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Acta Paul Enferm. 2017; 30(6):607-13.
Original Article
Mobile application for evaluation of feet
in people with diabetes mellitus
Aplicativo móvel para avaliação dos pés de pessoas com diabetes mellitus
Selma de Jesus Bof Vêscovi1
Cândida Caniçali Primo1
Hugo Cristo Sant’ Anna1
Maria Edla de Oliveira Bringuete1
Roseane Vargas Rohr1
Thiago Nascimento do Prado1
Sheilla Diniz Silveira Bicudo1
Corresponding author
Selma de Jesus Bof Vêscovi
Rua José Aurélio dos Santos, 1700,
29680-000, Santa Luzia, ES, Brazil.
selmabof@gmail.com
DOI
http://dx.doi.org/10.1590/1982-
0194201700087
1Universidade Federal do Espírito Santo, Espírito Santo, ES, Brazil.
Conflicts of interest: There are no conflicts of interest to declare.
Abstract
Objective: To describe the process of development and validation of a mobile application on foot assessment and risk classification of people
with Diabetes mellitus.
Methods: Methodological study, conducted in four stages: definition of requirements for and development of the conceptual model; generation
of alternatives for implementation and prototyping; testing; and, implementation. The application was developed based on the national
and international guidelines on Diabetes mellitus; it followed the standard of the Brazilian Association of Technical Standards for Software
Engineering, and used the Intel XDK program for IOS and Android platforms. The product was evaluated by the development team for usability
through the Nielsen heuristics, and validated by nurses regarding functionality, reliability, usability and efficiency aspects.
Results: The CuidarTech mobile application “Foot examination” is composed of seven screens that integrate the elements for assessment and
risk classification, and eight screens (forms) with the sequence of the examination. After its execution, a screen shows the risk classification
and the clinical findings, with recommendations for each type of risk.
Conclusion: According to the nurse experts, the application is functional, reliable, adequate, and efficient.
Resumo
Objetivo: Descrever o processo de desenvolvimento e validação de um aplicativo para dispositivos móveis sobre avaliação e classificação de
risco dos pés de pessoas com Diabetes mellitus.
Métodos: Estudo metodológico, realizado em quatro etapas: Definição de requisitos e elaboração do modelo conceitual; Geração das
alternativas de implementação e prototipagem; Testes e Implementação. O aplicativo foi desenvolvido baseado nas diretrizes nacionais e
internacionais sobre Diabetes mellitus; seguiu as normas da Associação Brasileira de Normas Técnicas para Engenharia de Software e utilizou
o programa Intel XDK, para plataformas IOS e Android. O produto foi avaliado quanto a usabilidade pelas heurísticas de Nielsen, pela equipe
de desenvolvimento e validado por enfermeiros quanto aos aspectos de funcionalidade, confiabilidade, usabilidade e eficiência.
Resultados: O aplicativo móvel CuidarTech “Exame dos Pés” possui sete telas que integram os elementos para avaliação e classificação de
risco e oito telas (formulários) com a sequência do exame, após sua execução aparece uma tela com a classificação de risco e os achados
clínicos com as recomendações para cada tipo de risco.
Conclusão: O aplicativo segundo avaliação dos juízes e enfermeiros é funcional, confiável, adequado e eficiente.
Keywords
Diabetes mellitus; Nursing process;
