Assessing the Feasibility and Acceptance of the Deaf-in-Touch Everywhere (DITE™) Mobile App: Insights from Healthcare Simulations and Stakeholder Discussions (HEARD Project)

Assessing the Feasibility and Acceptance of the Deaf-in-Touch Everywhere (DITE™) Mobile App: Insights from Healthcare Simulations and Stakeholder Discussions (HEARD Project) | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Assessing the Feasibility and Acceptance of the Deaf-in-Touch Everywhere (DITE™) Mobile App: Insights from Healthcare Simulations and Stakeholder Discussions (HEARD Project) E-Shuen Ng, Ruo Xian Wong, Weerahennadige Ninoshka Jonathan Elkan Fernando, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4392408/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Deaf individuals confront healthcare disparities from communication barriers, aggravated by Deaf culture ignorance and limitations of lip-reading. While medically-trained sign language interpreters (SLIs) offer solutions, shortages persist. Thus, the Deaf in Touch Everywhere (DITE™) app was developed to provide virtual SLI services through teleconferencing. This study investigates the app's feasibility and factors influencing the adaptation and utilization by the stakeholders. Methods This study adheres to the Consolidated Criteria for Reporting Qualitative Studies (COREQ) guidelines. Participants (≥ 18 years) were purposively sampled and comprised of three stakeholder groups: Malaysian sign language (BIM) users (BNUs), BIM interpreters (JBIMs), and healthcare providers (HCPs). They were involved in simulated medical consultations via video conferencing using the DITE™ app. Following this, three focus group discussions (FGDs) were conducted. Interview questionnaires were designed using the extended Unified Theory of Acceptance and Use of Technology (UTAUT); encompassing performance expectancy, effort expectancy, social influence, facilitating conditions, and behavioural intention. Recorded interviews with JBIMs and HCPs were transcribed verbatim, while transcripts from BNUs were derived from video recordings. Results were imported into NVivo 12 software, and thematic analysis was performed. Results Nineteen participants, comprising six BNUs, six JBIMs, and seven HCPs, participated in three FGDs. The findings were categorized according to the five UTAUT categories and were explored within each participant group. Within the performance expectancy , themes relating to the strengths and limitations of DITE app emerged. Effort expectancy themes encompassed adaptation/adjustment, challenges/setbacks, and navigation/interface of the app. Social influence themes included concerns about data privacy/confidentiality, medicolegal acceptance, and encouragement to use app from relevant stakeholders. Facilitating conditions encompassed themes like confidentiality, support availability, prior relationship with interpreters, previous consultation experiences, and familiarity with telecommunication tools. Regarding behavioural intention , themes that emerged were app usage and promotion and comparing telemedicine and face-to-face consultations with DITE app. In addition, limiting conditions and areas for improvement were discussed. Conclusion The DITE app holds the potential to tackle communication barriers between Deaf individuals and HCPs. However, ongoing research, fine-tuning, and strategic deployment are vital to maximize its effectiveness in enhancing healthcare accessibility and outcomes for the Deaf community in Malaysia. Deaf UTAUT mHealth PPI patient and public involvement participatory design sign-language interpreters Malaysia healthcare Figures Figure 1 Figure 2 Figure 3 Background According to the World Health Organization, approximately 466 million people worldwide experience disabling hearing loss [ 1 ], with around 70 million individuals being deaf and relying on sign language for communication [ 2 ]. Among this population, there is a subgroup that identifies themselves as culturally Deaf, denoted with an uppercase "D"[ 3 ]. Differing from the term “deaf” with a lowercase “d” which refers to the audiologic lack of hearing, the Deaf community define deafness as their linguistic and cultural identity rather than perceiving deafness as a disability. These individuals share a common experience of using sign language and adopting Deaf cultural norms [ 4 , 5 ]. Despite their substantial numbers, the healthcare needs of the Deaf community have not been adequately addressed, resulting in poorer health outcomes and different healthcare utilization patterns compared to the general hearing population. This phenomenon is mainly attributable to poor communication and patient engagement [ 3 , 6 , 7 ]. One of the barriers in communication between healthcare professionals (HCPs) and Deaf patients is the misconception that lip-reading is a viable means of communication for all Deaf patients, and that they can fully substitute spoken or sign language communication [ 3 ]. In reality, only 30–40% of English phonemes can be reliably identified by the Deaf through lip-reading even under the best conditions, while the rest requires guesswork [ 3 , 8 ]. This limitation becomes even more pronounced during healthcare consultations, where complex medical terminology may be used, and patients may not possess sufficient background knowledge. Therefore, while lip-reading can be useful for Deaf individuals with some residual hearing, it cannot replace the use of sign language [ 3 ]. Furthermore, research has shown that HCPs often lack awareness and understanding of Deaf culture [ 9 ], further hindering effective communication and meeting the needs of the Deaf community [ 10 ]. This issue was highlighted in the Sick Of It report published by SignHealth in 2014, which revealed that despite the majority of Deaf patients preferring sign language interpretation in healthcare consultations, only a fraction of them were given the opportunity, leading to misunderstandings, confusion, missed diagnoses, and inadequate treatment [ 11 ]. To address this communication gap between Deaf patients and HCPs, a solution would be the use of medically trained sign language interpreters (SLIs) in facilitating consultations [ 3 ]. However, several limitations exist regarding this solution. Firstly, the current availability of sign language interpretation services falls short of meeting the demand due to a severe shortage of SLIs [ 12 ]. Besides, there is a lack of consistent medical training for SLIs. Working in healthcare settings where SLIs will often be faced with complex healthcare concepts and terminologies, achieving accuracy in healthcare interpretation can be a challenge without appropriate training. Additionally, the absence of established equivalent medical terms in sign language introduces further risks of misinterpretation [ 13 ]. Therefore, there is a significant need for further research and development to improve the accessibility of sign language interpretation services and bridge this communication gap. According to the 2022 statistics report by the Department of Social Welfare Malaysia, they are 42,349 individuals registered as Deaf and Hard of Hearing [ 14 ] in Malaysia who prefer communicating in Malaysian sign language (BIM). There are only 30 SLI working with the Malaysia Federation of the Deaf, and there are merely around 20–30 freelance interpreters available across the country [ 15 ]. This glaring imbalance translates into a striking statistic: for each SLI, there are approximately 1,000 Deaf individuals in need of communication assistance. The Deaf community encounters substantial challenges when trying to access healthcare services, despite its significant size. Communication plays a crucial role in the patient-provider relationship within healthcare, as it ensures the best possible treatment for each individual. However, ineffective communication with Deaf individuals has resulted in various negative outcomes, including miscommunication leading to diagnostic and management errors [ 16 ], heightened levels of anxiety and embarrassment due to misunderstandings [ 17 ], delays in receiving treatment, unnecessary testing, breaches of privacy, and inadequate patient education leading to improper home care or medication usage [ 18 , 19 ]. These obstacles often discourage Deaf individuals from seeking healthcare services altogether. The absence of a legal mandate in Malaysia compelling HCPs to provide SLIs further compounds this issue, leaving Deaf patients feeling uncertain and vulnerable during their medical visits [ 20 ]. Indeed, research undertaken involving members of the Deaf community in Malaysia have also revealed fear and apprehension among the Deaf when accessing the healthcare system [ 21 ]. In response to this pressing challenge, our team created a cross-platform mobile application called Deaf in Touch Everywhere (DITE ™ ) to address the healthcare interpretation requirements of the Deaf community who rely on BIM, also referred to as BIM native users (BNUs). This was developed under the HEAlthcaRe needs of the Deaf (HEARD) Project – a series of studies aimed at improving the healthcare access of the Deaf community in Malaysia[ 21 ]. This app aims to connect Deaf individuals with a network of off-site interpreters via secure video conferencing. The primary purpose of DITE ™ is to enable Deaf users to schedule BIM interpreters (JBIMs) in advance or request them on-demand, providing convenience and flexibility similar to popular on-demand service platforms like Uber or Grab, but tailored specifically to the needs of the Deaf community. This comprehensive healthcare consultation solution encompasses all aspects, from the initial scheduling of SLI services to real-time interpretation during medical consultations. The development of DITE involved a community-based participatory approach, collaborating closely with key stakeholders from the Deaf community, BIM interpreters, and medical professionals. Utilizing participatory design methods is instrumental in enhancing health communication tools, ensuring their alignment with the specific requirements of the target audience [ 22 ]. One pivotal aspect that influenced the design of the DITE™ app was the pronounced preference of Deaf individuals for teleconferencing, particularly video-based communication, over text-based alternatives. This preference was corroborated through prior qualitative research that explored the Deaf perspective on a potential mobile health app designed to facilitate communication between pharmacists and Deaf individuals [ 20 ]. Furthermore, recent research conducted in 2021, which compared the utilization of smart devices, apps, and social media between adults with and without hearing impairment, elucidated a pertinent insight: adults with hearing impairment are no less inclined to employ smart devices than their hearing counterparts [ 23 ]. In fact, a substantial proportion of Deaf individuals have integrated mobile phones into their daily lives for multifaceted purposes, including communication and learning [ 24 ]. The appeal of mobile applications among Deaf individuals is attributed to the independence, flexibility, and mobility they offer, as highlighted in a study on Deaf mobile applications. This research underscored the convenience of downloading and installing apps, along with the accessibility they afford at any time and place [ 24 ]. The DITE™ app, thus, is poised to fulfil these specific needs within the Deaf community, rendering it a promising solution for widespread adoption in Malaysia. When considering the potential of the DITE™ app as a mobile health application tailored to the needs of BNUs, valuable insights can be gleaned from the milestones achieved by analogous applications in other countries. Notable examples include Pro Deaf Libras and Deaf Bible, which have achieved varying degrees of success, as evidenced by their download statistics on the Google Play Store[ 24 ]. The evolution and outcomes of these applications reflect the Deaf community's willingness to embrace mobile applications that aid in their day-to-day communications. We recently concluded a pilot assessment of the feasibility and acceptability of measuring the Unified Theory of Acceptance and Use of Technology (UTAUT2) constructs for DITE ™ among nine Deaf participants and nine BIM interpreters [ 25 ]. We observed that the contextualised UTAUT2 questionnaire serves as a valuable tool for gauging the adoption of the DITE ™ app among the Deaf community and SLIs in Malaysia. Involving targeted end users in the design process provided crucial insights, ensuring that the app continues to meet the genuine needs of both groups. In this research undertaking, we executed a healthcare simulation employing the DITE ™ app, followed by three distinct focus group discussions (FGDs), each engaging one of the critical stakeholders: BNUs, JBIMs, and HCPs. This provided a platform for open dialogue and the exchange of experiences and opinions regarding the feasibility and utilization of the DITE™ app in healthcare simulations. This paper is dedicated to presenting a thematic analysis of the outcomes from the FGDs involving all three stakeholders. Our analysis endeavours to evaluate the feasibility of the DITE ™ app and discern the factors that affect its uptake and use among the three stakeholders. Through this interdisciplinary approach, the study aimed to contribute valuable insights to the ongoing discourse surrounding technology adoption and utilization in healthcare settings. Method The methods and findings of this study are reported according to the Consolidated Criteria for Reporting Qualitative Studies (COREQ) (Additional file 1) Study Design and Participants Three FGDs were conducted adopting a framework methodology. The UTAUT framework [ 26 ] was adopted to discern both constraining and facilitating factors that shape the adoption and utilization of the DITE ™ app among the three stakeholders: BNUs, JBIMs, and HCPs. Participants' perspectives and experiences were systematically investigated and analysed within the framework's dimensions. This approach provided a structured framework for evaluating the potential effectiveness and acceptance of the DITE ™ app within the context of healthcare simulations, thereby enriching the thematic analysis of outcomes from the FGDs. Patient and public involvement and engagement were integral to the methodology of this study. The research team employed a participatory approach by actively involving individuals 18 years of age and above with lived experience and personal insights into the health challenges faced by the Deaf community. Specifically, participants were purposively sampled from non-governmental organization networks, ensuring representation from diverse backgrounds and across all races. See Additional File 2 for the GRIPP2 reporting checklist [ 27 ]. All participants were sent an explanatory statement and consent forms. After obtaining consent, BNU and JBIM participants were given access to their own WhatsApp group with one of the app developers and two research assistants in order to avoid influence on other participants. They were asked to download the DITE ™ app, through an APK (only for Android users), and install the app. Guidelines on how to register and log in, and continuous technical support was provided through WhatsApp. BNUs and JBIMs were allowed to use the app for a week before they participated in simulated medical consultations using the video conferencing feature in the DITE ™ app. The three simulated medical cases (Additional file 3) were on carpal tunnel, diabetes, and migraine (telemedicine). Cases were prepared by medically-trained researchers and trialled in a pilot test among BNUs, JBIMs and HCPs. BNUs were assigned to different JBIMs for each of the three simulated medical consultations, to ensure they were exposed to all JBIMs and HCPs. Each consultation took an average of 15 mins after which FGDs were carried out to evaluate the behavioural intention (BI) to use the DITE ™ app among the three participant groups (BNU, JBIM and HCP). The FGDs were facilitated by experienced researchers with the help of note takers. The FGDs with JBIM and HCPs were audio recorded while that with BNUs was video recorded and was carried out by a Deaf researcher. Demographic details were collected from all participants along with questions pertaining to their medical consultations (BNUs), interpretation experience (JBIMs) and experience with Deaf patients and understanding the communication needs of the Deaf (HCPs). Ethics approval was obtained from Monash University Human Research Ethics Committee (Project ID: 20452). Interview Guide Development The study questionnaire was designed using the extended Unified Theory of Acceptance and Use of Technology (UTAUT2)[ 26 ]. According to Venkatesh et al. [ 26 ], UTAUT2 explains 74% of BI and it is recommended to be applied in the introductory phase of a relevant technology (e.g., initial use, adoption). UTAUT2 identifies factors related to the prediction of BI to use a technology. The original UTAUT2 questionnaire consists of 32 items under nine constructs and uses Likert scales to measure responses. The factors identified in the original UTAUT2 model that were adopted in our questionnaire were i) performance expectancy , or the degree to which using a technology will provide benefits to those users, ii) effort expectancy , or the degree of ease associated with the use of the technology, iii) social influence , or the extent to which users think that important others (e.g., friends and family) believe they should use the technology, and iv) facilitating conditions , or the users’ perceptions of resources and support available to them and v) behavioural intention , or the degree to which users intend to or continue using the technology. With the growing use of telemedicine and the app’s capabilities to accommodate this feature, we included a question on telemedicine as a facilitating condition. Three versions of the interview guide (one for JBIMs, one for BNUs and another for HCPs) were developed using the UTAUT2 questionnaire, with the questions adapted to fit the context of the DITE™ app. The research team adapted the questionnaires for this study by first replacing the technology in the original questionnaire (mobile internet) with the DITE™ in all questions. Next, the research team reviewed the questions and removed some measures and items that were not relevant to the DITE™, such as the Price Value measure (as the app is currently free). The items measuring the use of technology were also updated from outdated technologies to newer ones (e.g., from “Java games” to “app games”). Third, additional questions were added to seek feedback on specific app features or aspects to help inform improvements to the design. Face and content validation of the interview guides were undertaken by experts in qualitative research and members of the research team. The interview guide for the BNUs were reviewed by a Deaf member of our research team (AC) and edited to ensure they would be understandable by BNUs. The interview guides were then pilot tested via a simulated case study involving a BNU, JBIM, and HCOP and rectifications were made to the guides based on the feedback received. The final interview guides are provided in Additional file 4. Data Analysis Baseline demographic data were presented using descriptive statistics. Recorded interviews involving JBIMS and HCPs were transcribed verbatim and anonymised prior to analysis. Transcription for the FGD involving BNUs was undertaken by JN, a Deaf research assistant, using one video recording and double-checked for accuracy using the second video recording. The expressions used in the transcription took into consideration the signing that corresponds with the participant's body language, emotions, and facial expressions. Results were then imported into NVivo 12 Software (QSR International Pty Ltd., Version 12, 2018)[ 28 ]. All audio recordings and interviewer field notes were also imported into NVivo for comparison and analysis. Thematic analysis was performed on the transcripts guided by Braun and Clarke’s six phase approach to coding [ 29 ]. Quotations by participants were edited on a limited basis to remove content that did not convey meaning (repeated words, stutters) or that had no relevance to the theme being discussed. An ellipsis was used to note the removal of such extraneous content. Square brackets were used in quotations to replace sensitive or identifiable information. Results Overview of participants A total of 19 participants were involved in the three FGDs - six BNUs, six JBIMs, and seven HCPs. Twenty percent of the invited participants either did not respond or declined to participate. The duration for each FGD is as follows: BNUs – 51 minutes; HCPs – 57 minutes; JBIM = 47 minutes. We present here the data and findings according to each participant group. Findings are presented according to the five UTAUT categories i.e. Performance Expectancy, Effort Expectancy, Social Influence, Facilitating Conditions, and Behavioural Intention. BNUs Demographic data Fifty percent of BNUs were females, with the majority aged between 31–40 (67%). Two were between 41–50 years of age. The majority used android phones (83%), most mentioned seeking healthcare for flu, fever, and cough, and all participants have never used any other app with video conferencing services (e.g. telegram, WhatsApp, WeChat etc) for a healthcare consultation. Further details on participants are presented in Table 1. Table 1 Characteristics of BNU participants (n = 6) Characteristic n (%) Highest level of education Graduate 1 (16.7) Certificate/diploma 2 (33.3) Form 3 (lower secondary) 2 (33.3) Primary 1 (16.7) Times seen doctor in the past year 0–5 4 (66.7) Never 1 (16.7) > 10 1 (16.7) Healthcare setting most often accessed to see doctor* Private clinic 5 (83.3) Government clinic 4 (66.7) Government hospital 2 (33.3) Private hospital 1 (16.7) Mode of communication often used to communicate with the doctor* Hand gesture 4 (66.7) Pen & paper 6 (100.0) Texting on computer or mobile 3 (50.0) Help from family members and friends 1 (16.7) Using graphics / images from the internet 1 (16.7) Average length of medical consultations < 15 minutes 5 (83.3) 15–30 minutes 1 (16.7) *Participants were allowed to select more than one option so totals might not equal 100% An overview of the themes and subthemes are presented in Fig. 1. Performance Expectancy The FGD revealed the effectiveness of the DITE app in achieving the desired outcomes of facilitating healthcare consultations and the existing