urgency concerns to what extend the stakeholders’ needs and wishes require
immediate action (Mitchell et al., 1997). Based on the stakeholder analysis, a substantiated
decision can be made about who key stakeholders are and should thus be involved during the
entire development process.

Of course, researchers or developers can attempt to determine the stakeholders’ power,

legitimacy and urgency themselves. However, it is unlikely that they are able to oversee all
interests, relationships and consequences of all different stakeholders for an eHealth technology.
It is therefore advisable to again involve experts in the field and/or the stakeholders themselves
in rating the stakeholders and identifying the key stakeholders.

Case: The wicked problem of antimicrobial resistance

Antimicrobial resistance is one of the major threats of modern healthcare. The prevention and
control of the infections that are caused by antimicrobial resistant pathogens is challenging and
highly complex. It is described as a ‘wicked’ problem (Van Woezik et al., 2016), as many factors
contribute to their occurrence, it involves many (often interdependent) stakeholders and there is
no single solution that would solve the entire problem. Most of such infections are zoonotic:
infections that are transmittable from animal to human (Pappas, 2011). Researchers of the
University of Twente aimed to develop an online platform to support smooth and swift
collaboration and risk communication to prevent and control outbreaks of zoonotic infections.

First, the researchers needed to investigate who should use the platform and who the other
stakeholders were (stakeholder identification). Initially, they performed a literature scan
concerning risk communications of zoonosis in the Netherlands, to formulate an initial list of
relevant stakeholders. Then, expert recommendations by experts in the fields of infectious
diseases and public health helped them validate the stakeholder list. A total of 73 stakeholder
groups were identified.

Second, key stakeholders had to be identified to decide who to involve in the further
development of the platform. For that purpose, the researchers sent a survey to a group of
stakeholders and asked them to rate their list of stakeholders, according to the approach by
Mitchell et al. about stakeholder salience (Mitchell et al., 1997). The researchers found a total of
28 stakeholders who were considered ‘key’ in one or more aspects of the stakeholder salience
approach. Once they were identified, these key stakeholders were actively involved during the
further development and implementation of the online platform for risk- and crisis
communication.

A stakeholder identification and analysis are not the only activities that should be conducted
during the contextual inquiry: many more methods can be used to learn as much as possible
about the context. Some of these methods make use of the identified stakeholders or can assist in
identifying and analysing stakeholders. This implies that methods in the contextual inquiry are
not used sequentially: several research activities can be performed alongside each other, and their
results might even be intertwined.

The next sections elaborate on what these methods may be, what their added value is, and what
kinds of results they can yield. Also, actual real-life cases are presented in which the described
methods were applied.

Desk research

What is desk research?

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.

What kind of results can desk research generate?

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.
Focus group

What is a focus group?

Focus groups are a useful method for the development of technology as well (Avis, van Mierlo,
Fournier, & Ball, 2015). 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’ (Wilkinson,
2004, p. 177). In the contextual inquiry, one type or a cross-section of key stakeholders can be
brought together within this discussion group format (Maguire & Bevan, 2002). 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 (Krueger & Casey,
2001).

Why conduct a focus group?

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 (Wilkinson, 2003). 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 (Wettergren, Eriksson, Nilsson, Jervaeus,
& Lampic, 2016). Some drawbacks might be greater planning and recruitment efforts to
assemble groups and the disproportionate influence of dominant participants (Maguire & Bevan,
2002).

What kind of results can focus groups generate?

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 (Lex Van Velsen, Wentzel, & Van Gemert-Pijnen, 2013). 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 (Haun et al., 2015).
• investigating the current use of internet among adults in order to gain insight into
attitudes, reasons, and current ways of internet use (Donnelly, Shaw, & van den Akker,
2008).
• the identification of sensitive topics among young people with cancer (Wettergren et al.,
2016).

Case: Focus groups in a hospital setting

Antimicrobial Stewardship Programs (ASPs) are propagated to optimize the use of antibiotics by
healthcare professionals, for example by ensuring that the dose isn’t too high or that antibiotics
aren’t administered for too long. Wentzel et al. (2014) aimed to develop information and
communication technology to support the correct prescription and use of antibiotics. In order to
develop this technology, the researchers first had to get an overview of the situation and identify
the problems that healthcare professionals were experiencing with the current way of
administering antibiotics. One of the methods used to achieve this, was a focus group. A ninety-
minute-long multi-stakeholder focus group was held with nurses, nurse managers, doctors and
pharmacists of a lung ward.