Diabetic foot; Mobile applications
Descritores
Diabetes mellitus; Processo de
enfermagem; Pé diabético; Aplicativos
móveis
Submitted
October 15, 2017
Accepted
November 27, 2017
608 Acta Paul Enferm. 2017; 30(6):607-13.
Mobile application for evaluation of feet in people with diabetes mellitus
Introduction
e World Health Organization recognizes that
public health faces a serious problem in terms of
diabetes mellitus.(1) Currently, one in 11 adults have
diabetes, that is 415 million people; one in seven
births is aected by diabetes and every six seconds
a person dies from diabetes, which corresponds to
ve million deaths worldwide. e new perspective
is that, in 2040, one in ten adults, totaling 642 mil-
lion people, will be aected by the disease.(2)
e complications of diabetes mellitus are
among the main causes of reduced quality of life,
disability, and death, in addition to creating a great
economic impact for the health services, increas-
ing costs with hospitalizations, dialysis for chronic
renal insuciency, and surgery for inferior limb
amputations, among others.(3) Diabetic neuropa-
thy is the most frequent among the complications,
characterized by a series of clinical syndromes that
aect the sensitive peripheral nervous system, mo-
tor and autonomic nervous system; the main out-
come is foot ulcers that, associated with ischemia,
deformities and/or infections, lead to the so-called
“diabetic foot”.(4)
Approximately 20% of hospitalizations of
individuals with diabetes occur due to injuries
to the lower limbs. The recurrent incidence of
life-long foot problems among people with the
disease is estimated at 25%, and 85% of lower
limb amputations are preceded by ulcerations;
the main associated factors are peripheral neu-
ropathy and deformities.(4,5) The risk of foot in-
volvement and consequent lower limb amputa-
tion in people with diabetes mellitus reinforces
the need for expansion of the nurse’s knowledge
and understanding on the importance of moni-
toring and foot assessment in people with diabe-
tes mellitus, at all levels of health care. Primary
health care is of great importance, because it is
considered by the Ministry of Health to be the
gateway to health services.(6,7)
According to the protocols of the Ministry of
Health and Primary Health Care, the nursing con-
sultation is an opportune moment, essential for
tracking and monitoring the suggestive risk fac-
tors triggering the diabetic foot, in order to iden-
tify those individuals at the highest risk for ulcers,
who may benet from prophylactic interventions,
including self-care stimulation.(6-9)
In addition, nursing care has undergone sev-
eral transformations with technological advances.
e introduction of computer technology and the
emergence of sophisticated gadgets such as com-
puters, notebooks, palmtops, tablets, smartphones,
and hand-held phones with internet support have
brought many benets, and swiftness, to the battle
against disease. ey have improved care by en-
abling practitioners access, at any place or time, to
a vast amount of information about the patient,
by means of their health record, and on the best
clinical practice.(10)
It is worth remembering that the more specic
the information that is possessed, the better the de-
cision that can be made, therefore, it is essential to
develop technological tools that make the clinical
management of the diabetic foot more ecient, as
well as to minimize the diculties and deciency of
nurses in relation to clinical practice.(10,11)
In the search for mobile applications related to
risk/diabetic foot in the virtual stores (Play Store
and Apple Store), no Brazilian product was found;
there were six developed in other nations. Among
those, one intended for professional use was called
Diabetic Foot 2017. e remainder were designated
for use by the person with diabetes: Diabetic Foot
Care; Diabetic Foot and Shoe; AQR - Diabetic Foot;
Foot Care, and Diabetic Foot.
In view of the presented aspects, the objective
of this study was to describe the process of develop-
ment and validation of a mobile application on foot
assessment and risk classication of people with di-
abetes mellitus.
Methods
is was a methodological study developed in four
stages: 1- denition of the requirements and devel-
opment of the conceptual map for the application;
2- generation of implementation and prototyping
alternatives; 3- testing; 4- implementation.
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Acta Paul Enferm. 2017; 30(6):607-13.
Vêscovi SJ, Primo CC, Sant’ Anna HC, Bringuete ME, Rohr RV, Prado TN, Bicudo SD
In the rst step, international and nation-
al guidelines on care for people with diabetes and
diabetic foot, published in the last ve years were
selected: National Institute for Health and Care Ex-
cellence (NICE);(12) International Working Group
on the Diabetic Foot - IWGFD,(6) and the Diabetic
foot manual: strategy for the care of person with
chronic disease,(7) and the Clinical Guidelines of the
Brazilian Society of Diabetes(13) for text production
of the screens, and development of the application’s
conceptual map.(14)
In the second stage, due to the specicity of
technological knowledge required in the creation
of a mobile application, a partnership was estab-
lished with the Laboratory and Observatory of
Ontologies Project - LOOP, and the Laboratory
of Nursing Technologies - CuidarTech, both of
the Federal University of Espírito Santo (UFES).
Prototyping alternatives were generated using
Intel XDK software(15) based on ABNT ISO/TR
16982: 2014(16) for the application’s functional-
ities, organized in repetitive design cycles, with
a view to adopting free and open technologies
whenever possible.