drawbacks of the developing app. Multiple themes and subthemes pertaining to the performance expectancy of the DITE app was uncovered during the discussion, which are mainly divided into its strengths and limitations. Theme 1: Strengths of DITE app Subtheme 1: Embracing Malaysian Sign Language Participants revealed that the DITE app allowed them to converse in their native language - BIM, during the simulated consultations. Having had to rely on pen and paper in previous consultations, one of the participants revealed that, “Now we have video, it makes it easier to communicate with the other party in sign language.” (D4, M) Hence, the DITE app provided a sense of ease and comfort for BNUs, as they need not trouble themselves with searching for suitable terms to describe their presenting complaint as required by their previous mode of communication. It also allowed their concerns to be acknowledged and to better understand the explanations provided by the doctor. This is illustrated by the following quote: “(Previously) it’s difficult to remember the right word. Need to refer to Google, and then show it to the doctor. So, it’s time consuming. Now I just need to sign, through (an) interpreter, the doctor knows my issue. It’s good this way. It gives me the satisfaction” (D4, M) The discussion also revealed the importance of enabling the Deaf community to relay their medical concerns through their native language, particularly with the Deaf who were not literate: “There are many Deaf who are illiterate. Interpreting must be provided to help them to understand even though (it will) require longer time. These group of illiterate Deaf, who are (the) majority of Deaf in Malaysia, are subjected to brief consultation with pen and paper, will not understand their condition. Interpreting is always preferred as it is easier to understand.” (D2, F) Subtheme 2: Improving quality of care Participants also revealed that being able to communicate in their native language via the DITE app added value to their consultations and improved their overall experience. Although the incorporation of the DITE app increased the length of consultations, it also increased its depth. As mentioned by one of the participants, when it comes to the value of consultations, the DITE app allowed the participants to have longer, more meaningful conversations with their doctor, whilst paying the same healthcare costs; “It was really brief in the past and we paid like (RM)60, 70 for it. Now it’s stretched with more information, it helps. Where cost is concerned, we pay the same price. Brief consultation is not worth our money. And with this (interpreting via the app), we have much to gain as we know more in order to manage ourselves.” (D4, M) Theme 2: Limitations of DITE app Subtheme 1: Lack of interaction with HCPs Despite its ability to improve communication, participants disclosed that they felt disconnected from the doctor as there was a lack of interaction between them and HCPs. When participants were using the DITE app on their mobile phones, they found that their sole focus was on the DITE app when communicating, with minimal interaction with the consulting doctor, saying “Having the app placed well in front of me, I am able to focus on my interpreter very well, but in doing so, I have no contact with the doctor” (D1, F) Participants also found that the presence of the DITE app has altered their relationship where the participants presented their complaint to the interpreter, instead of directly to their doctor, which felt unnatural to them. This proved to be a challenge to the doctor-patient relationship that they have been accustomed to: “…It’s weird in showing and explaining to my interpreter before he tells the doctor. The doctor’s impression of my trust in him is affected. It was (a) “messy” situation.” (D5, M) Subtheme 2: Importance of competent interpreters Participants highlighted the significance of a skilled interpreter when using the DITE app, as it risks loss of information or misinformation that may lead to dire consequences. From the experience during the simulation, one of the participants revealed, “…now with DITE, what I see is good but the interpreter isn’t skilled enough as there are missed-out information. (For) example, the doctor would be speaking for some time, but the interpreter’s delivery was brief. I suspect there was a lot not captured.” (D2, F) Another participant mentioned how the lack of adequate BIM skills by the interpreter resulted in additional stress during the consultation: “I was stressed with the interpreter who could not understand me and kept asking for clarification. There are times when I am asked for clarification of (the) signs I used, I could not because spelling is never me (finger spelling is not the participant’s style of signing). I had this problem with both interpreters for Case 1 and 2. They need to up their skills… I needed to change and adjust my way of thoughts to suit them, it needed working / effort on my part to communicate with the 1st and 2nd interpreter.” (D5, M) Subtheme 3: Real world feasibility of the DITE app In experiencing using the app under simulated and ideal circumstances, participants questioned the ability of the DITE app to perform its role and facilitate healthcare consultations under stressful and chaotic situations; “...if we are involved in an accident, how can we use DITE such as when we are injured and cannot handle it. Similarly, having to carry a sick child in our arm, it’d be difficult to handle DITE” (D4, M). Participants were also concerned about the scope of medical illness that could be effectively communicated with the aid of the DITE app due to its limitations. This is highlighted in the following quote: “Using video consultation, the consultation can be of simple sickness, where it’s easy to view (the) upper part of our body. But if we have more complicated ones, lower body, (such) as knee, do we stand to show, that will be difficult to communicate via video? That will be an issue. Without showing, (the) Interpreter won’t know, such as back pain. Simple ailment is fine, but complicated ones, I question this method.” (D2, F) Effort expectancy Participants discussed the effort required to use the DITE app during the simulation and some adaptations that were required to effectively utilize the DITE app. Additionally, the challenges of using the DITE app were also disclosed during the discussions. Theme 1: Adapting and adjusting While working with the DITE app, BNUs found that they had to adjust to the audio component in the app. One of the participants revealed that he was not mindful about turning on the speaker of his mobile during the consultations: “…The communication method requires listening, and it struck me that I’ve forgotten to turn on my volume. The app needs to combine both video and audio (automatically) together (when the app is launched).” (D5, M) The audio feature of the app also posed other challenges to the participants. Participants highlighted that the interpreters could not hear the doctor speaking. Hence, the participants had to make certain adjustments to ensure that the doctors and interpreters were able to communicate well, as evidenced by the following quote: “During my 1st and 2nd appointment, the phone was placed at my comfortable viewing point. But the interpreters couldn’t hear and so I have to move it closer to the doctor. In doing so, I am not able to see them well.” (D5, M) During the physical examinations, participants also revealed that they had to adapt to the presence of phone cameras and its limited view as a method of communicating with the interpreter through the DITE app, whilst displaying the relevant anatomy to the doctor: “Both the interpreter and the doctor had to look at my palm, so I lifted it up (chin level, with open palm facing both of them) and I proceeded to show what was wrong. In this way both of them are able to see my palm and me simultaneously. It helps with the flow of communication as the interpreter is able to know what I was referring to. I knew it would be a problem had I laid my palm on the desk. Lifting it up creating simultaneous viewing was good for all parties.” (D1, F) Theme 2: Challenges and setbacks While using the DITE app in the simulated consultations, participants found that it was a challenge to divide their attention when the doctor and interpreter were communicating with the participants at the same time. This is illustrated by the following quote, where a visual aid was being used by the HCP to provide explanation, whilst interpretation was occurring simultaneously through the DITE app; “I had to try to understand the relation between the text and the illustration. The doctor showed illustration, and also explaining using her own palm, with the interpreter interpreting, having to look at both what the doctor was indicating and the interpreter, I could not manage it.” (D4, M) Additionally, the lack of stable Internet and connectivity was a challenge for participants while using the DITE app, with problems such as their screen freezing and lagging that impaired the communication between all three parties. Participants also noted that the reliance of the DITE app on the internet may pose a hindrance as certain healthcare facilities may be located at areas with poor connectivity. Furthermore, some may not be able to afford a data plan that is adequate to support the use of the DITE app. This is captured in the following quote: “DITE depending on data is not good, it freezes / lags. Just now when I went into the consultation, I wasn’t aware that Monash has free Wi-Fi connection. I was using my data. And my interpreter informed me that my connection is bad before I made the switch. So, venues out there, we may encounter the same. And what about Deaf who cannot afford and have limited or insufficient data.” (D1, F) When navigating the DITE app for the first time, there were varied response from participants regarding the ease of use. Some participants had minimal issues and were able to manage after a while, whereas others required some assistance. When asked to compare with Grab (an established E-hailing app used by Malaysians), participants found that navigating the DITE app was more challenging as it was less user-friendly. Specifically, participants revealed that the booking process of the DITE app was anxiety-provoking. Without an immediate response, or an update on the status of their booking, participants felt that they are left to wait without knowing if their booking has gone through: “The Grab app is easy to use. However for DITE, it’s not as easy. Having done a booking, the interpreter does not respond immediately. It leaves me anxiously waiting, wondering. In comparison with Grab, it tells me immediately my status…” (D1, F) This left the participants with future concerns regarding the lead time of the booking process during an emergency, where an instant response is required, with one saying “…What happens if I need an interpreter at this very time and here, I am still waiting for the interpreter to accept my request. How will this (app) be helpful?” (D1, F) Facilitating Conditions The FGD also explored the various factors that support and encourage the use of the DITE app by the participants. Theme 1: Confidentiality of information When asked about the participants’ willingness to use the DITE app during physical examination of intimate body parts (e.g., breast or vaginal examination for women and penis examination for men), most participants did not agree. Participants revealed concerns regarding the confidentiality of the information shared during the consultation, noting “I will not (use the DITE app for examination of the vagina), even though I trust the interpreter, but there is risk of the environment she is in at that moment, who or what else would be at her background?” (D2, F) However, participants felt reassured if there was a privacy and confidentiality agreement to ensure that the information shared maintained confidential: “First of all, there needs to be a confidentiality agreement by the interpreter. Then, prior to the appointment, I’d have a chat with the interpreter, what my issue is. I don’t need to show but explain so that she understands clearly my impending consultation. On the consultation, I do not hesitate to show as there is confidentiality.” (D1, F) Theme 2: Availability of support Upon questioning the participants perception of their ability to use the DITE app during illness, participants highlighted the role of support from a trusted family member in facilitating the use of the DITE app. One noted “We, being a couple (D1 & D4), it should be fine. My partner is able to help. If I’m alone, simple illness, such as flu it is alright (to use DITE). But if he is really sick and unable to drive, I will help to make booking for him and accompany him to the doctor.” (D1, F) Theme 3: Prior relationship with interpreter One participant revealed that the process of using the DITE app for the simulated consultation was made smoother because of the relationship he had with the interpreter previously. This allowed him to communicate better with the interpreter as he was familiar with the interpreter’s style of communication, saying “ While the 3rd interpreter, whom I know several years back, I am able to assimilate to his interpreting and him to me and the consultation went on smoothly. He was able to convey to the doctor my content and I felt good… with the 3rd Interpreter, it was merely communicating naturally and effortlessly.” (D5, F) Theme 4: Previous consultation experience The participant’s previous consultation experience where sign language was not utilized was also a facilitating factor that encouraged the use of the DITE app. While participants were reliant on pen and paper, mobile text, and notes for previous consultations, they were often unsatisfied with the outcomes of these consultations. However, with the DITE app, they see hope in using their own native language in consultations and the potential of gaining more useful information from their visits. This is illustrated in the following quote: “In comparison, in the past, sign language wasn’t available, but now it’s possible. With interpreter, I pick up more. While without interpreter, even depending on family members was difficult for us as father and mother who are Deaf. Now we have interpreter available through video, it makes things easier. I didn’t have good experience. In the past it was really difficult. Now with DITE, it’s improvement for the future.” (D6, M) Limiting Conditions From the participants’ discussion, the following limiting condition was identified as a hurdle for them to utilize the DITE app. Theme 1: No-phone policies in hospitals Participants revealed that the no-phone policies in hospitals would not allow for the DITE app to be utilized in certain hospital settings, noting “There’s a setback, phones are not allowed in hospitals. There are no-handphone signages everywhere. I think there is need to make known to MOH (Ministry of Health) and throughout Malaysia that DITE is a necessity for Deaf.” (D4, M) One participant also shared their own experience during a hospital visit where handphones were not allowed: “In my experience before giving birth to my child, I have been informed that handphone is not allowed. I was left to lay. They were talking to me, and I could not follow. In the end we had to communicate by pen and paper.” (D1, F) Behavioural Intentions The FGD also ventured into the intentions of the participants to use the DITE app and how likely they were to use it in their own medical consultations. Theme 1: Usage and promotion of the DITE app There was unanimous agreement from all participants that they would use the DITE when it is ready and available. Next, the frequency of the intended use was explored. From a total of 10 hypothetical consultations, some participants stated that they would utilize the DITE app in all 10 consultations, whereas others choose to utilize the DITE app during complex diseases only, with one saying “It depends on the situation. If simple cold, I’d not use DITE. I’m ok to use pen and paper. But if I am sick that I really do not know what’s wrong, and need interpreting, then I will use DITE.” (D1, F) There was general agreement from participants that they would promote the DITE app to their friends. However, participants believed that the promotion should extend beyond the Deaf community, to doctors, government agencies, and the public so that they are aware of its availability. Theme 2: Comparing Telemedicine and face-to-face consultations with the DITE app Participants were given a choice between Telemedicine and face-to-face consultations with the DITE app as their preferred mode of consultation. The responses gathered were varied and was dependent on the severity of the illness. Participants who preferred face-to-face consultations with DITE app stated that their choice was based on the availability of comprehensive services when being physically present at the facility. This includes getting detailed explanations, getting their medications, and collecting medical certificates. These are captured in the quote below: “I prefer face to face than zoom. Because I get detailed advice such as diet, etc from face-to-face consultation. Zoom method doesn’t give me that.” (D2, F) Face-to-face consultations with the DITE app was also preferred by participants when the illness they faced was complex and required immediate medical attention: “I’d normally go to a doctor… If I have simple cold, it’s not necessary. But if It’s (illness) is serious, which we know ourselves, we’d go to the doctor. Face to face with an interpreter is better.” (D6, M) In contrast, some participants preferred Telemedicine over face-to-face consultations when the illness faced was simple: “That would be my first choice (zoom). But if it doesn’t work, then going to the doctor will be my last choice. For simple things going all the way to the doctor is a waste of time. So it depends if (through zoom) what the doctor advice if I should just stay put or need to get to the doctor.” (D5, M) Areas for Improvement Lastly, participants highlighted some key areas of the DITE app that required improvement to increase the effectiveness of the app. Theme 1: Availability of emergency feature One of the most pertinent areas for improvement brought up by the participants was the incorporation of an emergency feature in the DITE app. Participants believe that the DITE app should provide immediate connection with an interpreter during emergencies, saying “There is a need to add the emergency call feature that is available 24 hours, especially during the night when we need interpreting. Perhaps if there’s heart attack at 2am. There need to be immediate help, a last-minute emergency feature.” (D2, F) Theme 2: Improving DITE app interface Participants revealed that multiple features can be included to improve the communication between the patient, interpreter, and HCP. This included a suggestion to have a dual camera feature. One of the participants also suggested that an attachment feature for images to be included to act as a visual aid for communication: “I would like to suggest the features to attach picture for the particular appointment we made. We have the appointment details above, and attachment feature below. Example to take pictures of the injury sustained and seeking consultation for. This is to facilitate those who are illiterate / unable to explain well.” (D2, F) Theme 3: Allowing time for communication with the interpreter prior to the consultation Lastly, participants suggested allocating time for the patient to communicate with the interpreter before the consultation. This would allow the interpreter to familiarize with the patient’s issues to allow for better communication during the consultation: “Before meeting the doctor, one should communicate with the Interpreter first so that the interpreter know what are our medical concerns. And when we meet the doctor, the interpreter is well aware of or problem. It saves time.” (D1, M) HCPs Demographic details The majority of participants were female (71%) and aged between 20–30 years of age (57%). The remaining three (43%) were between 31–40 years of age. The majority (86%) were not aware of the Persons with Disability Act 685, 2008 on Access to health, and had not attended sign language classes (57%), while all were comfortable using telecommunication applications (such as WhatsApp, Skype, Facetime etc). Further details are provided in Table 2. Table 2 Characteristics of healthcare providers (n = 7) Characteristics n (%) Work experience 10 years 3 (42.9) Current job designation Intern 1 (14.3) Medical officer 4 (57.1) Specialist 2 (28.6) Mobile operating system Android 3 (42.9) IOs 4 (57.1) Number of Deaf patients managed/treated in the past 1 year None 4 (57.1) 1–5 3 (42.9) Mode of communication used previously to communicate with the Deaf* Hand Gestures 4 (57.1) Pen & Paper 7 (100.0) Help from family members or friends 3 (42.9) I am able to communicate in Sign Language 2 (28.6) Texting on computer or mobile 1 (14.3) Awareness of the Dos and Don'ts communicating with a Deaf person No 4 (57.1) Yes 1 (14.3) Somewhat 2 (28.6) *Participants were allowed to select more than one option so totals might not equal 100% An overview of the themes and subthemes are presented in Fig. 2. Performance Expectancy Theme 1: Strengths of the DITE app Performance expectancy is understood as the benefits and limitations HCPs will face during their consultation experiences with Deaf patients in relation to the use of the DITE app. In the interview, the HCPs were requested to share ways in which the DITE app helped them during the healthcare consultation. Subtheme 1: Optimizing communication and history-taking HCPs mentioned that the DITE app managed to facilitate communication with Deaf patients by enabling a more detailed two-way communication. It allowed both stakeholders to express and comprehend each-other more effectively, which the HCPs think is the foundation in building patient rapport. It was highlighted that the HCPs were able to gather a much more comprehensive medical history from the patients when using the DITE app, as compared to that obtained when using the traditional written-paper method. There was a unanimous agreement from the HCPs that they are keen to use the app for this reason, despite the limitation of having to take up a longer time during the consultation: “I’ll say that I did require more time using the app but that’s because I was able to take a better history. (…) But