To map the current ASP-related care, the researchers made use of a case from practice about
Mrs. Jansen, a fictional patient that was administered to the lung ward because of a pneumonia.
The participants of the focus group had to read the case and tell something about their own tasks,
ways of communication, and information needs for this case. The next phase of the focus group
aimed to identify possible problems and bottlenecks that could occur during the process of
looking for or using information about antibiotics. The researchers asked the group to think
about possible problems, based on the case and their own experience, and to discuss them
amongst each other to identify the most relevant problems. Some examples of problems that
were identified were a lack of knowledge on (new) guidelines, unclear information about
prescribed medication, and user-unfriendliness of ICT systems for protocols (Wentzel et al.,
2014). This information provided the researchers with insight into relevant issues that could be
addressed by an eHealth technology, and thus provided the basis for the remainder of the
development process.

Interviews

What is an interview?

The most common aim of an interview is obtaining answers to questions of an individual

participant (Dooley, 2001). An interview can range from highly structured, to semi-structured
and completely structured.

What kind of results can interviews generate?

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 (Lex Van Velsen et al., 2013). 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 (L. van
Velsen, Beaujean, Wentzel, Van Steenbergen, & van Gemert-Pijnen, 2015)
 • questioning several kinds of stakeholders working in public health about their personal
experience with social media and the context of public health (Hart, Stetten, &
Castaneda, 2016).
• 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 (Mishna et al., 2016).

Scoping review

What is a scoping review?

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
(Arksey & O’Malley, 2005). Thus, a scoping review can help to quickly explore a field, without
excluding studies based on their quality.

What kinds of results can a scoping review generate?

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.

Observations

What are observations?

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.
What kinds of results can observations generate?

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.

Diary study

What is a diary study?

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 (Trull & Ebner-Priemer, 2009).

Why do a diary study?

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.

What kinds of results can diary studies generate?

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.

Case: EHEC outbreak – Social Media use

Governments need to know how people get information and how information spreads, so that
they can proactively inform citizens in the case of a crisis. Often, citizens have high information
needs, but not all available information is correct or contributes to keeping the crisis under
control. Therefore, a study was done to investigate if and how social media was used and
perceived by citizens during an outbreak of an infectious disease (Van Velsen, Van Gemert-
Pijnen, Beaujean, Wentzel, & van Steenbergen, 2012). During the 2011 EHEC outbreak,
participants from Germany and the Netherlands kept a diary for four weeks on 1) the information
they received (unrequested) about the outbreak and 2) the information needs they had, and for
which they actively sought answers. The participants filled out electronic forms which they had
to fill out daily and whenever they had searched for information.

The internet turned out to be an important source of unrequested information for the participants.
From this study the researchers learned that citizens prefer regular updates, from well-known
(traditional) information sources. In addition, social media may be used by governments to guide
persons towards the reliable information sources. The results of this study can be used by
governments to shape their crisis communication interventions.

Log data analysis

What is log data analysis?

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, see Chapter 14 for more explanation on that type of
application.

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.

What kind of results can log data analysis generate?

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, an example of this is provided in Figure 2. 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 (Van Gemert-
Pijnen, Kelders, & Bohlmeijer, 2014). 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.
Figure 2. A visualization of a log data analysis of a Personal Health Record (Sieverink et al.,
2015)

Case: behaviour log data to analyse nursing home logistics

An example of using log data to monitor behaviour is provided by a study that focuses on a
nursing home. When residents of this nursing home have a request, they make use of call
buttons. Every call button request is registered automatically in a database. Additionally, all care
workers are equipped with a key card, and every time a care worker enters or leaves the room of
a resident, this key card is swiped along an electronic keypad, registering the timestamp and
location. These log data were used to calculate the response time: the time between the call
request and the moment a care worker is present. The patterns were analysed to provide a better
understanding of the current situation (Van Eeden, Moeke, & Bekker, 2016). This kind of
analysis can be relevant for eHealth development because eHealth technology can help in, for
example, reducing the response time.

Using the Results of the Contextual Inquiry

The results of the contextual inquiry

As we have seen, multiple methods can be used in the contextual inquiry. Consequently,
conclusions about the context should be drawn based on different kinds of results to prevent a
too narrow vision or overlooking important information. Based on the results of the contextual
inquiry, decisions on the direction of the eHealth development are made. These can be decisions
about the target group, the main problem that an intervention should address, or the behaviour
that has to be influenced. However, not every decision might be feasible because of e.g. a lack of
funding or specific regulations. Therefore, possible decisions based on research should always
also be discussed with stakeholders that know about the practical matters and secondary
conditions. During the contextual inquiry, the development team weighs these practical concerns
against the gathered information and research outcomes during, for example, stakeholder
meetings.

