Development of an educational mobile application for patients submitted to orthognathic surgery

Objective: to develop, evaluate and correlate the acceptability of an educational mobile application to patients submitted to orthognathic surgery. Method: methodological study based on systematic instructional design with contents aimed at patient learning through a mobile application. Usability and user satisfaction were evaluated by 30 patients in the perioperative stage through an electronic questionnaire sent by social networks, e-mail and business card, measured using the System Usability Scale instrument validated in Portuguese and user satisfaction with an instrument based on another study, after its applications. Data were analyzed with descriptive statistics and Spearman correlation. Results: the application named “OrtogApp” features content validated in a previous study included five learning content sessions essential for managing perioperative care, and it is available on IOS and Android platforms. Usability corresponded to 79.8 + 15.4 points and the satisfaction index was 82.9%; correlation of age, schooling and uses of the application with the instruments was not significant. Conclusion: OrtogApp is an educational application with content validated by professionals, resulting in high user satisfaction and good usability. Patients may use the application as supportive educational material to supplement guidance provided by perioperative nurses and/or surgeons during perioperative care.


Introduction
There is a current growing movement in mobile technologies and applications that collaborate to build a new modality of health care. A systematic review aimed at identifying the use of smartphone applications in the health area retrieved 39 studies that were categorized into eight domains: diagnosis (n = 11), telemedicine (n = 9), surgical simulator (n = 6), training (n = 5), data collection (n = 3), patient education (n = 2), behavior (n = 2), and surgical planning (n = 1) (1) .
There are no review studies targeting the use of educational applications for surgical patients. Two studies (2)(3) described applications as a resource for preoperative preparation and obtained satisfactory results. However, no publication portrays patients of the maxillofacial specialty.
Using technology in the education of surgical patients represents an evolution in nursing care.
Applications are a resource capable of expanding access to information, since smartphones and access to the internet have become popular.
A study aimed at evaluating the use of an application to increase the knowledge of surgical patients about safety in general, urology, orthopedics and neurology surgeries observed a significant increase in patient knowledge resulting from the use of this tool (4) .
Despite studies on surgical preparation, guidance or monitoring, there are no studies on applications as a complementary resource for health education. The present study describes an educational application that is ideal to facilitate access to information and to increase the number of patients with access to content to assist in the management of self-care during the perioperative period. It is the first mobile application developed by nursing and focusing on surgical patients.
The postoperative period of orthognathic patients lasts around two months and requires management of self-care with respect to oral hygiene, feeding, pain, opening of the oral cavity, resting, and control of facial edema. Patients need clear guidance on how to perform post-operative care, and the use of educational materials as an auxiliary method to reinforce verbal guidance has shown effective results (5)(6)(7) . In the first stages of analysis and design, the content and scope of the project were based on the educational material "Orthognathic Surgery for Patients", which was constructed by the researcher and validated in a previous study (10) . The existing smartphone applications for patient education were also analyzed.    The content was arranged to be viewed comfortably.
After startup, the icons with images appear on the screen, and by tapping the icon, the user has access to the sub- questions of social networks, link for sending e-mail to specialist nurse, logbook) ( Figure 2).
Icons are displayed in the images as well as in written text. Once the icon is activated, the reader is directed to a page with its sub-contents with information about the perioperative period of orthognathic surgery and self-care post-discharge.
In the implementation and dissemination phase, the "OrtogApp" application was designed for IOS and Android systems. The operational platforms (IOS/ Android) perform an evaluation of the app before it is published and made available for download.
In this process, the App Store returned with a message saying the application was simple and required more interactivity to be more attractive, which led to the reconstruction of the design and functions of the app.
The functions of contact with specialist nurse to clarify doubts and geographical locator of possible points to access medical service were inserted.  Usability is defined as the potential to be used in software engineering -product quality. Usability is a set of attributes of the software that are based on the effort required for using it and individual evaluation of such use for an implicit set of users (11) .
The instrument used to evaluate usability was the System Usability Scale (SUS) in a translated and validated version in the Portuguese language (12) . The 68 points reflect acceptable usability (13) .
The evaluation items include: I would like to use the product frequently; complexity of the product; ease of use; help is necessary to use it; the features were well integrated; there were many inconsistencies; it is possible to learn quickly how to use the product; it is complicated to use; confidence in using the product; learning is necessary before dealing with the product.

Development
• The app received the name "OrtogApp" • Creation of the prototype with icons to access each content with images Implementation • Submitted to evaluation by the IOS and Android platforms and publication in the store for download

Disclosure
• In bucomaxilofacial surgery clinics with presentation cards of the app • Social networks -Facebook and Instagram Design • Learning contents: surgery, before surgery, day of the surgery, recovery, and postoperative care

Analysis
• Content of app based on the educational material "Orthognathic surgery for patients" The instrument to evaluate satisfaction was based on an instrument of another study (14) for evaluation of  The frequency of accesses to the application was 40% (n = 12) two to three times, followed by 30% (n = 30) once, 20% (n = 6) more than five times, and 10% (n = 3) five times. The user satisfaction corresponded to the average of 24.9 + 1.0 users corresponding to 82.9%. Satisfaction indexes per question are presented in Figure 4; there was no one case of evaluation as "unsatisfied" in the Likert-type scale.
The correlation of the variables age, schooling, and use of the application with the level of satisfaction tested by the Spearman correlation test were not significant.
Age (p = 0.798), schooling (p = 0.281), and use of the application (p = 0.428). Postoperative -up to one week 4 13.3 Postoperative -more than one week 10 33.3 Postoperative -more than six months 1 3.3 Postoperative -more than twelve months Usability results were lower than a study conducted in the US where guidance was given to 15 patients undergoing colorectal surgery, which reached a score of 95 (17) . The present results were similar to another study with 45 patients undergoing colorectal surgery with a score of 87 points (18) . Indexes above 70 points are considered good values for usability and acceptability of the user, and over 85 are considered excellent (13) .
In this study, higher usability and satisfaction scores were observed among individuals between 31 and 39 years old, individuals with superior education, and among those who had higher number of repetitions in the use of the application. A systematic review on usability and efficacy of applications for diabetes patients identified the main usability problems: multi-step tasks, limited functionality and interaction, and difficult system navigation (19) .
OrtogApp is easy to navigate, it does not require task execution by the patient, but has limited interaction (e-mail only), a format that makes instant  (20) .
In an American educational application with 20 patients undergoing bariatric surgery, user satisfaction was high with respect to this application (21) . It was observed an increase in the knowledge and commitment of the patients and the tool was useful for the preparation of surgical patients.
Another application with 13 mastectomized women obtained only 46.2% for good and 38.5% for excellent (22) . The use of the application reduced the anxiety and depression levels measured by the

Conclusion
The application developed for patients submitted to orthognathic surgery is an innovative resource for perioperative nursing; it allows the patients to have immediate access to information with content validated by a multiprofessional team, and can work as an application with educational material to complement the guidance provided by nurses in the perioperative stage.
The findings of the study resulted in high user satisfaction and good usability, confirming the acceptability of the product by the users.