in terms of being able to achieve quality history and to be able build a better relationship with the patient, definitely, I am very happy to use the app, not because it saves me time, but because now I know exactly what the patient is trying to tell me” (HCP2, F). Subtheme 2: Enhancing accuracy and comfort in healthcare consultations The HCPs also added that, with the use of the DITE app, Deaf patients can more readily have access to professional third-party interpretation services, rather than having to rely on casual interpretation by their family members or friends. Not only does this prevent information from being lost or modified (should family/friend selectively translate), it also creates a more conducive environment for patients to open-up: “The patient is speaking to someone who is totally unknown, so they will be able to open whatever that is withhold, because in real life, they come with their family, sometimes I wonder how much of what I am being said is being passed on, but now it is a total stranger, so they might also be able to totally open up” (HCP5, F). Subtheme 3: Streamlining logistics and efficiency Another point raised was that the usage of the DITE app could greatly facilitate logistical arrangements given the fact that it allows pre-bookings with the JBIMs: “I like that (…) this is pre-booked, because in a sense that sometimes when I am in the hospital and I run into problems with translating for [immigrant patients who cannot communicate with English or Malay], I actually have to wait for the physical interpreter to be free, and they can only come at X time for example, and I have to coordinate with the patient’s family who can only come at X time. So, I can end up easily a delay of surgery of 1 to 2 days just trying to coordinate everyone to sit down together to get the damn consent. So, I think with the app, the fact that its pre-booked, I can arrange the time. I'm looking forward to it shortening the logistics as well as the effort required just to arrange a meeting” (HCP2, F) . Theme 2: Limitations of the DITE app Subtheme 1: Limited non-verbal communication and interaction On the other hand, the HCPs also noticed some limitations to the trialled version of the DITE app. Firstly, the DITE app did not allow all three stakeholders (the HCP, JBIM, and BNUs) to see each other simultaneously, as what would happen should the interpretation be conducted in-person. During the simulation, the patient’s device was positioned such that the JBIM and the patient would see each other through the screens of their devices, whereas the HCP and JBIM could not see each other. In addition, the patients will be focused on the screen of their device, rather than on the HCP, hence there will be a total lack of eye-contact between both the HCP-JBIM and HCP-BNU. HCPs felt that this limited their ability to effectively integrate non-verbal cues and physical demonstrations during their speech, thereby serving as a barrier to communication. For example, HCP2 explained: “I wanted to demonstrate to the patient what (exercises) I wanted him or her to do and then to feedback to me what were the sensation the patient experienced as they were performing the examination. So, because the camera was initially only focused on the patient, the translator couldn’t see what I was doing to explain it to the patient (...) The second thing was also that there were sometimes, when I wanted to get the patient’s attention but again, they were so focused on the screen, so I had to actively reach out to the deaf patient, touch them, get their attention, ‘look at me’, and then explain, and then turn the camera to get them to explain…” (HCP2, F). It was also raised by the HCPs that the lack of eye-contact not only inhibits the HCPs from expressing themselves through non-verbal cues, but also deters them from picking-up the non-verbal cues from Deaf patients, which they think is equally important in the HCP-patient communication. Limiting conditions Limiting conditions are understood as the degree to which the HCPs believe that their work environment would deter the use of the DITE app during their consultations with Deaf patients. Theme 1: Potential Challenges in Real-World Implementation Subtheme 1: Environmental distractions and resource limitations During the FGD, the need for a conducive environment to use the DITE app was brought to light by a few of the participants. When asked whether the HCPs would use the app during consultations, one said “Depends on the scenario, if it’s in ED, labour room, with all sorts of distraction, I don't think it will be very conducive and then I will be like fine, I’ll use pen and paper instead.” (HCP6, F). Additionally, some HCPs indicated that there was a lack of necessary resources at their workplace to conduct a successful consultation utilising the DITE app. They suggested necessities such as a strong WIFI connection and even tripods would be difficult to access. Subtheme 2: User familiarity and technical challenges Many of the HCPs noted that patients faced difficulties during the consultation as they were unfamiliar with the use of the technology. According to one HCP, the interpreter hadn’t downloaded the correct link, so they were unable to proceed. Another HCP stated that at one point the Deaf patient and the interpreter couldn’t see each other as one of them had not clicked on something and at another point, both the Deaf patient as well as the interpreter couldn’t hear the HCP. One added that both his patients found it difficult to attach a phone to the tripod located on the table as well. Subtheme 3: Appointment scheduling complexity When using the DITE app, Deaf patients are allowed to pre-book their timeslot with an interpreter. However, HCPs noted that in the real-world, at clinics, with long queues and unknown waiting times, this becomes a hurdle as the patient is unaware of what time their appointment will be. Social influence Social influence is understood as the extent to which other medical professionals’ beliefs and opinions of the DITE app influence a HCP’s perception. Theme 1: Data Privacy and Patient Confidentiality There were shared concerns for data privacy and patient confidentiality with the use of a third-party app during medical consultations as HCPs were worried that conversations with patients would be recorded. Queries such as what would be done with the recordings, who has access to it, how they would be stored, how long they would be stored for, and whether they would be used for any other purposes, arose as the possibility of a leak is a real threat to patient confidentiality. Further concerns were highlighted regarding obtaining patient consent, as patients had to be informed of what and how exactly they were consenting to use the recordings. On the other hand, the benefit of consultations being recorded was also acknowledged in the case that a medicolegal complication was to arise. Theme 2: Medicolegal Acceptance of DITE App Translations HCPs expressed concern as to whether using the DITE app to translate is medicolegally accepted. As an element of obtaining patient consent, patients are required to disclose who explained what they were consenting to. This would generally have been done by the hospital’s official translator. However, when translations are done via the app there isn’t an ‘official hospital translator’ as such, which is an issue. To overcome this obstacle, the HCPs suggested exploring the possibility of using the sign language interpreter’s name on the consent form as a legal translator to fulfil this requirement and suggested looking over whether it is applicable to surgical procedures as well. This is of importance as should a communication breakdown occur with a Deaf patient and they decide to take legal action, it goes back to all the records and documentation, “… which record do you take on board, do you take on board the recording of the consulting between the SLI and the patient? Do you take on board the transcript of the doctor having recorded his or her perception of the conversation. Maybe, again once you have all the legal bits ironed out, then I’d feel more comfortable because my signature is on the form at the end of the day.”(HCP2, F) Behavioural Intention Theme 1: Usage and promotion of DITE app When asked about their willingness to use and advocate for the use of the DITE app in future consultations with Deaf patients, all HCPs answered affirmatively, with the condition that the major concerns mentioned in above are resolved. Areas for improvement Theme 1: Drawing functionality and spelling assistance The use of the DITE app enabled the HCPs to take a more detailed history in many ways. However, the lack of a function to draw out diagrams on the app directly, acted as a barrier to conveying some of the explanations across smoothly. On one occasion, the HCP used a pen and paper to illustrate an explanation and then first showed it to the translator on screen and then again to the patient. Another such instance was when the patient proceeded to spell out the name of a medication and the interpreter couldn’t quite catch the spelling and had difficulty interpreting it even after the patient had spelt it multiple times. As seen from the two previous examples, a drawing feature built into the app itself would be a great addition for all three parties, especially during surgical procedures as otherwise the practitioner would have to draw out the whole anatomy and also explain in further detail, which would be quite tedious. Theme 2: Improving visibility and interaction HCPs highlighted that the camera and screen were only facing the patient, which prevented HCPs from seeing the interpreter throughout the consultation, “…sometimes I feel both of them are talking to each other then I’m talking to the interpreter instead of the patient. I'm looking at the patient but the patient is not looking at me.” (HCP4, F). Participants expressed that being able to see the interpreter’s face in addition to the patient’s face, in a similar manner to that of the telecommunication consultations, would be beneficial as they would be able to gauge whether they were speaking too fast or slow, or even needed to stop talking if there were any issues/ miscommunication. Furthermore, they added that the ability for all three parties to make eye contact would enable the HCP to build a better rapport with the patient. SLIs Demographic details The majority of participants were males (67%), and all were freelance interpreters. The majority used android phones (67%) and of the six, only one had received training for the medical setting. Of the two who had experience interpreting in the medical setting, they interpreted 0–5 times in the past one year. Further details are provided in Table 3. Table 3 Characteristics of JBIM participants (n = 6) Characteristics n (%) Age 31–40 3 (50.0) 51–60 2 (33.3) 61–70 1 (16.7) Number of years as an interpreter 10 years 3 (50.0) Ability to reverse translate Maybe 4 (66.7) Yes 2 (33.3) Experience interpreting in medical setting Yes 2 (33.3 No 4 (66.7) Highest qualification Diploma 1 (16.7) Undergraduate 2 (33.3) Postgraduate 3 (50.0) An overview of the themes and subthemes are presented in Fig. 3. Performance Expectancy Theme 1: Strengths of DITE app Subtheme 1: Improving interpreter’s service & performance With the use of the DITE app, participants believe that their productivity as a JBIM increased. As they are able to provide their services without being physically present at the healthcare facility, participants were able to accept more bookings with the extra time. This is illustrated in the following quote: “... It improved (my) productivity in the sense that I could probably help more Deaf (people) (…) with this (DITE app), I could have multiple bookings back-to-back throughout the day, or you know, on demand...” (JBIM 2, M) JBIMs felt the DITE app allowed them to provide their service to BNUs from different states across Malaysia. This is particularly useful as there are limited numbers of JBIMs. Additionally, participants unanimously agreed that the use of the DITE app reduced consultation time. The ability to provide interpretation services remotely also served an advantage of time as they need not spend time travelling: “…(By) using the app, I don’t have to travel over there (to be physically present at the consultation), and this can save up a lot a lot of time.” (JBIM 3, M) One of the participants also shared their personal experience of a medical emergency, where the DITE app’s advantage of virtual interpretation would have been lifesaving: “… few months back there was an accident which happened to a Deaf … and it was during peak hour, about 5PM or 6PM. He called me and he said: “Can you come because I need an interpreter?”. And from my home to (the) hospital, it takes minimum one hour during peak hours, and doctors cannot wait for that one hour. And if with this app… I can immediately (provide the interpreting service) to the doctors and to the Deaf. But because we don’t have this thing (DITE app), I can’t go (to the patient physically). Even if I went, the doctor cannot wait for me, so it (the physical distance and the lack of a suitable video conferencing tool such as the app) become such a big problem. In the emergency situation, this app would really come in handy. And even during pandemic, we had to go to, I’m talking about myself, I go to the hospital to interpret for the Deaf. I have to be physically there, and now, with this app, I would say it is really fantastic.” (JBIM4, M) The interface face of the DITE app which allows BNUs to view all available JBIMs and select their preferred JBIM was noted as a helpful and user-friendly feature, with a JBMI saying “…it (DITE app) is good because for the Deaf, they can see all the interpreters’ name and contact. So, this is a plus point to this app. They can straight away pull up and select (their preferred interpreter) or put up their demand and the interpreters who see it can immediately react to it. As compared to using Zoom or other apps where you don’t know who the interpreters are. You cannot choose.” (JBIM1, F) Subtheme 2: Video and audio quality Participants revealed that the quality of the DITE app’s audio and video was satisfactory to facilitate their interpretation. This includes appropriate size and quality of video displayed on the app and good audio clarity. This is illustrated in the following comment: “For me, the app is fantastic… Number one, I can see (BNUs) clearly as the Deaf is actually being highlighted as my main point, because if the Deaf is very small, I cannot see whatever that was communicated to me. That’s number one, (where the Deaf) is highlighted big enough. Number two is the voice (audio quality). The quality of the voice (audio) is also quite good, because whatever the doctor says, if I cannot hear it, I cannot interpret. But in this app, it is quite clear, so for me it doesn’t have any big problem.” (JBIM4, M) Theme 2: Limitations of DITE app Participants disclosed that multiple limitations hindered their interpretation process. This included limited view of the JBIMs, especially when they needed to sign using body parts that were beyond the camera’s field of view: “…I’m very satisfied with it (DITE app). But of course, if I can go physically, it will be much better, because I can see the whole thing (body gesture of the doctor and the patient), and I can show them the whole thing (entire body gesture), (while using the app) can only show them part of it. Before (when interpreting) medical terms, sometimes you (JBIMs) would need to sign up to your neck or your leg, or (perform some actions) so it will be easier for them to understand. This limitation happens because we are using phones, which screens are quite small.” (JBIM3, M) The limited field of view also interfered with the interpretation process during physical examinations. When the HCPs performed physical examinations on BNUs, the JBIMs were unable to interpret accordingly as the physical examination was not captured by the camera, with one noting “…we can’t see the doctor... (when) the doctors say: “OK, I want to check your hand” … we will just tell the Deaf: “Stretch out your hand”. But (when using DITE), we don’t know where the doctor is pressing (on) the hand (of the Deaf), or which part of it, we will just interpret whatever the doctor told us, or (we will just tell the Deaf): “Now I am pressing on this part, how do you feel?”. When the Deaf stretch out their hands to the doctor, their eye contact is not on the screen (focusing on the interpreters), they are looking at their hands… So, in this way, there is a little bit of slowing down (of the interpretation because) we have to ask: Okay, please look at me first. How is it? When pressing on this part (the part which the doctor is pressing on) how do you feel? Then only would they (BNUs) express to you. (JBIMs).” (JBIM1, F) Participants also questioned the feasibility of using the DITE app in a real-world setting, particularly when the environment is less conducive: “…just now when I try to interpret, there was some (construction) work going on. So, there was a (background noise) ... If you are looking at an actual environment, maybe the surrounding is very noisy so you cannot hear.” (JBIM 3, M) Finally, participants noted that the lack of notification features such as ringtones when a booking was received and this could potentially lead to unnoticed calls that are missed, as noted by one JBIM: “…now we are under testing, so I was very alert with what I have. I will check (my phone for notifications) every time, but normally I don’t check my phone, only when there is some ringing. So, when there is no ringing, I won’t know if there is an incoming call. Even in an emergency, I won’t know.” (JBIM3, M) Effort Expectancy Theme 1: Navigating DITE app Participants agreed that navigating and mastering the DITE app was effortless and easy. However, some participants did face minor troubles as they were unsure how to properly use the DITE app. For instance, one participant did not know that they had to turn on the ‘I’m available’ option in the app, leading to their status showing as they were unavailable. Theme 2: DITE app interface Participants also had issues with the DITE app being unable to update their booking status automatically after accepting a booking. They received error messages that would only be resolved when participants manually refreshed the app. One participant suggested "...if there is an arrow or something to show you to pull down to refresh, that would be helpful.” (JBIM 6, M) Social influence Theme 1: Encouragement to use DITE app from relevant stakeholders Participants were asked if they believe that relevant stakeholders such as other JBIMs, Deaf associations, and HCPs would encourage the use of DITE app. One of the participants was confident that there would be encouragement from these stakeholders, citing the improvement in accessibility to interpreter services as the motivator, “I think yes, definitely, because like during the pandemic time, and even prior to pandemic, when we had a fear about one of our best friends being admitted to the hospital, you know it was so difficult they needed to get interpreters to go there and all, and a lot of us were working because we have our full-time jobs, so it's very difficult for us to take time off to go there. But with that app, it is so much easier. They (BNUs) don't have to tell us to go there. Just use the app and we (JBIMs) are available to interpret from wherever we are. So, I think it's something that a lot of people, our peers, and even the Deaf would be very keen to use.” (JBIM 2, M) Facilitating conditions Theme 1: Previous experience with telecommunication All participants had experience using other teleconferencing apps for video calls. During the COVID-19 pandemic where social distancing measures were in place, the use of teleconferencing apps surged, and this experience was deemed useful in easing the process of navigating the DITE app. Theme 2: Environment and supportive devices A quiet and appropriate background was deemed necessary by the participants to fully optimize the use of the DITE app: “I think the area that I was placed at was quite good, because first of all, it was quiet and then second thing which was very important for me was that it was a clear empty background behind me.” (JBIM6, M) Resources should also be available to support the use of the DITE app. This includes the availability of Internet access and additional devices such as headphones, especially when the surroundings are noisy. Limiting conditions Theme 1: Lack of cultural competency among HCP Participants found that there was a need to improve the cultural competency of HCPs, particularly when communicating with a Deaf-sign user in the presence of an interpreter. During the simulated consultations, participants noted that the HCPs were either speaking too quickly or too slowly. This made it difficult for the participants to interpret to the patient, as captured in the following comments: “When the voice was tested just now, the doctor was speaking too fast. It's very difficult to catch up. (I had to ask the doctor), ‘What was it again, sorry’.” (JBIM 5, F) “I think (speaking) too slow also makes it very difficult because sometimes I want to listen to the whole sentence to know what else (the doctor) wants to say. I want to hear everything, before I sign, and the Deaf are waiting (for me to interpret).” (JBIM 3, M) Theme 2: DITE app not available on iPhone operating system (iOS) As the DITE app was not available on the iPhone operating system, participants stated that this was one of the major limiting conditions as they struggled to find and navigate an Android phone: “I feel that because (the app is not available on) iOS (iPhone operating system) phones, so for me, I did face some problems because I need to look for another Android phone… Besides, I am not so used to Android phones, this was the first time I have used an Android phone, so it also posed an issue to me.” (JBIM1, F) Theme 3: Difficulty in signing medical terminologies Participants also revealed that they were challenged with medical terminologies that were difficult to sign as “I find the medical terminologies difficult to spell. For example, in the (simulation) just now, we had to ask the doctors how to spell the names of the medications. We were not familiar with the (medical) terminologies” (JBIM5, F) Behavioural intention Theme 1: Promotion and use of the DITE app When asked if they would use the DITE app frequently when it is available, participants