In the third step for evaluation and validation
of the application, two strategies were used. First,
the application development team, consisting of
ten students from the Design Course of the Fed-
eral University of Espírito Santo, evaluated it by
means of the heuristics developed by Jakob Niel-
sen,(17) which consist of ten general principles for
the development of evaluation: 1- system visibili-
ty; 2- correspondence between the system and the
real world; 3- control and freedom of individual;
4- consistency and standardization; 5- recognition
rather than memorization; 6- exibility and e-
ciency of individual; 7- aesthetic and minimalist
design; 8- error prevention; 9- helping individu-
als to recognize, diagnose and recover from errors;
10- help and documentation. ree more specic
heuristics(18) were included for evaluation in mobile
devices, which are: 1- little man/device interaction;
2- physical interaction and ergonomics; 3- legibility
and layout.
Initially, the evaluators were given a check list to
inspect the entire system using the heuristics(19) as a
guide to detect possible problems. en, degree of
severity was classied according to the problem, us-
ing a scale of zero to four, where zero= unimportant
(does not aect the operation of the interface); 1=
cosmetic (there is no immediate need for solution);
2= small problem (low priority - can be repaired);
3= large problem (high priority - must be repaired);
and 4= catastrophic problem (serious - must be
reapaired immediately).
Four catastrophic problems and four large
problems were detected. As a result, the applica-
tion was improved by correcting all detected fail-
ures, before proceeding with the evaluation and
validation by nurses.
In the second strategy, the application was
evaluated and validated according to the Brazilian
standard ABNT ISO/IEC 25062:2011,(20) which
recommends a minimum sampling of eight partic-
ipants in the test stage. Eight nurses participated,
with at least two years of experience in caring for
people with diabetes. e evaluations occurred in
May of 2017.
Initially, the nurses received a case study with
the purpose of simulating the practice of exam-
ining the feet of people with diabetes mellitus.
Analyzing the case, the evaluator consulted the
CuidarTech application “Foot Examination”
for assessment and risk classification of diabetic
foot. Then, the nurse answered a questionnaire,
validated in another study and adapted to the
present test,(21) that addresses aspects of func-
tionality, reliability, usability, efficiency and sus-
tainability.(21-23) This questionnaire uses a Likert
scale that allows answers from one (strongly dis-
agree) to five (strongly agree); a score of three
indicates cases of doubt as to whether to agree
or disagree, or if the evaluator does not feel pre-
pared to respond. Scores equal to or greater than
four were considered appropriate.
In the fourth stage, implementation, a release
version will be published based on the tests results,
in the Google Play application store, free of charge,
and the site will be updated at the address by UFES.
Subsequently, an intervention with a clinical trial is
intended to be developed, where the eciency of
the product will be evaluated.
610 Acta Paul Enferm. 2017; 30(6):607-13.
Mobile application for evaluation of feet in people with diabetes mellitus
e research was approved by the Research Ethics
Committee of the Health Sciences Center of UFES,
under CAAE number 65500516.0.0000.5060.
Results
e CuidarTech application, “Foot Examination”,
is a hard technology (23) because it is the production
of software that provides the nurse with a tool to
assist in the assessment and classi cation of risk in
a person with diabetes mellitus for the development
of diabetic foot.
After a thorough reading by the authors, and
identi cation of similar content of the mentioned
guidelines, a conceptual map was developed, which
means the design and organization of the necessary
text was produced for the risk classi cation of the
feet of people with diabetes mellitus, and the con-
tents of each screen were developed, as well as appli-
cation tutorials and examination execution.
Seven screens were developed that integrate the
necessary elements for assessment and risk classi -
cation of the feet of people with diabetes mellitus,
and eight screens (forms) have the examination se-
quence. After its execution, a screen appears with
the risk classi cation and the clinical ndings with
recommendations for each type of risk, according
to gures 1 and 2.