The development process of eHealth technology has an iterative nature (Van Gemert-Pijnen et
al., 2011), meaning that the development team should go back and forth between different
development activities and should be flexible enough to revise some of their decisions.
Adaptations and changes can be made at every step of the process; choices are often not set in
stone. To illustrate: during the design phase, a new stakeholder might arise that wasn’t accounted
for in the initial stakeholder identification. Focus groups with these stakeholders to identify their
problems and needs might be held at that point, even though the development team is already in
the design phase.

This flexibility also implies the importance of a systematic and transparent development process.
A well organized, methodical approach enables the development team to evaluate their process
and to figure out where and why certain decisions were made. This makes it easier to go back to
a specific point in the development process when decisions need to be revised. In order to do
this, it is essential that every activity and every choice that is made within the contextual inquiry
are well documented. Good documentation is also important because the team has to be able to
retrieve the results of the contextual inquiry during the entire development process, since they
constantly have to check if the output of other development activities still matches the
stakeholders and their environment.

The contextual inquiry and the development process

During eHealth development, it is necessary to always keep the context in mind, since this
ensures the fit with the context of the output of development activities. When looking at the
CeHRes Roadmap, as described in Chapter 7 of this book, the results of the contextual inquiry
are relevant in multiple ways.
 • during the value specification, the key stakeholders identified during the contextual
inquiry should be involved. Their needs and wishes regarding a technology that addresses
the problem analysed in the contextual inquiry have to be identified.
• in the design phase the technology that addresses the problem or aims to improve a
current situation is developed. During the design process, key stakeholders should again
be involved. Furthermore, the development team should constantly check if the
prototypes are still feasible when looking at the environment as it was analysed in the
contextual inquiry (see Chapter 10).
• the operationalization phase is focused on the implementation of the technology within
the already analysed context. Because of the involvement of the stakeholders and
consideration of the context, the implementation of the technology already begun at the
start of the development process (see Chapters 9 and 12).
• the evaluation should focus on the technology within the specific context. It should be
holistic, just like the entire development process. This means that, again, relevant
stakeholders have to be involved, e.g. by interviewing them or measuring health
outcomes. The environment also has to be included in the evaluation, since researchers
should make clear what the impact of the technology on the entire context is (see Chapter
14).

Summary
This chapter has shown that the contextual inquiry serves as the basis for the entire development
process of eHealth development. A thorough understanding of the stakeholders, their
perspectives and their environment is necessary for good eHealth development. It is essential to
always know and understand for whom, what, and where you are developing. The take home
messages of this chapter are:

• The contextual inquiry is often skipped, but is pivotal since it serves as the basis for the
development process.
• Multiple methods can and should be used to get a thorough understanding of the context.
• Decisions on what methods to use should be based on research questions and practical
considerations.
• The stakeholders identified during the contextual inquiry continue to play an important
role in every stage of development, implementation and evaluation.
• A common mistake during the contextual inquiry is the assumption that you know who
the stakeholders are and what they want and need, while it is best to ask the stakeholders
themselves.

Key References for Further Reading

Beyer, H., & Holtzblatt, K. (1997). Contextual design: defining customer-centered systems.
Elsevier.
Woezik, A.F. van, Braakman-Jansen, L.M., Kulyk, O., Siemons, L., & van Gemert-Pijnen, J.E.
(2016). Tackling wicked problems in infection prevention and control: a guideline for co-
creation with stakeholders. Antimicrobial Resistance & Infection Control, 5(1), 20.
Mitchell, R. K., Agle, B. R., & Wood, D. J. (1997). Toward a theory of stakeholder identification
and salience: Defining the principle of who and what really counts. Academy of Management
Review, 22(4), 853-886.
Van Gemert-Pijnen, J.E., Nijland, N., van Limburg, M., Ossebaard, H. C., Kelders, S. M.,
Eysenbach, G., & Seydel, E. R. (2011). A holistic framework to improve the uptake and
impact of eHealth technologies. Journal of Medical Internet Research, 13(4): e111.
Van Velsen, L., Wentzel, J., & van Gemert-Pijnen, J.E. (2013). Designing eHealth that Matters
via a Multidisciplinary Requirements Development Approach. JMIR Research Protocols,
2(1): e21.

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