unanimously agreed that they would. However, one participant mentioned that they would not use the app all the time, depending on the role they are playing in the consultation, “For me, it’s 50–50. It is all dependent on my role. If I know them personally, I prefer to go to them... because apart from interpreting, I’m also their friend, I also want to visit them. So, I can do two things at once. But for someone I do not really know, I prefer using this app. So, it depends on what the role that I’m playing is.” (JBIM4, M) Participants unanimously agreed that they would encourage other stakeholders such as doctors to use the DITE app. Areas for improvement Theme 1: User guide With the aforementioned challenges in using the DITE app, the moderator suggested to establish a user guide, and this was positively accepted by participants. The user guide would clearly delineate practical approaches to maximize the benefits of the DITE app. This includes features that needed to be switched on, positioning of the device, and instructions on how to use the DITE app during physical examinations. Theme 2: Communication and setting expectations Participants suggested that DITE app is designed so that the HCP, JBIM, and BNU can be seen on the screen to allow for three-way communication. However, this should not compromise the view of the BNUs. Hence, there needs to be a feature that allows JBIM to pin the BNU on their screen: “I would prefer it if there were a three-way (communication), because, (during the simulation), it was just two ways (BNUs and JBIMs), but if we have three-way and pinning are there, then yeah it will be a lot better.” (JBIM2, M) Additionally, participants also found that there was a need to communicate with BNUs and HCPs before the consultation. It was noted that communicating with HCPs would be a method to overcome the lack of Deaf culture awareness among HCPs. This provides an opportunity for JBIMs to inform HCPs that they are not medically trained and to avoid medical jargons. Privacy and confidentiality of information could also be reassured to HCPs during this process, with one noting: “…if I (am interpreting in a) medical setting, I would want to meet up with the doctor first. Why? Because I'm going to tell them that I am representing the Deaf, so that they know that certain P&C (privacy & confidentiality) thing I am allowed to do. Number 2, they also know that I am not a medical trainee. They have to cut short some of the some of the medical terms by using very laymen language. Otherwise, whatever word you say to me, I have to spell it to the Deaf. If I don't understand, the Deaf definitely don’t understand. It’s just a word, but what is that word? So, that is the preliminary meeting with the doctor which is compulsory. And from there, if you want to talk about the speed and if the app allows us to have just a two-minute talk to the doctor, then it will be fantastic.” (JBIM4, M) Communicating with BNUs before the consultation was also necessary to understand the literacy level of the patient and their fluency in BIM: “we have to know who our clients are, and their respective background in sign language before the consultation. Sometimes, for Deaf people, their level of (expertise) in sign language differs. So I think before the call, interpreters can first meet up with the client, so we can check with the client on their level of comprehension in sign language, and whether they can keep up with the interpreters” (JBIM5, F) Theme 3: Notification for calls and emergency bookings With regards to the lack of notification when participants received bookings, participants suggested the DITE app should include ringtones as a notification and to have a special ringtone for emergency bookings. Participants also mentioned a need for pop-up notifications for emergency bookings to make it more eye-catching, with one saying “…those in emergency cases, those (who are calling) on demand, (the ringtone should be) something that really catches our attention, telling us that: “Hey, the app requires our attention now”. Yeah, it could be a siren or something. Something that is not a common ringtone that people would be using. Yeah, because if it's a normal ringtone we would... like... just ignore it. But if it is something that alerts us, that the app requires our attention, yeah, (we would attend to the app).” (JBIM2, M) Participants also hope to see the incorporation of emergency booking status in the DITE app. Whenever BNUs request for an emergency booking, JBIMs hope to receive an update on whether the request has been fulfilled, especially when they are unable to attend to them: “I think, especially when they apply for the ‘on demand’ (emergency booking), (I want to know) whether another interpreter accepts it. (If) I'm not able to pick up, at the back of my mind, “Oh my gosh, did somebody pick it up or not, or is that Deaf person left hanging there without anybody assisting,” because I have no idea whether it’s picked up or not.” (JBIM2, M) Theme 4: DITE app logo and icons Participants suggested that the logo of the DITE app should include components that represent Deaf and health. This would inform users that the app was meant for the Deaf and healthcare consultations, saying “The sign (logo) will be related to Deaf and medical, so at least when they look at it, they know that this is helpful for the Deaf in medical consultations.” (JBIM1, F) One of the participants also revealed that some BNUs may navigate the app through graphic representations rather than words. Hence, the app should incorporate graphic icons to improve its user-friendliness as “…we know that Deaf is the eye person (uses their eyes to navigate). So instead of putting words in the icon there, it would be better (if) you could change it to an emoji.” (JBIM4, M) Theme 5: Additional features Participants identified multiple features that could be included in the DITE app to improve its effectiveness and user experience. Firstly, a suggestion was made to include the data of interpreters available in Malaysia into the DITE app. This allows BNUs to easily search for their preferred interpreters and make bookings for their healthcare consultation. Participants found that there were safety concerns regarding the identity of the users. Hence, a suggestion to have identity verification in the DITE app was made. This would ensure that bookings were made by those who truly needed it: “…in order to use the app, them (users) needing to at least upload their profile and a picture of themselves before they can actually start using it, so at least when you (JBIMs) accept it, you can identify the person. They are legit, not something like (a robot or spam).” (JBIM6, M) Additionally, participants also noted the need for close captioning during the healthcare consultations, especially for medical terms. This is highlighted in the following comment: “If we can see what the doctor said on the screen, (that would be good). Because for some medical terms, we may not be very familiar. If it can appear at the bottom of the screen, we don't have to ask the doctor what he was trying to say or how to spell the word. It may not be accurate, but at least, we already know, more or less, what it is.” (JBIM4, M) There was also a suggestion to record the healthcare consultation to cross-check whether the interpretation was accurate, as “For me, (the recording is) not for the doctor, (it is) only for the Deaf, to see whether what they are signing is correct or incorrect, (or) if the voice-over is correct or incorrect. We need the recording (of the consultation) for the Deaf.” (JBIM5, F) To improve the convenience and user experience of the DITE app, the moderator explored the feasibility and benefits of syncing the bookings in the DITE app to the participants’ personal calendars such as Google Calendar. Participants agreed that this would be a good feature to have. Finally, participants believed that the potential of the DITE app could be expanded beyond the limits of medical consultations: “In terms of using it in a medical setting, I think it can be expanded from medical settings because I think the ‘on demand’ and the ‘booking’ features, are not just limited to medical settings.” (JBIM6, M) Discussion The discussion section delves into the multifaceted implications and potential of the DITE app in bridging communication barriers between HCPs and Deaf patients. Key themes explored include the significance of communication in patients' preferred languages, the scarcity of certified JBIMs in Malaysia, the importance of diversity and inclusivity in JBIM selection, assurance of accuracy and confidentiality, logistical benefits, impact on doctor-patient relationship, cultural competency in HCPs, extended consultations with the app, medicolegal issues, limitations in internet access, and avenues for future research and enhancement. The analysis underscores the promising role of the DITE app in facilitating effective healthcare communication for the Deaf community in Malaysia, while emphasizing the imperative for ongoing research, refinement, and strategic implementation to maximize its impact on healthcare accessibility and outcomes. Enabling communication in patient’s language During the FGD, it was emphasized that a significant benefit of the DITE app is its ability to enable communication for Deaf patients using sign language, which is their native and preferred mode of communication. Both the BNUs and HCPs concur that this dynamic interaction between healthcare providers and patients is pivotal in shaping the quality of patient care. This importance is further underscored in an article by Ranjan et al which stresses the necessity for HCPs to communicate in their patients' preferred language to strengthen the practitioner-patient relationship [ 30 ]. In addition to enhancing patient comfort and facilitating information sharing, effective communication in the patient's language has the potential to improve treatment adherence significantly [ 30 ]. Besides facilitating healthcare consultation, the importance of popularizing sign language communication in healthcare to enhance the overall health of the Deaf population must be emphasized. Deaf patients exhibit lower health literacy levels compared to their hearing counterparts with equivalent formal education levels for several reasons [ 13 ]. Firstly, while hearing individuals acquire knowledge through incidental learning opportunities such as overhearing conversations and media broadcasts, Deaf signers are deprived of this exposure, hindering their acquisition of health-related information [ 31 ]. Additionally, the reliance on visual language makes written health education materials less accessible to Deaf individuals, compounded by materials often being written at a reading level above their literacy level [ 16 , 32 ]. Moreover, the scarcity of health resources available in sign language further limits Deaf patients' access to vital health information [ 33 ]. Consequently, these factors contribute to the diminished health literacy levels observed in Deaf signers compared to their hearing peers with similar educational backgrounds. For instance, in a study assessing cardiovascular risk knowledge among 203 Deaf signers in the United States, 40% failed to mention any symptoms of a heart attack, while 60% were unable to list any symptoms of a stroke. This increases their susceptibility to health issues and leads to inferior health statuses and outcomes compared to the general population [ 13 ]. Hence, facilitating and promoting healthcare communication in sign language stands as a crucial measure to ensure effective healthcare accessibility for the Deaf community, thereby enhancing their healthcare literacy and, consequently, improving health outcomes. The DITE app's provision of SLIs addresses the critical need for effective communication in the native language of the Deaf community in Malaysia, emphasizing the cultural and linguistic competency required for accurate healthcare communication. Improving productivity and accessibility of JBIMs During the FGDs, both BNUs and JBIMs unanimously emphasized that the DITE app has the potential to enhance the efficiency and accessibility of JBIMs. As mentioned earlier, there is a notable shortage of JBIMs in Malaysia. As of 2021, only 95 certified JBIMs were registered with the Malaysian Federation of the Deaf, predominantly concentrated in Kuala Lumpur, the capital of the country [ 34 ]. This scarcity of interpreters poses a substantial obstacle to effective healthcare communication between Deaf patients and HCPs, resulting in limited access to healthcare services for many Deaf individuals. The DITE app shows promise in addressing this scarcity by potentially enhancing the efficiency of SLIs, a critical factor in overcoming this challenge. However, it is essential to acknowledge potential limitations in rural areas, where limited internet access may impact the app's accessibility. Equality, diversity, and inclusion in JBIM selection In the FGD, JBIMs highlighted a potential benefit of the DITE app for the Deaf community in that the app offers a unique feature allowing patients to select JBIMs based on preferences related to race, gender, and potentially religion. This ensures that Deaf patients can choose interpreters who resonate with their own backgrounds, fostering a sense of representation and inclusivity [ 35 ]. This dedicated effort to promote equality, diversity, and inclusion within the Deaf patient community is particularly crucial in Malaysia's diverse, multiracial, and multireligious context. The importance of representation and diversity in healthcare is paramount, especially in the private and sensitive nature of the healthcare setting. A qualitative survey investigating the importance of interpreter gender across the United Kingdom, Finland, and Spain highlighted that nearly 60% of participants recognized the significance of interpreter gender, specifically within healthcare settings. Clients feel more comfortable sharing their symptoms and concerns with an interpreter of the same sex, especially in mental health contexts. Furthermore, female interpreters are perceived as less intimidating, particularly in social work, such as child protection cases [ 36 ]. Recognizing this importance, the DITE app not only addresses the scarcity of JBIMs but also emphasizes the significance of a diverse JBIM community and the ability for patients to choose their preferred interpreter. This approach aligns with the broader goal of respecting patients' autonomy in healthcare, ultimately improving compliance and overall health outcomes [ 37 ]. Assurance of accuracy and confidentiality During both FGDs involving BNUs and HCPs, it was observed that the utilization of DITE apps could eliminate the need for family members to act as intermediaries between Deaf patients and HCPs, a factor regarded positively by participants. This is supported by research which underscores the suboptimal nature of relying on family members for interpretation within healthcare settings due to their potential emotional involvement, untested language proficiency, and lack of proficiency in medical terminology [ 38 – 40 ]. For example, in a study on errors in medical interpretation and their potential clinical consequences in paediatric encounters, it was found that errors made by non-professional interpreters were notably more likely to have potential clinical consequences compared to those made by professional interpreters (77% vs. 53%) [ 41 ]. Additionally, utilizing family members for interpretation also poses a risk to patient confidentiality, with no assurance of impartiality or adherence to professional conduct [ 38 ]. The DITE app, by facilitating professional interpretation, aligns with established best practices for upholding patient confidentiality and fostering effective communication. Logistical benefits and time efficiency During the FGDs with HCPs, the DITE app was commended for its ability to streamline SLI services, which was seen as a key advantage for its adoption. Specifically, the app simplifies the process of acquiring interpreters, addressing challenges associated with lengthy waiting times. This aligns with the broader objective of enhancing interpretation services for the Deaf community and improving overall efficiency. These benefits of mobile applications offering video remote interpreting (VRI) services were illustrated in an observational study assessing the integration of VRI in a hospital that previously relied on in-person and over-the-phone interpreting services, where it was observed that VRI implementation led to several notable improvements. These included enhanced utilization of interpreters, a reduction in over-the-phone interpreting, shortened wait times (from 60 minutes to 5 minutes), and facilitated access to interpreters in clinics where in-person interpreting services were previously unavailable. Additionally, the adoption of VRI resulted in an increase in the overall number of interpreting encounters conducted annually [ 42 ]. Overall, the findings underscore the potential of applications offering VRI services, such as the DITE app, in improving logistical efficiency and accessibility in healthcare interpretation services. Impact on doctor-patient relationship An issue highlighted regarding the utilization of the DITE app revolves around the limited interaction between HCPs and patients. During consultations, patients directed their focus towards the JBIM rather than the HCPs, primarily due to the constraints within the user interface of the DITE app. The HCPs in the study mentioned finding this challenging for them to effectively convey and interpret non-verbal cues. Non-verbal cues such as haptic communication (via touch), kinesics (gestures, head movements, eye contact, and facial expressions), and proxemics (use of space and distance) are essential in ensuring effective communication[ 43 ]. Research suggests that the non-verbal communication behaviours of HCPs are pivotal in doctor-patient interactions, playing a significant role in establishing rapport and trust between HCPs and patients. This importance is underscored in a review by Chandra et al which highlights a positive correlation between trust, communication, and patient satisfaction [ 44 ]. Indeed, improved communication has been shown to enhance adherence to medication and to medical advice, both in developed and developing countries [ 44 ]. Further supporting this, a meta-analysis examining the relationship between physician communication and patient adherence revealed a substantial impact of communication skills on patient adherence to treatment regimens across various medical conditions. Patients whose physicians communicate poorly face a 19% higher risk of non-adherence compared to those whose physicians effectively communicate [ 45 ]. Given these findings, addressing the limited interaction between HCPs and patients on the DITE app remains a crucial priority for enhancing its effectiveness and ensuring optimal patient care. Cultural competency in HCPs Deaf culture competency stands as a pivotal factor in enriching the healthcare experiences of Deaf patients, as highlighted by JBIMs in this study. Despite advancements like the DITE app designed to streamline healthcare consultations for the Deaf community, significant barriers remain if HCPs lack sufficient training in Deaf cultural competency [ 13 ]. In the United States, HCPs were observed to treat Deaf patients paternalistically, offering treatment without ensuring patients fully comprehended their health condition or provided informed consent, leading to nonadherence and undermining patients' autonomy rights [ 46 ]. This underscores the urgent need for HCPs to understand and address the specific needs of the Deaf to optimize healthcare outcomes. Nevertheless, despite legislative mandates for equitable access and communication, culturally incompetent healthcare practices endure, exacerbating disparities within signing Deaf communities. Many HCPs are unaware of Deaf cultural norms and linguistic rights, impeding effective communication and comprehensive care [ 13 ]. In a survey involving pharmacists in Malaysia, less than 5% had utilized the services of a JBIM during consultations and more than 80% relied on written communication when interacting with the Deaf [ 47 ].Bridging these divides necessitates thorough cultural competency training for HCPs, emphasizing critical self-awareness and reflection in cross-cultural situations. Research indicates that culturally-competent care can bolster healthcare accessibility for Deaf patients. For instance, medical students trained in American Sign Language (ASL) and Deaf culture displayed a deeper understanding of the challenges faced by Deaf patients within the healthcare system [ 48 ]. Similarly, workshops on ASL and Deaf culture for osteopathic medical students bolstered their confidence and understanding in engaging with Deaf patients [ 49 ]. Positive healthcare experiences for Deaf patients often hinge on the presence of medically-certified interpreters and HCPs proficient in sign language. However, cultural competence education should extend beyond interpreters and be integrated into the early stages of HCP training. By reshaping attitudes and behaviours, HCPs can cultivate enhanced communication and patient involvement, ultimately diminishing healthcare disparities among Deaf patients [ 13 ]. Therefore, the development of the DITE app and the qualitative research on its usability extend beyond merely creating a communication tool; they also aim to raise awareness of Deaf culture among HCPs. Extended healthcare consultations and long-term benefits with the DITE app The utilization of the DITE app was observed to result in extended healthcare consultations, as both HCPs and Deaf patients engaged in more in-depth communication. While this may be perceived as a drawback due to the prolonged consultation duration, it is imperative to recognize potential long-term benefits, particularly the enhancement of patient comprehension. Research indicates that sufficient consultation time is crucial for ensuring that patients receive comprehensive assistance, treatment, and education, thereby promoting equal access to and quality of healthcare [ 50 ]. The reality is that Deaf patients often face challenges in effectively communicating with HCPs, leading to shorter and less effective consultations [ 40 ]. The improvements facilitated by the app have the potential to alleviate these issues and, in turn, contribute to a reduction in future healthcare burdens. This