In the evaluation of usability by the Nielson(17)
heuristic, four catastrophic problems and four large
problems were detected. Six evaluators considered
it to be a catastrophic problem when the individual
experienced di culty in completing a topic, clicked
the “?” symbol which opened the help screen, but
he could not return to the original screen where he
had been. It was only possible to return to the rst
registration screen, violating the heuristic of control
and freedom of the individual.
ree evaluators identi ed a catastrophic prob-
lem when, after completing all the check boxes on
the screen, a message still appeared saying that the
topics on the screen must be checked or, in other
words, complete the items. In this case, the heu-
ristic violated was Flexibility and E ciency of use.
Figure 1. Application presentation screen
Figure 2. Sample application screens
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Acta Paul Enferm. 2017; 30(6):607-13.
Vêscovi SJ, Primo CC, Sant’ Anna HC, Bringuete ME, Rohr RV, Prado TN, Bicudo SD
ree evaluators indicated a catastrophic problem
when pressing the “back” button of the cell phone
the menu is open and the application execute the
action back to the page on which the menu is open.
For example: during the data completion for
the physical examination, the application returns
to the home screen, causing the individual to lose
all the progress made during the examination, vi-
olating the heuristic of Control and Freedom of
the individual. An evaluator characterized a prob-
lem as catastrophic when, after saving data, it was
not possible to edit the patient’s examinations, in-
fringing on the heuristic, Control and freedom of
individual.
As a result, the application was improved by
correcting all detected failures before proceeding
with the assessment and validation by nurses.
In the meeting with the nurses a case study was
distributed with the purpose of simulating the prac-
tice of examining the feet of people with diabetes
mellitus. With this case, the evaluator consulted the
CuidarTech APP “Foot examination” and answered
the questionnaire, addressing aspects of functional-
ity, reliability, usability, eciency, and maintainabil-
ity.(21,22) Data obtained from assessment responses
performed by the nurses are presented in Table 1.
Scores equal to or greater than four were considered
to be adequate. Table 1 presents the mean and stan-
dard deviation of the nurses’ responses.
According to table 1, the scores ranged between
3.9 and 5, therefore the application achieved ade-
quacy for all the questions. A second analysis of the
assessment was performed, from the answers of the
dierent experts to the same question. ese means
ranged from 3.75 to 4.75.
When the evaluators were questioned regarding
ease of use of mobile applications, the responses
showed a greater diversication among the nurses,
with a standard deviation of 1.03 (Table 1). In sev-
eral questions (2, 3, 8, 9, 10 and 11) a smaller vari-
ability was identied, revealing that there was no
diculty in handling the application. According to
the nurses’ assessment, the application is functional,
reliable, adequate, and ecient.
After completing the evaluation phase, and -
nalizing all corrections, the application was regis-
tered at the Institute of Technological Innovation of
the Federal University of Espírito Santo.
Discussion
Mobile applications have gained momentum in
health care in recent years.(24) Online stores oer
a multitude of application options that grow dai-
ly, ranging from tness systems to monitoring and
controlling of various diseases. When these are well
developed and used, they are teaching tools that can
bring benets to patients and health professionals.
(25) Similar studies conducted in Brazil, that con-
sidered the use of mobile applications focused on
nursing practice, highlight the importance of in-
vestment in this eld of research.(25- 27)
Applications developed for this purpose may
have features that help to improve accessibility to
treatments, as well as the speed and accuracy of
exams and diagnostics. ese can also be provided
with functions that bring patients closer to caregiv-
ers, contributing to adherence to therapy or care,
reminding the patient to take medications, as well
Table 1. Mean and standard deviation of the nurses’ responses
Question Mean Standard deviation
1.Are you confident in using mobile applications? (functionality) 3.75 1.03
2. Does the software perform its functions accurately? (functionality) 4.75 0.46
3. Does the software provide the main functions necessary to evaluate and classify the risk of the feet of people with Diabetes Mellitus? (functionality) 4.75 0.46