underscores the app's significance in facilitating accessible and effective healthcare communication for the Deaf community. Medicolegal Issues HCPs participating in their FGD have expressed concerns regarding the medicolegal acceptance of using the DITE app, particularly in obtaining patient consent. The issue arises from the interpretation process not being conducted by an official hospital translator, leading to doubts about the validity of the consent obtained. One suggested solution to address this challenge is to explore the possibility of including the SLI's name on the consent form as a legal translator, ensuring proper documentation for potential legal actions involving Deaf patients. This concern is indeed valid and supported by existing literature. A literature review of current practices in the utility of mobile technology in medical interpretation highlights the danger of inaccurate application translations and discussed the importance of having trained, professional interpreters present in medico-legal discussions, such as obtaining informed consent [ 51 ]. Additionally, a study comparing informed consent scores between consultations requiring a medically trained interpreter and those without language barriers highlights the significant hindrance posed by the absence of medically-trained interpreters in obtaining informed consent, which is a crucial aspect of medicolegal discussions. While nearly two-thirds of consultations without language barriers achieved high information scores, only about a quarter of those requiring professional medical interpretation attained similar levels of understanding [ 52 ]. The crux of the matter lies in determining the medicolegal validity of interpreting services provided by SLIs who are not certified in medicolegal consultations. There is a pressing need to assess the risks and benefits associated with allowing them to testify in consultations of this nature. One potential solution to mitigate these challenges is to invest in training more SLIs in medical and medicolegal consultations, which will be further elaborated on below. By equipping them with the necessary skills and knowledge, healthcare systems can better meet the demands of the Deaf community while ensuring compliance with medicolegal standards. Limitations in internet access It is crucial to tackle the constraint of the DITE app in regions with inadequate internet connectivity. Amid the COVID-19 situation, where the reliance on online platforms has become imperative, there is an opportune moment to enhance the prevalence and acceptance of telehealth, including accessing healthcare interpreting services [ 53 , 54 ]. Resolving this challenge necessitates concerted efforts on a broader scale, particularly in addressing internet coverage issues in Malaysia. In our pilot study assessing the feasibility and acceptability of DITE among Deaf and JBIM participants, the majority acknowledged having adequate internet speed. However, some encountered difficulties accessing internet data, emphasising the necessity of reliable internet access for seamless connectivity. One proposed solution was to incorporate the cost of data into the DITE app, guaranteeing at least an hour of free data or credit for emergency use to enhance accessibility [ 25 ]. Study limitations and future research This study is the first such study of its kind involving three key stakeholders to assess the feasibility of an app for healthcare consultations for the Deaf. The study is not without limitations. Most of the JBIMs involved did not have prior experience translating in healthcare settings. The study was also conducted in an urban setting where internet connectivity was good, and involved participants who were technologically-capable. In addition, it was not conducted in the real-world setting i.e. an actual healthcare setting, where various other factors could have affected the use and functionality of the app, as mentioned by participants above. The study's sample size was relatively small and the sample might not have adequately reflected the diversity present within each stakeholder group, which could restrict the broader applicability of the results. The inclusion criteria requiring participants to have Android phones may have also excluded individuals who use other types of devices, potentially biasing the sample towards a particular demographic. Participants were recruited through the research team's networks, which may introduce bias towards individuals who are more familiar with or supportive of the project, potentially skewing the results. In addition, participants were only given access to the DITE app for a week before engaging in simulated medical consultations. This short duration may not have allowed participants sufficient time to fully explore and become accustomed to the app's features, potentially affecting their perceptions and feedback. The study primarily focused on evaluating the feasibility and acceptability of the DITE app, through the lens of the UTAUT2 framework. While this approach provides valuable insights into users' behavioural intentions, it may not capture all relevant factors influencing the adoption and utilisation of the app. Finally, despite efforts to ensure accuracy in transcription and thematic analysis, interpreting sign language and capturing its nuances in written form can present challenges. This may introduce potential limitations in the analysis and interpretation of data from Deaf participants. Moving forward, our research points towards key avenues for future exploration and enhancement of the DITE app. To address limitations highlighted by participants, we propose conducting larger scale testing over a longer period, particularly in rural areas, to ensure a comprehensive understanding of the app's effectiveness across diverse settings. Potential biases in recruitment and analysis methods should also be mitigated. Real-world evaluations in healthcare settings will provide insights into the practical utility of the app in routine patient care. To address the challenges faced by HCPs in effectively communicating with deaf signers, it is imperative to implement training programs focused on Deaf cultural competency. These programs should aim to educate HCPs about the linguistic and cultural norms of the Deaf community, emphasizing the importance of recognizing and respecting Deaf identity. Moreover, training should include practical strategies for facilitating communication with deaf signers, such as learning basic sign language phrases and understanding the significance of visual communication in Deaf culture. By enhancing HCPs' cultural competence, healthcare settings can become more inclusive and responsive to the needs of deaf signers, ultimately improving patient-provider interactions and health outcomes [ 28 ]. Additionally, SLIs play a crucial role in facilitating communication between HCPs and deaf signers, yet many lack systematic, in-depth medical training. To address this gap, comprehensive training programs tailored specifically for SLIs in medical settings are essential. These programs should cover a wide range of topics, including medical terminology, ethics, and cultural sensitivity. Additionally, SLIs should receive hands-on experience and guidance on navigating complex medical situations, ensuring they are well-equipped to accurately convey information between HCPs and deaf patients. By providing SLIs with specialized medical training, healthcare facilities can enhance the quality and effectiveness of interpreter-mediated healthcare interactions, ultimately improving accessibility and outcomes for deaf signers [ 13 ]. These initiatives collectively aim to fortify the DITE app's functionality, advancing SLI service accessibility and cultural competency in healthcare settings. Conclusion The DITE app's potential in bridging communication barriers for Deaf patients in Malaysia unveils crucial insights. Key themes explored include the significance of communication in patients' preferred languages, scarcity of certified interpreters, diversity and inclusivity in interpreter selection, assurance of accuracy and confidentiality, logistical benefits, impact on doctor-patient relationships, cultural competency in healthcare providers, extended consultations, medicolegal issues, and limitations in internet access. The analysis emphasises the promising role of the DITE app in facilitating effective healthcare communication for the Deaf community in Malaysia. However, it also highlights the imperative for ongoing research, refinement, and strategic implementation to maximize its impact on healthcare accessibility and outcomes. Future efforts should focus on larger-scale testing, particularly in rural areas, real-world evaluations in healthcare settings, and the implementation of training programs for healthcare providers and interpreters to enhance cultural competency and medical expertise. By addressing these challenges, the DITE app can truly revolutionize healthcare accessibility and outcomes for the Deaf community in Malaysia. Abbreviations BI Behavioural intention BIM Malaysian Sign Language BNU BIM native users DITE Deaf In Touch Everywhere FGD Focus group discussion HCP Healthcare provider JBIM BIM interpreter SLI Sign language interpreter UTAUT Unified Theory of Acceptance and Use of Technology Declarations Ethics approval and consent to participate Ethical approval was granted by the Monash University Human Rights and Ethics Committee (Ref no: 2021-20452-53435) Consent for publication Not applicable Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This study was funded by the Network for Equity through Digital Health (NEED) Platform, Monash University Authors' contributions NES undertook transcribing, coding and thematic analysis on the interview transcripts and was a major contributor in writing the manuscript. WRX undertook transcribing, coding and thematic analysis on the interview transcripts and was a major contributor in writing the manuscript. WNJEF undertook coding and thematic analysis on the interview transcripts and contributed to writing the manuscript. AD was involved in the conception and design of the work and data acquisition. VR was involved in the conception and design of the case scenarios. AC was involved in facilitating the FGD, drafting the manuscript based on the findings from the interview and providing relevant inputs/feedback in the manuscript. JN was involved in the design of the study, data acquisition, and transcribing of transcripts and video recordings. 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Loo JS, Yow HY, Ten YY, Govindaraju K, Megat Mohd Zubairi MH, Oui HC, et al. Exploring the rise of telehealth services in Malaysia: A retrospective study. Digit Health. 2023;9:20552076231216275. Rabanifar N, Abdi K. Barriers and Challenges of Implementing Telerehabilitation: A Systematic Review. Iranian-Rehabilitation-Journal. 2021;19(2):121–8. Additional Declarations No competing interests reported. Supplementary Files Additionalfile1COREQ.docx Additionalfile2GRIPP2.docx Additionalfile3Casestudies.docx Additionalfile4InterviewGuides.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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themes, and subthemes for HCP group\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4392408/v1/b67b41dbfaa19f99cd6567b1.png"},{"id":57289654,"identity":"f4be37d0-490e-4236-9a0e-e6eba811a182","added_by":"auto","created_at":"2024-05-28 17:49:29","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":265380,"visible":true,"origin":"","legend":"\u003cp\u003eCategories, themes, and subthemes for JBIM group\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4392408/v1/7f559ec539812e8b900aa175.png"},{"id":76558386,"identity":"b58f91dc-43e3-4b8b-b7e4-767393cf66e7","added_by":"auto","created_at":"2025-02-18 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17:57:30","extension":"docx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":3826836,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile4InterviewGuides.docx","url":"https://assets-eu.researchsquare.com/files/rs-4392408/v1/551ef6e38882cc509d9b6ccb.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Assessing the Feasibility and Acceptance of the Deaf-in-Touch Everywhere (DITE™) Mobile App: Insights from Healthcare Simulations and Stakeholder Discussions (HEARD Project)","fulltext":[{"header":"Background","content":"\u003cp\u003eAccording to the World Health Organization, approximately 466\u0026nbsp;million people worldwide experience disabling hearing loss [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], with around 70\u0026nbsp;million individuals being deaf and relying on sign language for communication [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Among this population, there is a subgroup that identifies themselves as culturally Deaf, denoted with an uppercase \"D\"[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Differing from the term \u0026ldquo;deaf\u0026rdquo; with a lowercase \u0026ldquo;d\u0026rdquo; which refers to the audiologic lack of hearing, the Deaf community define deafness as their linguistic and cultural identity rather than perceiving deafness as a disability. These individuals share a common experience of using sign language and adopting Deaf cultural norms [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Despite their substantial numbers, the healthcare needs of the Deaf community have not been adequately addressed, resulting in poorer health outcomes and different healthcare utilization patterns compared to the general hearing population. This phenomenon is mainly attributable to poor communication and patient engagement [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOne of the barriers in communication between healthcare professionals (HCPs) and Deaf patients is the misconception that lip-reading is a viable means of communication for all Deaf patients, and that they can fully substitute spoken or sign language communication [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In reality, only 30\u0026ndash;40% of English phonemes can be reliably identified by the Deaf through lip-reading even under the best conditions, while the rest requires guesswork [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. This limitation becomes even more pronounced during healthcare consultations, where complex medical terminology may be used, and patients may not possess sufficient background knowledge. Therefore, while lip-reading can be useful for Deaf individuals with some residual hearing, it cannot replace the use of sign language [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Furthermore, research has shown that HCPs often lack awareness and understanding of Deaf culture [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], further hindering effective communication and meeting the needs of the Deaf community [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. This issue was highlighted in the Sick Of It report published by SignHealth in 2014, which revealed that despite the majority of Deaf patients preferring sign language interpretation in healthcare consultations, only a fraction of them were given the opportunity, leading to misunderstandings, confusion, missed diagnoses, and inadequate treatment [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo address this communication gap between Deaf patients and HCPs, a solution would be the use of medically trained sign language interpreters (SLIs) in facilitating consultations [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, several limitations exist regarding this solution. Firstly, the current availability of sign language interpretation services falls short of meeting the demand due to a severe shortage of SLIs [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Besides, there is a lack of consistent medical training for SLIs. Working in healthcare settings where SLIs will often be faced with complex healthcare concepts and terminologies, achieving accuracy in healthcare interpretation can be a challenge without appropriate training. Additionally, the absence of established equivalent medical terms in sign language introduces further risks of misinterpretation [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Therefore, there is a significant need for further research and development to improve the accessibility of sign language interpretation services and bridge this communication gap.\u003c/p\u003e \u003cp\u003eAccording to the 2022 statistics report by the Department of Social Welfare Malaysia, they are 42,349 individuals registered as Deaf and Hard of Hearing [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] in Malaysia who prefer communicating in Malaysian sign language (BIM). There are only 30 SLI working with the Malaysia Federation of the Deaf, and there are merely around 20\u0026ndash;30 freelance interpreters available across the country [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. This glaring imbalance translates into a striking statistic: for each SLI, there are approximately 1,000 Deaf individuals in need of communication assistance. The Deaf community encounters substantial challenges when trying to access healthcare services, despite its significant size. Communication plays a crucial role in the patient-provider relationship within healthcare, as it ensures the best possible treatment for each individual. However, ineffective communication with Deaf individuals has resulted in various negative outcomes, including miscommunication leading to diagnostic and management errors [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], heightened levels of anxiety and embarrassment due to misunderstandings [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], delays in receiving treatment, unnecessary testing, breaches of privacy, and inadequate patient education leading to improper home care or medication usage [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. These obstacles often discourage Deaf individuals from seeking healthcare services altogether. The absence of a legal mandate in Malaysia compelling HCPs to provide SLIs further compounds this issue, leaving Deaf patients feeling uncertain and vulnerable during their medical visits [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Indeed, research undertaken involving members of the Deaf community in Malaysia have also revealed fear and apprehension among the Deaf when accessing the healthcare system [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn response to this pressing challenge, our team created a cross-platform mobile application called Deaf in Touch Everywhere (DITE\u003csup\u003e\u0026trade;\u003c/sup\u003e) to address the healthcare interpretation requirements of the Deaf community who rely on BIM, also referred to as BIM native users (BNUs). This was developed under the HEAlthcaRe needs of the Deaf (HEARD) Project \u0026ndash; a series of studies aimed at improving the healthcare access of the Deaf community in Malaysia[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. This app aims to connect Deaf individuals with a network of off-site interpreters via secure video conferencing. The primary purpose of DITE\u003csup\u003e\u0026trade;\u003c/sup\u003e is to enable Deaf users to schedule BIM interpreters (JBIMs) in advance or request them on-demand, providing convenience and flexibility similar to popular on-demand service platforms like Uber or Grab, but tailored specifically to the needs of the Deaf community. This comprehensive healthcare consultation solution encompasses all aspects, from the initial scheduling of SLI services to real-time interpretation during medical consultations. The development of DITE involved a community-based participatory approach, collaborating closely with key stakeholders from the Deaf community, BIM interpreters, and medical professionals. Utilizing participatory design methods is instrumental in enhancing health communication tools, ensuring their alignment with the specific requirements of the target audience [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOne pivotal aspect that influenced the design of the DITE\u0026trade; app was the pronounced preference of Deaf individuals for teleconferencing, particularly video-based communication, over text-based alternatives. This preference was corroborated through prior qualitative research that explored the Deaf perspective on a potential mobile health app designed to facilitate communication between pharmacists and Deaf individuals [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Furthermore, recent research conducted in 2021, which compared the utilization of smart devices, apps, and social media between adults with and without hearing impairment, elucidated a pertinent insight: adults with hearing impairment are no less inclined to employ smart devices than their hearing counterparts [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. In fact, a substantial proportion of Deaf individuals have integrated mobile phones into their daily lives for multifaceted purposes, including communication and learning [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe appeal of mobile applications among Deaf individuals is attributed to the independence, flexibility, and mobility they offer, as highlighted in a study on Deaf mobile applications. This research underscored the convenience of downloading and installing apps, along with the accessibility they afford at any time and place [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The DITE\u0026trade; app, thus, is poised to fulfil these specific needs within the Deaf community, rendering it a promising solution for widespread adoption in Malaysia. When considering the potential of the DITE\u0026trade; app as a mobile health application tailored to the needs of BNUs, valuable insights can be gleaned from the milestones achieved by analogous applications in other countries. Notable examples include Pro Deaf Libras and Deaf Bible, which have achieved varying degrees of success, as evidenced by their download statistics on the Google Play Store[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The evolution and outcomes of these applications reflect the Deaf community's willingness to embrace mobile applications that aid in their day-to-day communications.\u003c/p\u003e \u003cp\u003eWe recently concluded a pilot assessment of the feasibility and acceptability of measuring the Unified Theory of Acceptance and Use of Technology (UTAUT2) constructs for DITE\u003csup\u003e\u0026trade;\u003c/sup\u003e among nine Deaf participants and nine BIM interpreters [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. We observed that the contextualised UTAUT2 questionnaire serves as a valuable tool for gauging the adoption of the DITE\u003csup\u003e\u0026trade;\u003c/sup\u003e app among the Deaf community and SLIs in Malaysia. Involving targeted end users in the design process provided crucial insights, ensuring that the app continues to meet the genuine needs of both groups.\u003c/p\u003e \u003cp\u003eIn this research undertaking, we executed a healthcare simulation employing the DITE\u003csup\u003e\u0026trade;\u003c/sup\u003e app, followed by three distinct focus group discussions (FGDs), each engaging one of the critical stakeholders: BNUs, JBIMs, and HCPs. This provided a platform for open dialogue and the exchange of experiences and opinions regarding the feasibility and utilization of the DITE\u0026trade; app in healthcare simulations. This paper is dedicated to presenting a thematic analysis of the outcomes from the FGDs involving all three stakeholders. Our analysis endeavours to evaluate the feasibility of the DITE\u003csup\u003e\u0026trade;\u003c/sup\u003e app and discern the factors that affect its uptake and use among the three stakeholders. Through this interdisciplinary approach, the study aimed to contribute valuable insights to the ongoing discourse surrounding technology adoption and utilization in healthcare settings.\u003c/p\u003e"},{"header":"Method","content":"\u003cp\u003eThe methods and findings of this study are reported according to the Consolidated Criteria for Reporting Qualitative Studies (COREQ) (Additional file 1)\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Participants\u003c/h2\u003e \u003cp\u003eThree FGDs were conducted adopting a framework methodology. The UTAUT framework [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] was adopted to discern both constraining and facilitating factors that shape the adoption and utilization of the DITE\u003csup\u003e\u0026trade;\u003c/sup\u003e app among the three stakeholders: BNUs, JBIMs, and HCPs. Participants' perspectives and experiences were systematically investigated and analysed within the framework's dimensions. This approach provided a structured framework for evaluating the potential effectiveness and acceptance of the DITE\u003csup\u003e\u0026trade;\u003c/sup\u003e app within the context of healthcare simulations, thereby enriching the thematic analysis of outcomes from the FGDs.\u003c/p\u003e \u003cp\u003ePatient and public involvement and engagement were integral to the methodology of this study. The research team employed a participatory approach by actively involving individuals 18 years of age and above with lived experience and personal insights into the health challenges faced by the Deaf community. Specifically, participants were purposively sampled from non-governmental organization networks, ensuring representation from diverse backgrounds and across all races. See Additional File 2 for the GRIPP2 reporting checklist [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. All participants were sent an explanatory statement and consent forms. After obtaining consent, BNU and JBIM participants were given access to their own WhatsApp group with one of the app developers and two research assistants in order to avoid influence on other participants. They were asked to download the DITE\u003csup\u003e\u0026trade;\u003c/sup\u003e app, through an APK (only for Android users), and install the app. Guidelines on how to register and log in, and continuous technical support was provided through WhatsApp.\u003c/p\u003e \u003cp\u003eBNUs and JBIMs were allowed to use the app for a week before they participated in simulated medical consultations using the video conferencing feature in the DITE\u003csup\u003e\u0026trade;\u003c/sup\u003e app. The three simulated medical cases (Additional file 3) were on carpal tunnel, diabetes, and migraine (telemedicine). Cases were prepared by medically-trained researchers and trialled in a pilot test among BNUs, JBIMs and HCPs. BNUs were assigned to different JBIMs for each of the three simulated medical consultations, to ensure they were exposed to all JBIMs and HCPs. Each consultation took an average of 15 mins after which FGDs were carried out to evaluate the behavioural intention (BI) to use the DITE\u003csup\u003e\u0026trade;\u003c/sup\u003e app among the three participant groups (BNU, JBIM and HCP). The FGDs were facilitated by experienced researchers with the help of note takers. The FGDs with JBIM and HCPs were audio recorded while that with BNUs was video recorded and was carried out by a Deaf researcher. Demographic details were collected from all participants along with questions pertaining to their medical consultations (BNUs), interpretation experience (JBIMs) and experience with Deaf patients and understanding the communication needs of the Deaf (HCPs). Ethics approval was obtained from Monash University Human Research Ethics Committee (Project ID: 20452).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eInterview Guide Development\u003c/h2\u003e \u003cp\u003eThe study questionnaire was designed using the extended Unified Theory of Acceptance and Use of Technology (UTAUT2)[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. According to Venkatesh et al. [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], UTAUT2 explains 74% of BI and it is recommended to be applied in the introductory phase of a relevant technology (e.g., initial use, adoption). UTAUT2 identifies factors related to the prediction of BI to use a technology. The original UTAUT2 questionnaire consists of 32 items under nine constructs and uses Likert scales to measure responses. The factors identified in the original UTAUT2 model that were adopted in our questionnaire were i) \u003cem\u003eperformance expectancy\u003c/em\u003e, or the degree to which using a technology will provide benefits to those users, ii) \u003cem\u003eeffort expectancy\u003c/em\u003e, or the degree of ease associated with the use of the technology, iii) \u003cem\u003esocial influence\u003c/em\u003e, or the extent to which users think that important others (e.g., friends and family) believe they should use the technology, and iv) \u003cem\u003efacilitating conditions\u003c/em\u003e, or the users\u0026rsquo; perceptions of resources and support available to them and v) \u003cem\u003ebehavioural intention\u003c/em\u003e, or the degree to which users intend to or continue using the technology. With the growing use of telemedicine and the app\u0026rsquo;s capabilities to accommodate this feature, we included a question on telemedicine as a facilitating condition.\u003c/p\u003e \u003cp\u003eThree versions of the interview guide (one for JBIMs, one for BNUs and another for HCPs) were developed using the UTAUT2 questionnaire, with the questions adapted to fit the context of the DITE\u0026trade; app. The research team adapted the questionnaires for this study by first replacing the technology in the original questionnaire (mobile internet) with the DITE\u0026trade; in all questions. Next, the research team reviewed the questions and removed some measures and items that were not relevant to the DITE\u0026trade;, such as the \u003cem\u003ePrice Value\u003c/em\u003e measure (as the app is currently free). The items measuring the use of technology were also updated from outdated technologies to newer ones (e.g., from \u0026ldquo;Java games\u0026rdquo; to \u0026ldquo;app games\u0026rdquo;). Third, additional questions were added to seek feedback on specific app features or aspects to help inform improvements to the design. Face and content validation of the interview guides were undertaken by experts in qualitative research and members of the research team. The interview guide for the BNUs were reviewed by a Deaf member of our research team (AC) and edited to ensure they would be understandable by BNUs. The interview guides were then pilot tested via a simulated case study involving a BNU, JBIM, and HCOP and rectifications were made to the guides based on the feedback received. The final interview guides are provided in Additional file 4.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eBaseline demographic data were presented using descriptive statistics. Recorded interviews involving JBIMS and HCPs were transcribed verbatim and anonymised prior to analysis. Transcription for the FGD involving BNUs was undertaken by JN, a Deaf research assistant, using one video recording and double-checked for accuracy using the second video recording. The expressions used in the transcription took into consideration the signing that corresponds with the participant's body language, emotions, and facial expressions. Results were then imported into NVivo 12 Software (QSR International Pty Ltd., Version 12, 2018)[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. All audio recordings and interviewer field notes were also imported into NVivo for comparison and analysis. Thematic analysis was performed on the transcripts guided by Braun and Clarke\u0026rsquo;s six phase approach to coding [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Quotations by participants were edited on a limited basis to remove content that did not convey meaning (repeated words, stutters) or that had no relevance to the theme being discussed. An ellipsis was used to note the removal of such extraneous content. Square brackets were used in quotations to replace sensitive or identifiable information.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eOverview of participants\u003c/h2\u003e \u003cp\u003eA total of 19 participants were involved in the three FGDs - six BNUs, six JBIMs, and seven HCPs. Twenty percent of the invited participants either did not respond or declined to participate. The duration for each FGD is as follows: BNUs \u0026ndash; 51 minutes; HCPs \u0026ndash; 57 minutes; JBIM\u0026thinsp;=\u0026thinsp;47 minutes. We present here the data and findings according to each participant group. Findings are presented according to the five UTAUT categories i.e. Performance Expectancy, Effort Expectancy, Social Influence, Facilitating Conditions, and Behavioural Intention.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eBNUs\u003c/h2\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003eDemographic data\u003c/h2\u003e \u003cp\u003eFifty percent of BNUs were females, with the majority aged between 31\u0026ndash;40 (67%). Two were between 41\u0026ndash;50 years of age. The majority used android phones (83%), most mentioned seeking healthcare for flu, fever, and cough, and all participants have never used any other app with video conferencing services (e.g. telegram, WhatsApp, WeChat etc) for a healthcare consultation. Further details on participants are presented in Table\u0026nbsp;1.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of BNU participants (n\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHighest level of education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (16.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCertificate/diploma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (33.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eForm 3 (lower secondary)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (33.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (16.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTimes seen doctor in the past year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u0026ndash;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (66.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (16.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (16.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealthcare setting most often accessed to see doctor*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrivate clinic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5 (83.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGovernment clinic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (66.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGovernment hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (33.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrivate hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (16.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMode of communication often used to communicate with the doctor*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHand gesture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (66.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePen \u0026amp; paper\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6 (100.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTexting on computer or mobile\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (50.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHelp from family members and friends\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (16.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUsing graphics / images from the internet\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (16.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAverage length of medical consultations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;15 minutes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5 (83.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15\u0026ndash;30 minutes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (16.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e*Participants were allowed to select more than one option so totals might not equal 100%\u003c/p\u003e \u003cp\u003eAn overview of the themes and subthemes are presented in Fig.\u0026nbsp;1.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003ePerformance Expectancy\u003c/h2\u003e \u003cp\u003eThe FGD revealed the effectiveness of the DITE app in achieving the desired outcomes of facilitating healthcare consultations and the existing drawbacks of the developing app. Multiple themes and subthemes pertaining to the performance expectancy of the DITE app was uncovered during the discussion, which are mainly divided into its strengths and limitations.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eTheme 1: Strengths of DITE app\u003c/h2\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003eSubtheme 1: Embracing Malaysian Sign Language\u003c/h2\u003e \u003cp\u003e Participants revealed that the DITE app allowed them to converse in their native language - BIM, during the simulated consultations. Having had to rely on pen and paper in previous consultations, one of the participants revealed that, \u003cem\u003e\u0026ldquo;Now we have video, it makes it easier to communicate with the other party in sign language.\u0026rdquo; (D4, M)\u003c/em\u003e Hence, the DITE app provided a sense of ease and comfort for BNUs, as they need not trouble themselves with searching for suitable terms to describe their presenting complaint as required by their previous mode of communication. It also allowed their concerns to be acknowledged and to better understand the explanations provided by the doctor. This is illustrated by the following quote: \u003cem\u003e\u0026ldquo;(Previously) it\u0026rsquo;s difficult to remember the right word. Need to refer to Google, and then show it to the doctor. So, it\u0026rsquo;s time consuming. Now I just need to sign, through (an) interpreter, the doctor knows my issue. It\u0026rsquo;s good this way. It gives me the satisfaction\u0026rdquo; (D4, M)\u003c/em\u003e\u003c/p\u003e \u003cp\u003eThe discussion also revealed the importance of enabling the Deaf community to relay their medical concerns through their native language, particularly with the Deaf who were not literate: \u003cem\u003e\u0026ldquo;There are many Deaf who are illiterate. Interpreting must be provided to help them to understand even though (it will) require longer time. These group of illiterate Deaf, who are (the) majority of Deaf in Malaysia, are subjected to brief consultation with pen and paper, will not understand their condition. Interpreting is always preferred as it is easier to understand.\u0026rdquo; (D2, F)\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eSubtheme 2: Improving quality of care\u003c/h2\u003e \u003cp\u003e Participants also revealed that being able to communicate in their native language via the DITE app added value to their consultations and improved their overall experience. Although the incorporation of the DITE app increased the length of consultations, it also increased its depth. As mentioned by one of the participants, when it comes to the value of consultations, the DITE app allowed the participants to have longer, more meaningful conversations with their doctor, whilst paying the same healthcare costs; \u003cem\u003e\u0026ldquo;It was really brief in the past and we paid like (RM)60, 70 for it. Now it\u0026rsquo;s stretched with more information, it helps. Where cost is concerned, we pay the same price. Brief consultation is not worth our money. And with this (interpreting via the app), we have much to gain as we know more in order to manage ourselves.\u0026rdquo; (D4, M)\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eTheme 2: Limitations of DITE app\u003c/h2\u003e \u003cp\u003eSubtheme 1: Lack of interaction with HCPs\u003c/p\u003e \u003cp\u003e Despite its ability to improve communication, participants disclosed that they felt disconnected from the doctor as there was a lack of interaction between them and HCPs. When participants were using the DITE app on their mobile phones, they found that their sole focus was on the DITE app when communicating, with minimal interaction with the consulting doctor, saying \u003cem\u003e\u0026ldquo;Having the app placed well in front of me, I am able to focus on my interpreter very well, but in doing so, I have no contact with the doctor\u0026rdquo; (D1, F)\u003c/em\u003e Participants also found that the presence of the DITE app has altered their relationship where the participants presented their complaint to the interpreter, instead of directly to their doctor, which felt unnatural to them. This proved to be a challenge to the doctor-patient relationship that they have been accustomed to: \u003cem\u003e\u0026ldquo;\u0026hellip;It\u0026rsquo;s weird in showing and explaining to my interpreter before he tells the doctor. The doctor\u0026rsquo;s impression of my trust in him is affected. It was (a) \u0026ldquo;messy\u0026rdquo; situation.\u0026rdquo; (D5, M)\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eSubtheme 2: Importance of competent interpreters\u003c/h2\u003e \u003cp\u003eParticipants highlighted the significance of a skilled interpreter when using the DITE app, as it risks loss of information or misinformation that may lead to dire consequences. From the experience during the simulation, one of the participants revealed, \u003cem\u003e\u0026ldquo;\u0026hellip;now with DITE, what I see is good but the interpreter isn\u0026rsquo;t skilled enough as there are missed-out information. (For) example, the doctor would be speaking for some time, but the interpreter\u0026rsquo;s delivery was brief. I suspect there was a lot not captured.\u0026rdquo; (D2, F)\u003c/em\u003e Another participant mentioned how the lack of adequate BIM skills by the interpreter resulted in additional stress during the consultation: \u003cem\u003e\u0026ldquo;I was stressed with the interpreter who could not understand me and kept asking for clarification. There are times when I am asked for clarification of (the) signs I used, I could not because spelling is never me (finger spelling is not the participant\u0026rsquo;s style of signing). I had this problem with both interpreters for Case 1 and 2. They need to up their skills\u0026hellip; I needed to change and adjust my way of thoughts to suit them, it needed working / effort on my part to communicate with the 1st and 2nd interpreter.\u0026rdquo; (D5, M)\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eSubtheme 3: Real world feasibility of the DITE app\u003c/h2\u003e \u003cp\u003eIn experiencing using the app under simulated and ideal circumstances, participants questioned the ability of the DITE app to perform its role and facilitate healthcare consultations under stressful and chaotic situations; \u003cem\u003e\u0026ldquo;...if we are involved in an accident, how can we use DITE such as when we are injured and cannot handle it. Similarly, having to carry a sick child in our arm, it\u0026rsquo;d be difficult to handle DITE\u0026rdquo; (D4, M).\u003c/em\u003e Participants were also concerned about the scope of medical illness that could be effectively communicated with the aid of the DITE app due to its limitations. This is highlighted in the following quote: \u003cem\u003e\u0026ldquo;Using video consultation, the consultation can be of simple sickness, where it\u0026rsquo;s easy to view (the) upper part of our body. But if we have more complicated ones, lower body, (such) as knee, do we stand to show, that will be difficult to communicate via video? That will be an issue. Without showing, (the) Interpreter won\u0026rsquo;t know, such as back pain. Simple ailment is fine, but complicated ones, I question this method.\u0026rdquo; (D2, F)\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eEffort expectancy\u003c/h2\u003e \u003cp\u003eParticipants discussed the effort required to use the DITE app during the simulation and some adaptations that were required to effectively utilize the DITE app. Additionally, the challenges of using the DITE app were also disclosed during the discussions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eTheme 1: Adapting and adjusting\u003c/h2\u003e \u003cp\u003eWhile working with the DITE app, BNUs found that they had to adjust to the audio component in the app. One of the participants revealed that he was not mindful about turning on the speaker of his mobile during the consultations: \u003cem\u003e\u0026ldquo;\u0026hellip;The communication method requires listening, and it struck me that I\u0026rsquo;ve forgotten to turn on my volume. The app needs to combine both video and audio (automatically) together (when the app is launched).\u0026rdquo; (D5, M)\u003c/em\u003e The audio feature of the app also posed other challenges to the participants. Participants highlighted that the interpreters could not hear the doctor speaking. Hence, the participants had to make certain adjustments to ensure that the doctors and interpreters were able to communicate well, as evidenced by the following quote: \u003cem\u003e\u0026ldquo;During my 1st and 2nd appointment, the phone was placed at my comfortable viewing point. But the interpreters couldn\u0026rsquo;t hear and so I have to move it closer to the doctor. In doing so, I am not able to see them well.