4. Does the software respond properly when errors occur? (reliability) 4.12 0.83
5. Does the software inform the individual of invalid data entry? (reliability) 4.50 0.53
6. Is it easy to understand the software concept and application? (usability) 4.60 0.51
7. Is it easy to learn how to use the software? (usability) 4.62 0.51
8. Does the software offer clear help? (usability) 4.75 0.46
9. Is the software tutorial easy to understand? (usability) 4.75 0.46
10. Is the software runtime adequate? (efficiency) 4.75 0.46
11. Are the features provided in the software adequate? (efficiency) 4.75 0.46
612 Acta Paul Enferm. 2017; 30(6):607-13.
Mobile application for evaluation of feet in people with diabetes mellitus
as helping health professionals to be more eective
and ecient in theoretical-practical information.(25)
Developing an application in a coherent and
appropriate manner is paramount, in addition to
recognizing the needs of the individual, so that
the development is appropriate to the specic de-
mands, tested through research and implement-
ed in practice.(25-27) Unlike the currently available
applications, which mostly deal with theoretical
aspects, and are little related to clinical practice,
the CuidarTech “Foot Examination”, developed in
this study, sought to meet the needs of nurses for
the assessment and risk classication of the feet of
people with diabetes mellitus, helping to identify
the clinical ndings, to perform the foot examina-
tion, and showing as an outcome the risk classi-
cation and its necessary recommendations for the
patient examined.
CuidarTech “Foot Examination” is a tech-
nological innovation in health, as it is the first
mobile application developed in Brazil that can
bring benefits to nurses, the person with diabe-
tes, the Health Care Services, and the Unified
Health System in coping with the problem of the
diabetic foot.
e CuidarTech “Foot Examination” allows the
nurse, through the use of smartphones and tablets,
quick access during the nursing consultation to in-
formation of primary national and international
guidelines. It assists in the nursing process by col-
lecting data, assessing and rating the feet of people
with diabetes, and providing recommendations for
each clinical nding. It contributes to the nurses’
routine, by increasing their scientic knowledge;
due to the complexity of the guidelines, it places
in the nurse’s pocket an updated tool that assists in
the practice of the role in developing actions for risk
prevention, clinical monitoring, control of the dis-
ease and its complications, such as amputation of
the lower extremities of people susceptible to foot
problems due to diabetes mellitus.
From this perspective, adequate care, especially
in primary care, can improve the quality of life of
these people, reduce hospitalization rates, disabili-
ties and deaths, and reduce the socioeconomic im-
pact on the health services.
e use of technologies provides nurses with a
continuous, updated training process; however, the
study showed that some professionals have not yet
adhered to the use of this type of technology. (24)
Some limitations need to be highlighted, and
it is necessary to reect on the improper and abu-
sive use of mobile devices, with prejudice to the
work process, which has led to many discussions
about its prohibition in health institutions in Bra-
zil and in the world. In addition, hand hygiene,
infection, and patient safety must be considered,
as mobile devices can lead to risks of contamina-
tion. In order to minimize risks and limitations
in the use of mobile devices, it is necessary to
raise the awareness of nurses on the importance
of following safety standards, highlighting the
proper hygiene for personal use objects such as
mobile devices, in order to prevent the spread of
possible infections.(29)
Conclusion
is study developed and validated the CuidarTech
mobile application, “Foot Examination”, for assess-
ment and risk classication of the feet of people with
diabetes mellitus. According to the evaluators and
nurses, the application is functional, reliable, ade-
quate, and ecient. Use of the CuidarTech “Foot
Examination” by nurses can improve their scientif-
ic knowledge, provide support during the nursing
consultation in the prevention of risks, monitoring
and controlling complications in the feet of people
with diabetes mellitus, and increase the ability of
Primary Health Care to prevent and detection early
changes in the feet of people with diabetes mellitus.
It is hoped that this research will engage the interest
of other nurses to develop new technologies, align-
ing the theoretical-practical knowledge of nursing,
and seeking to improve the quality of care in the
Unied Health System.
Collaborations
Vêscovi SJB, Primo CC, Sant’ Anna HC,
Bringuete MEO, Rohr RV, Prado TN and Bicu-
do SDS contributed to the study design, analysis,
613
Acta Paul Enferm. 2017; 30(6):607-13.
Vêscovi SJ, Primo CC, Sant’ Anna HC, Bringuete ME, Rohr RV, Prado TN, Bicudo SD
data interpretation, relevant critical review of the
intellectual content, and nal approval of the ver-
sion to be published.
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