\u0026rdquo; (D5, M)\u003c/em\u003e\u003c/p\u003e \u003cp\u003eDuring the physical examinations, participants also revealed that they had to adapt to the presence of phone cameras and its limited view as a method of communicating with the interpreter through the DITE app, whilst displaying the relevant anatomy to the doctor: \u003cem\u003e\u0026ldquo;Both the interpreter and the doctor had to look at my palm, so I lifted it up (chin level, with open palm facing both of them) and I proceeded to show what was wrong. In this way both of them are able to see my palm and me simultaneously. It helps with the flow of communication as the interpreter is able to know what I was referring to. I knew it would be a problem had I laid my palm on the desk. Lifting it up creating simultaneous viewing was good for all parties.\u0026rdquo; (D1, F)\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eTheme 2: Challenges and setbacks\u003c/h2\u003e \u003cp\u003e While using the DITE app in the simulated consultations, participants found that it was a challenge to divide their attention when the doctor and interpreter were communicating with the participants at the same time. This is illustrated by the following quote, where a visual aid was being used by the HCP to provide explanation, whilst interpretation was occurring simultaneously through the DITE app; \u003cem\u003e\u0026ldquo;I had to try to understand the relation between the text and the illustration. The doctor showed illustration, and also explaining using her own palm, with the interpreter interpreting, having to look at both what the doctor was indicating and the interpreter, I could not manage it.\u0026rdquo; (D4, M)\u003c/em\u003e Additionally, the lack of stable Internet and connectivity was a challenge for participants while using the DITE app, with problems such as their screen freezing and lagging that impaired the communication between all three parties. Participants also noted that the reliance of the DITE app on the internet may pose a hindrance as certain healthcare facilities may be located at areas with poor connectivity. Furthermore, some may not be able to afford a data plan that is adequate to support the use of the DITE app. This is captured in the following quote: \u003cem\u003e\u0026ldquo;DITE depending on data is not good, it freezes / lags. Just now when I went into the consultation, I wasn\u0026rsquo;t aware that Monash has free Wi-Fi connection. I was using my data. And my interpreter informed me that my connection is bad before I made the switch. So, venues out there, we may encounter the same. And what about Deaf who cannot afford and have limited or insufficient data.\u0026rdquo; (D1, F)\u003c/em\u003e\u003c/p\u003e \u003cp\u003eWhen navigating the DITE app for the first time, there were varied response from participants regarding the ease of use. Some participants had minimal issues and were able to manage after a while, whereas others required some assistance. When asked to compare with Grab (an established E-hailing app used by Malaysians), participants found that navigating the DITE app was more challenging as it was less user-friendly. Specifically, participants revealed that the booking process of the DITE app was anxiety-provoking. Without an immediate response, or an update on the status of their booking, participants felt that they are left to wait without knowing if their booking has gone through: \u003cem\u003e\u0026ldquo;The Grab app is easy to use. However for DITE, it\u0026rsquo;s not as easy. Having done a booking, the interpreter does not respond immediately. It leaves me anxiously waiting, wondering. In comparison with Grab, it tells me immediately my status\u0026hellip;\u0026rdquo; (D1, F)\u003c/em\u003e This left the participants with future concerns regarding the lead time of the booking process during an emergency, where an instant response is required, with one saying \u003cem\u003e\u0026ldquo;\u0026hellip;What happens if I need an interpreter at this very time and here, I am still waiting for the interpreter to accept my request. How will this (app) be helpful?\u0026rdquo; (D1, F)\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eFacilitating Conditions\u003c/h2\u003e \u003cp\u003eThe FGD also explored the various factors that support and encourage the use of the DITE app by the participants.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eTheme 1: Confidentiality of information\u003c/h2\u003e \u003cp\u003e When asked about the participants\u0026rsquo; willingness to use the DITE app during physical examination of intimate body parts (e.g., breast or vaginal examination for women and penis examination for men), most participants did not agree. Participants revealed concerns regarding the confidentiality of the information shared during the consultation, noting \u003cem\u003e\u0026ldquo;I will not (use the DITE app for examination of the vagina), even though I trust the interpreter, but there is risk of the environment she is in at that moment, who or what else would be at her background?\u0026rdquo; (D2, F)\u003c/em\u003e However, participants felt reassured if there was a privacy and confidentiality agreement to ensure that the information shared maintained confidential: \u003cem\u003e\u0026ldquo;First of all, there needs to be a confidentiality agreement by the interpreter. Then, prior to the appointment, I\u0026rsquo;d have a chat with the interpreter, what my issue is. I don\u0026rsquo;t need to show but explain so that she understands clearly my impending consultation. On the consultation, I do not hesitate to show as there is confidentiality.\u0026rdquo; (D1, F)\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eTheme 2: Availability of support\u003c/h2\u003e \u003cp\u003eUpon questioning the participants perception of their ability to use the DITE app during illness, participants highlighted the role of support from a trusted family member in facilitating the use of the DITE app. One noted \u003cem\u003e\u0026ldquo;We, being a couple (D1 \u0026amp; D4), it should be fine. My partner is able to help. If I\u0026rsquo;m alone, simple illness, such as flu it is alright (to use DITE). But if he is really sick and unable to drive, I will help to make booking for him and accompany him to the doctor.\u0026rdquo; (D1, F)\u003c/em\u003e\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eTheme 3: Prior relationship with interpreter\u003c/h2\u003e \u003cp\u003e One participant revealed that the process of using the DITE app for the simulated consultation was made smoother because of the relationship he had with the interpreter previously. This allowed him to communicate better with the interpreter as he was familiar with the interpreter\u0026rsquo;s style of communication, saying \u003cb\u003e\u0026ldquo;\u003c/b\u003e\u003cem\u003eWhile the 3rd interpreter, whom I know several years back, I am able to assimilate to his interpreting and him to me and the consultation went on smoothly. He was able to convey to the doctor my content and I felt good\u0026hellip; with the 3rd Interpreter, it was merely communicating naturally and effortlessly.\u0026rdquo; (D5, F)\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eTheme 4: Previous consultation experience\u003c/h2\u003e \u003cp\u003e The participant\u0026rsquo;s previous consultation experience where sign language was not utilized was also a facilitating factor that encouraged the use of the DITE app. While participants were reliant on pen and paper, mobile text, and notes for previous consultations, they were often unsatisfied with the outcomes of these consultations. However, with the DITE app, they see hope in using their own native language in consultations and the potential of gaining more useful information from their visits. This is illustrated in the following quote: \u003cem\u003e\u0026ldquo;In comparison, in the past, sign language wasn\u0026rsquo;t available, but now it\u0026rsquo;s possible. With interpreter, I pick up more. While without interpreter, even depending on family members was difficult for us as father and mother who are Deaf. Now we have interpreter available through video, it makes things easier. I didn\u0026rsquo;t have good experience. In the past it was really difficult. Now with DITE, it\u0026rsquo;s improvement for the future.\u0026rdquo; (D6, M)\u003c/em\u003e\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eLimiting Conditions\u003c/h2\u003e \u003cp\u003eFrom the participants\u0026rsquo; discussion, the following limiting condition was identified as a hurdle for them to utilize the DITE app.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eTheme 1: No-phone policies in hospitals\u003c/h2\u003e \u003cp\u003eParticipants revealed that the no-phone policies in hospitals would not allow for the DITE app to be utilized in certain hospital settings, noting \u003cem\u003e\u0026ldquo;There\u0026rsquo;s a setback, phones are not allowed in hospitals. There are no-handphone signages everywhere. I think there is need to make known to MOH (Ministry of Health) and throughout Malaysia that DITE is a necessity for Deaf.\u0026rdquo; (D4, M)\u003c/em\u003e One participant also shared their own experience during a hospital visit where handphones were not allowed: \u003cem\u003e\u0026ldquo;In my experience before giving birth to my child, I have been informed that handphone is not allowed. I was left to lay. They were talking to me, and I could not follow. In the end we had to communicate by pen and paper.\u0026rdquo; (D1, F)\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003eBehavioural Intentions\u003c/h2\u003e \u003cp\u003eThe FGD also ventured into the intentions of the participants to use the DITE app and how likely they were to use it in their own medical consultations.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eTheme 1: Usage and promotion of the DITE app\u003c/h2\u003e \u003cp\u003eThere was unanimous agreement from all participants that they would use the DITE when it is ready and available. Next, the frequency of the intended use was explored. From a total of 10 hypothetical consultations, some participants stated that they would utilize the DITE app in all 10 consultations, whereas others choose to utilize the DITE app during complex diseases only, with one saying \u003cem\u003e\u0026ldquo;It depends on the situation. If simple cold, I\u0026rsquo;d not use DITE. I\u0026rsquo;m ok to use pen and paper. But if I am sick that I really do not know what\u0026rsquo;s wrong, and need interpreting, then I will use DITE.\u0026rdquo; (D1, F)\u003c/em\u003e There was general agreement from participants that they would promote the DITE app to their friends. However, participants believed that the promotion should extend beyond the Deaf community, to doctors, government agencies, and the public so that they are aware of its availability.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003eTheme 2: Comparing Telemedicine and face-to-face consultations with the DITE app\u003c/h2\u003e \u003cp\u003eParticipants were given a choice between Telemedicine and face-to-face consultations with the DITE app as their preferred mode of consultation. The responses gathered were varied and was dependent on the severity of the illness. Participants who preferred face-to-face consultations with DITE app stated that their choice was based on the availability of comprehensive services when being physically present at the facility. This includes getting detailed explanations, getting their medications, and collecting medical certificates. These are captured in the quote below:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I prefer face to face than zoom. Because I get detailed advice such as diet, etc from face-to-face consultation. Zoom method doesn\u0026rsquo;t give me that.\u0026rdquo; (D2, F)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eFace-to-face consultations with the DITE app was also preferred by participants when the illness they faced was complex and required immediate medical attention: \u003cem\u003e\u0026ldquo;I\u0026rsquo;d normally go to a doctor\u0026hellip; If I have simple cold, it\u0026rsquo;s not necessary. But if It\u0026rsquo;s (illness) is serious, which we know ourselves, we\u0026rsquo;d go to the doctor. Face to face with an interpreter is better.\u0026rdquo; (D6, M)\u003c/em\u003e In contrast, some participants preferred Telemedicine over face-to-face consultations when the illness faced was simple: \u003cem\u003e\u0026ldquo;That would be my first choice (zoom). But if it doesn\u0026rsquo;t work, then going to the doctor will be my last choice. For simple things going all the way to the doctor is a waste of time. So it depends if (through zoom) what the doctor advice if I should just stay put or need to get to the doctor.\u0026rdquo; (D5, M)\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eAreas for Improvement\u003c/h3\u003e\n\u003cp\u003eLastly, participants highlighted some key areas of the DITE app that required improvement to increase the effectiveness of the app.\u003c/p\u003e \u003cdiv id=\"Sec31\" class=\"Section2\"\u003e \u003ch2\u003eTheme 1: Availability of emergency feature\u003c/h2\u003e \u003cp\u003eOne of the most pertinent areas for improvement brought up by the participants was the incorporation of an emergency feature in the DITE app. Participants believe that the DITE app should provide immediate connection with an interpreter during emergencies, saying \u003cem\u003e\u0026ldquo;There is a need to add the emergency call feature that is available 24 hours, especially during the night when we need interpreting. Perhaps if there\u0026rsquo;s heart attack at 2am. There need to be immediate help, a last-minute emergency feature.\u0026rdquo; (D2, F)\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec32\" class=\"Section2\"\u003e \u003ch2\u003eTheme 2: Improving DITE app interface\u003c/h2\u003e \u003cp\u003e Participants revealed that multiple features can be included to improve the communication between the patient, interpreter, and HCP. This included a suggestion to have a dual camera feature. One of the participants also suggested that an attachment feature for images to be included to act as a visual aid for communication: \u003cem\u003e\u0026ldquo;I would like to suggest the features to attach picture for the particular appointment we made. We have the appointment details above, and attachment feature below. Example to take pictures of the injury sustained and seeking consultation for. This is to facilitate those who are illiterate / unable to explain well.\u0026rdquo; (D2, F)\u003c/em\u003e\u003c/p\u003e \u003cdiv id=\"Sec33\" class=\"Section3\"\u003e \u003ch2\u003eTheme 3: Allowing time for communication with the interpreter prior to the consultation\u003c/h2\u003e \u003cp\u003e Lastly, participants suggested allocating time for the patient to communicate with the interpreter before the consultation. This would allow the interpreter to familiarize with the patient\u0026rsquo;s issues to allow for better communication during the consultation: \u003cem\u003e\u0026ldquo;Before meeting the doctor, one should communicate with the Interpreter first so that the interpreter know what are our medical concerns. And when we meet the doctor, the interpreter is well aware of or problem. It saves time.\u0026rdquo; (D1, M)\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec34\" class=\"Section3\"\u003e \u003ch2\u003eHCPs\u003c/h2\u003e \u003cdiv id=\"Sec35\" class=\"Section4\"\u003e \u003ch2\u003eDemographic details\u003c/h2\u003e \u003cp\u003eThe majority of participants were female (71%) and aged between 20\u0026ndash;30 years of age (57%). The remaining three (43%) were between 31\u0026ndash;40 years of age. The majority (86%) were not aware of the Persons with Disability Act 685, 2008 on Access to health, and had not attended sign language classes (57%), while all were comfortable using telecommunication applications (such as WhatsApp, Skype, Facetime etc). Further details are provided in Table\u0026nbsp;2.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of healthcare providers (n\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWork experience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;5 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (57.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (42.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCurrent job designation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntern\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (14.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedical officer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (57.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecialist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (28.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMobile operating system\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAndroid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (42.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIOs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (57.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of Deaf patients managed/treated in the past 1 year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (57.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (42.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMode of communication used previously to communicate with the Deaf*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHand Gestures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (57.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePen \u0026amp; Paper\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7 (100.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHelp from family members or friends\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (42.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI am able to communicate in Sign Language\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (28.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTexting on computer or mobile\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (14.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAwareness of the Dos and Don'ts communicating with a Deaf person\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (57.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (14.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSomewhat\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (28.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e*Participants were allowed to select more than one option so totals might not equal 100%\u003c/p\u003e \u003cp\u003eAn overview of the themes and subthemes are presented in Fig.\u0026nbsp;2.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003ePerformance Expectancy\u003c/h3\u003e\n\u003cdiv id=\"Sec37\" class=\"Section2\"\u003e \u003ch2\u003eTheme 1: Strengths of the DITE app\u003c/h2\u003e \u003cp\u003ePerformance expectancy is understood as the benefits and limitations HCPs will face during their consultation experiences with Deaf patients in relation to the use of the DITE app. In the interview, the HCPs were requested to share ways in which the DITE app helped them during the healthcare consultation.\u003c/p\u003e \u003cdiv id=\"Sec38\" class=\"Section3\"\u003e \u003ch2\u003eSubtheme 1: Optimizing communication and history-taking\u003c/h2\u003e \u003cp\u003eHCPs mentioned that the DITE app managed to facilitate communication with Deaf patients by enabling a more detailed two-way communication. It allowed both stakeholders to express and comprehend each-other more effectively, which the HCPs think is the foundation in building patient rapport. It was highlighted that the HCPs were able to gather a much more comprehensive medical history from the patients when using the DITE app, as compared to that obtained when using the traditional written-paper method. There was a unanimous agreement from the HCPs that they are keen to use the app for this reason, despite the limitation of having to take up a longer time during the consultation: \u003cem\u003e\u0026ldquo;I\u0026rsquo;ll say that I did require more time using the app but that\u0026rsquo;s because I was able to take a better history. (\u0026hellip;) But in terms of being able to achieve quality history and to be able build a better relationship with the patient, definitely, I am very happy to use the app, not because it saves me time, but because now I know exactly what the patient is trying to tell me\u0026rdquo; (HCP2, F).\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec39\" class=\"Section2\"\u003e \u003ch2\u003eSubtheme 2: Enhancing accuracy and comfort in healthcare consultations\u003c/h2\u003e \u003cp\u003eThe HCPs also added that, with the use of the DITE app, Deaf patients can more readily have access to professional third-party interpretation services, rather than having to rely on casual interpretation by their family members or friends. Not only does this prevent information from being lost or modified (should family/friend selectively translate), it also creates a more conducive environment for patients to open-up: \u003cem\u003e\u0026ldquo;The patient is speaking to someone who is totally unknown, so they will be able to open whatever that is withhold, because in real life, they come with their family, sometimes I wonder how much of what I am being said is being passed on, but now it is a total stranger, so they might also be able to totally open up\u0026rdquo; (HCP5, F).\u003c/em\u003e\u003c/p\u003e \u003cdiv id=\"Sec40\" class=\"Section3\"\u003e \u003ch2\u003eSubtheme 3: Streamlining logistics and efficiency\u003c/h2\u003e \u003cp\u003eAnother point raised was that the usage of the DITE app could greatly facilitate logistical arrangements given the fact that it allows pre-bookings with the JBIMs: \u003cem\u003e\u0026ldquo;I like that (\u0026hellip;) this is pre-booked, because in a sense that sometimes when I am in the hospital and I run into problems with translating for [immigrant patients who cannot communicate with English or Malay], I actually have to wait for the physical interpreter to be free, and they can only come at X time for example, and I have to coordinate with the patient\u0026rsquo;s family who can only come at X time. So, I can end up easily a delay of surgery of 1 to 2 days just trying to coordinate everyone to sit down together to get the damn consent. So, I think with the app, the fact that its pre-booked, I can arrange the time. I'm looking forward to it shortening the logistics as well as the effort required just to arrange a meeting\u0026rdquo; (HCP2, F)\u003c/em\u003e.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 2: Limitations of the DITE app\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eSubtheme 1: Limited non-verbal communication and interaction\u003c/em\u003e \u003c/p\u003e \u003cp\u003eOn the other hand, the HCPs also noticed some limitations to the trialled version of the DITE app. Firstly, the DITE app did not allow all three stakeholders (the HCP, JBIM, and BNUs) to see each other simultaneously, as what would happen should the interpretation be conducted in-person. During the simulation, the patient\u0026rsquo;s device was positioned such that the JBIM and the patient would see each other through the screens of their devices, whereas the HCP and JBIM could not see each other. In addition, the patients will be focused on the screen of their device, rather than on the HCP, hence there will be a total lack of eye-contact between both the HCP-JBIM and HCP-BNU. HCPs felt that this limited their ability to effectively integrate non-verbal cues and physical demonstrations during their speech, thereby serving as a barrier to communication. For example, \u003cem\u003eHCP2\u003c/em\u003e explained: \u003cem\u003e\u0026ldquo;I wanted to demonstrate to the patient what (exercises) I wanted him or her to do and then to feedback to me what were the sensation the patient experienced as they were performing the examination. So, because the camera was initially only focused on the patient, the translator couldn\u0026rsquo;t see what I was doing to explain it to the patient (...) The second thing was also that there were sometimes, when I wanted to get the patient\u0026rsquo;s attention but again, they were so focused on the screen, so I had to actively reach out to the deaf patient, touch them, get their attention, \u0026lsquo;look at me\u0026rsquo;, and then explain, and then turn the camera to get them to explain\u0026hellip;\u0026rdquo; (HCP2, F).\u003c/em\u003e It was also raised by the HCPs that the lack of eye-contact not only inhibits the HCPs from expressing themselves through non-verbal cues, but also deters them from picking-up the non-verbal cues from Deaf patients, which they think is equally important in the HCP-patient communication.\u003c/p\u003e \u003cp\u003e \u003cb\u003eLimiting conditions\u003c/b\u003e \u003c/p\u003e \u003cp\u003eLimiting conditions are understood as the degree to which the HCPs believe that their work environment would deter the use of the DITE app during their consultations with Deaf patients.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 1: Potential Challenges in Real-World Implementation\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eSubtheme 1: Environmental distractions and resource limitations\u003c/em\u003e \u003c/p\u003e \u003cp\u003eDuring the FGD, the need for a conducive environment to use the DITE app was brought to light by a few of the participants. When asked whether the HCPs would use the app during consultations, one said \u003cem\u003e\u0026ldquo;Depends on the scenario, if it\u0026rsquo;s in ED, labour room, with all sorts of distraction, I don't think it will be very conducive and then I will be like fine, I\u0026rsquo;ll use pen and paper instead.\u0026rdquo; (HCP6, F).\u003c/em\u003e Additionally, some HCPs indicated that there was a lack of necessary resources at their workplace to conduct a successful consultation utilising the DITE app. They suggested necessities such as a strong WIFI connection and even tripods would be difficult to access.\u003c/p\u003e \u003cp\u003e \u003cem\u003eSubtheme 2: User familiarity and technical challenges\u003c/em\u003e \u003c/p\u003e \u003cp\u003eMany of the HCPs noted that patients faced difficulties during the consultation as they were unfamiliar with the use of the technology. According to one HCP, the interpreter hadn\u0026rsquo;t downloaded the correct link, so they were unable to proceed. Another HCP stated that at one point the Deaf patient and the interpreter couldn\u0026rsquo;t see each other as one of them had not clicked on something and at another point, both the Deaf patient as well as the interpreter couldn\u0026rsquo;t hear the HCP. One added that both his patients found it difficult to attach a phone to the tripod located on the table as well.\u003c/p\u003e \u003cp\u003e \u003cem\u003eSubtheme 3: Appointment scheduling complexity\u003c/em\u003e \u003c/p\u003e \u003cp\u003eWhen using the DITE app, Deaf patients are allowed to pre-book their timeslot with an interpreter. However, HCPs noted that in the real-world, at clinics, with long queues and unknown waiting times, this becomes a hurdle as the patient is unaware of what time their appointment will be.\u003c/p\u003e \u003cp\u003e \u003cb\u003eSocial influence\u003c/b\u003e \u003c/p\u003e \u003cp\u003eSocial influence is understood as the extent to which other medical professionals\u0026rsquo; beliefs and opinions of the DITE app influence a HCP\u0026rsquo;s perception.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 1: Data Privacy and Patient Confidentiality\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThere were shared concerns for data privacy and patient confidentiality with the use of a third-party app during medical consultations as HCPs were worried that conversations with patients would be recorded. Queries such as what would be done with the recordings, who has access to it, how they would be stored, how long they would be stored for, and whether they would be used for any other purposes, arose as the possibility of a leak is a real threat to patient confidentiality. Further concerns were highlighted regarding obtaining patient consent, as patients had to be informed of what and how exactly they were consenting to use the recordings. On the other hand, the benefit of consultations being recorded was also acknowledged in the case that a medicolegal complication was to arise.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 2: Medicolegal Acceptance of DITE App Translations\u003c/b\u003e \u003c/p\u003e \u003cp\u003eHCPs expressed concern as to whether using the DITE app to translate is medicolegally accepted. As an element of obtaining patient consent, patients are required to disclose who explained what they were consenting to. This would generally have been done by the hospital\u0026rsquo;s official translator. However, when translations are done via the app there isn\u0026rsquo;t an \u0026lsquo;official hospital translator\u0026rsquo; as such, which is an issue. To overcome this obstacle, the HCPs suggested exploring the possibility of using the sign language interpreter\u0026rsquo;s name on the consent form as a legal translator to fulfil this requirement and suggested looking over whether it is applicable to surgical procedures as well. This is of importance as should a communication breakdown occur with a Deaf patient and they decide to take legal action, it goes back to all the records and documentation, \u003cem\u003e\u0026ldquo;\u0026hellip; which record do you take on board, do you take on board the recording of the consulting between the SLI and the patient? Do you take on board the transcript of the doctor having recorded his or her perception of the conversation. Maybe, again once you have all the legal bits ironed out, then I\u0026rsquo;d feel more comfortable because my signature is on the form at the end of the day.\u0026rdquo;(HCP2, F)\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eBehavioural Intention\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 1: Usage and promotion of DITE app\u003c/b\u003e \u003c/p\u003e \u003cp\u003eWhen asked about their willingness to use and advocate for the use of the DITE app in future consultations with Deaf patients, all HCPs answered affirmatively, with the condition that the major concerns mentioned in above are resolved.\u003c/p\u003e \u003cp\u003e \u003cb\u003eAreas for improvement\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 1: Drawing functionality and spelling assistance\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe use of the DITE app enabled the HCPs to take a more detailed history in many ways. However, the lack of a function to draw out diagrams on the app directly, acted as a barrier to conveying some of the explanations across smoothly. On one occasion, the HCP used a pen and paper to illustrate an explanation and then first showed it to the translator on screen and then again to the patient. Another such instance was when the patient proceeded to spell out the name of a medication and the interpreter couldn\u0026rsquo;t quite catch the spelling and had difficulty interpreting it even after the patient had spelt it multiple times. As seen from the two previous examples, a drawing feature built into the app itself would be a great addition for all three parties, especially during surgical procedures as otherwise the practitioner would have to draw out the whole anatomy and also explain in further detail, which would be quite tedious.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 2: Improving visibility and interaction\u003c/b\u003e \u003c/p\u003e \u003cp\u003eHCPs highlighted that the camera and screen were only facing the patient, which prevented HCPs from seeing the interpreter throughout the consultation,\u003cem\u003e\u0026ldquo;\u0026hellip;sometimes I feel both of them are talking to each other then I\u0026rsquo;m talking to the interpreter instead of the patient. I'm looking at the patient but the patient is not looking at me.\u0026rdquo; (HCP4, F).\u003c/em\u003e Participants expressed that being able to see the interpreter\u0026rsquo;s face in addition to the patient\u0026rsquo;s face, in a similar manner to that of the telecommunication consultations, would be beneficial as they would be able to gauge whether they were speaking too fast or slow, or even needed to stop talking if there were any issues/ miscommunication. Furthermore, they added that the ability for all three parties to make eye contact would enable the HCP to build a better rapport with the patient.\u003c/p\u003e \u003cp\u003e \u003cb\u003eSLIs\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eDemographic details\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe majority of participants were males (67%), and all were freelance interpreters. The majority used android phones (67%) and of the six, only one had received training for the medical setting. Of the two who had experience interpreting in the medical setting, they interpreted 0\u0026ndash;5 times in the past one year. Further details are provided in Table\u0026nbsp;3.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of JBIM participants (n\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e31\u0026ndash;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (50.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e51\u0026ndash;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (33.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e61\u0026ndash;70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (16.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of years as an interpreter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;1 year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (16.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u0026ndash;5 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (16.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u0026ndash;10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (16.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (50.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbility to reverse translate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaybe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (66.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (33.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExperience interpreting in medical setting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (33.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (66.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHighest qualification\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiploma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (16.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUndergraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (33.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostgraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (50.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAn overview of the themes and subthemes are presented in Fig.\u0026nbsp;3.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003ePerformance Expectancy\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 1: Strengths of DITE app\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eSubtheme 1: Improving interpreter\u0026rsquo;s service \u0026amp; performance\u003c/em\u003e \u003c/p\u003e \u003cp\u003eWith the use of the DITE app, participants believe that their productivity as a JBIM increased. As they are able to provide their services without being physically present at the healthcare facility, participants were able to accept more bookings with the extra time. This is illustrated in the following quote: \u003cem\u003e\u0026ldquo;... It improved (my) productivity in the sense that I could probably help more Deaf (people) (\u0026hellip;) with this (DITE app), I could have multiple bookings back-to-back throughout the day, or you know, on demand...\u0026rdquo; (JBIM 2, M)\u003c/em\u003e JBIMs felt the DITE app allowed them to provide their service to BNUs from different states across Malaysia. This is particularly useful as there are limited numbers of JBIMs. Additionally, participants unanimously agreed that the use of the DITE app reduced consultation time. The ability to provide interpretation services remotely also served an advantage of time as they need not spend time travelling: \u003cem\u003e\u0026ldquo;\u0026hellip;(By) using the app, I don\u0026rsquo;t have to travel over there (to be physically present at the consultation), and this can save up a lot a lot of time.\u0026rdquo; (JBIM 3, M)\u003c/em\u003e\u003c/p\u003e \u003cp\u003eOne of the participants also shared their personal experience of a medical emergency, where the DITE app\u0026rsquo;s advantage of virtual interpretation would have been lifesaving: \u003cem\u003e\u0026ldquo;\u0026hellip; few months back there was an accident which happened to a Deaf \u0026hellip; and it was during peak hour, about 5PM or 6PM. He called me and he said: \u0026ldquo;Can you come because I need an interpreter?\u0026rdquo;. And from my home to (the) hospital, it takes minimum one hour during peak hours, and doctors cannot wait for that one hour. And if with this app\u0026hellip; I can immediately (provide the interpreting service) to the doctors and to the Deaf. But because we don\u0026rsquo;t have this thing (DITE app), I can\u0026rsquo;t go (to the patient physically). Even if I went, the doctor cannot wait for me, so it (the physical distance and the lack of a suitable video conferencing tool such as the app) become such a big problem. In the emergency situation, this app would really come in handy. And even during pandemic, we had to go to, I\u0026rsquo;m talking about myself, I go to the hospital to interpret for the Deaf. I have to be physically there, and now, with this app, I would say it is really fantastic.\u0026rdquo; (JBIM4, M)\u003c/em\u003e\u003c/p\u003e \u003cp\u003eThe interface face of the DITE app which allows BNUs to view all available JBIMs and select their preferred JBIM was noted as a helpful and user-friendly feature, with a JBMI saying \u003cem\u003e\u0026ldquo;\u0026hellip;it (DITE app) is good because for the Deaf, they can see all the interpreters\u0026rsquo; name and contact. So, this is a plus point to this app. They can straight away pull up and select (their preferred interpreter) or put up their demand and the interpreters who see it can immediately react to it. As compared to using Zoom or other apps where you don\u0026rsquo;t know who the interpreters are. You cannot choose.\u0026rdquo; (JBIM1, F)\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003eSubtheme 2: Video and audio quality\u003c/em\u003e \u003c/p\u003e \u003cp\u003eParticipants revealed that the quality of the DITE app\u0026rsquo;s audio and video was satisfactory to facilitate their interpretation. This includes appropriate size and quality of video displayed on the app and good audio clarity. This is illustrated in the following comment: \u003cem\u003e\u0026ldquo;For me, the app is fantastic\u0026hellip; Number one, I can see (BNUs) clearly as the Deaf is actually being highlighted as my main point, because if the Deaf is very small, I cannot see whatever that was communicated to me. That\u0026rsquo;s number one, (where the Deaf) is highlighted big enough. Number two is the voice (audio quality). The quality of the voice (audio) is also quite good, because whatever the doctor says, if I cannot hear it, I cannot interpret. But in this app, it is quite clear, so for me it doesn\u0026rsquo;t have any big problem.\u0026rdquo; (JBIM4, M)\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 2: Limitations of DITE app\u003c/b\u003e \u003c/p\u003e \u003cp\u003eParticipants disclosed that multiple limitations hindered their interpretation process. This included limited view of the JBIMs, especially when they needed to sign using body parts that were beyond the camera\u0026rsquo;s field of view: \u003cem\u003e\u0026ldquo;\u0026hellip;I\u0026rsquo;m very satisfied with it (DITE app). But of course, if I can go physically, it will be much better, because I can see the whole thing (body gesture of the doctor and the patient), and I can show them the whole thing (entire body gesture), (while using the app) can only show them part of it. Before (when interpreting) medical terms, sometimes you (JBIMs) would need to sign up to your neck or your leg, or (perform some actions) so it will be easier for them to understand. This limitation happens because we are using phones, which screens are quite small.\u0026rdquo; (JBIM3, M)\u003c/em\u003e\u003c/p\u003e \u003cp\u003eThe limited field of view also interfered with the interpretation process during physical examinations. When the HCPs performed physical examinations on BNUs, the JBIMs were unable to interpret accordingly as the physical examination was not captured by the camera, with one noting \u003cem\u003e\u0026ldquo;\u0026hellip;we can\u0026rsquo;t see the doctor... (when) the doctors say: \u0026ldquo;OK, I want to check your hand\u0026rdquo; \u0026hellip; we will just tell the Deaf: \u0026ldquo;Stretch out your hand\u0026rdquo;. But (when using DITE), we don\u0026rsquo;t know where the doctor is pressing (on) the hand (of the Deaf), or which part of it, we will just interpret whatever the doctor told us, or (we will just tell the Deaf): \u0026ldquo;Now I am pressing on this part, how do you feel?\u0026rdquo;. When the Deaf stretch out their hands to the doctor, their eye contact is not on the screen (focusing on the interpreters), they are looking at their hands\u0026hellip; So, in this way, there is a little bit of slowing down (of the interpretation because) we have to ask: Okay, please look at me first. How is it? When pressing on this part (the part which the doctor is pressing on) how do you feel? Then only would they (BNUs) express to you. (JBIMs).\u0026rdquo; (JBIM1, F)\u003c/em\u003e\u003c/p\u003e \u003cp\u003eParticipants also questioned the feasibility of using the DITE app in a real-world setting, particularly when the environment is less conducive: \u003cem\u003e\u0026ldquo;\u0026hellip;just now when I try to interpret, there was some (construction) work going on. So, there was a (background noise) ... If you are looking at an actual environment, maybe the surrounding is very noisy so you cannot hear.\u0026rdquo; (JBIM 3, M)\u003c/em\u003e Finally, participants noted that the lack of notification features such as ringtones when a booking was received and this could potentially lead to unnoticed calls that are missed, as noted by one JBIM: \u003cem\u003e\u0026ldquo;\u0026hellip;now we are under testing, so I was very alert with what I have. I will check (my phone for notifications) every time, but normally I don\u0026rsquo;t check my phone, only when there is some ringing. So, when there is no ringing, I won\u0026rsquo;t know if there is an incoming call. Even in an emergency, I won\u0026rsquo;t know.\u0026rdquo; (JBIM3, M)\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eEffort Expectancy\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 1: Navigating DITE app\u003c/b\u003e \u003c/p\u003e \u003cp\u003eParticipants agreed that navigating and mastering the DITE app was effortless and easy. However, some participants did face minor troubles as they were unsure how to properly use the DITE app. For instance, one participant did not know that they had to turn on the \u0026lsquo;I\u0026rsquo;m available\u0026rsquo; option in the app, leading to their status showing as they were unavailable.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 2: DITE app interface\u003c/b\u003e \u003c/p\u003e \u003cp\u003eParticipants also had issues with the DITE app being unable to update their booking status automatically after accepting a booking. They received error messages that would only be resolved when participants manually refreshed the app. One participant suggested \u003cem\u003e\"...if there is an arrow or something to show you to pull down to refresh, that would be helpful.\u0026rdquo; (JBIM 6, M)\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eSocial influence\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 1: Encouragement to use DITE app from relevant stakeholders\u003c/b\u003e \u003c/p\u003e \u003cp\u003e Participants were asked if they believe that relevant stakeholders such as other JBIMs, Deaf associations, and HCPs would encourage the use of DITE app. One of the participants was confident that there would be encouragement from these stakeholders, citing the improvement in accessibility to interpreter services as the motivator, \u003cem\u003e\u0026ldquo;I think yes, definitely, because like during the pandemic time, and even prior to pandemic, when we had a fear about one of our best friends being admitted to the hospital, you know it was so difficult they needed to get interpreters to go there and all, and a lot of us were working because we have our full-time jobs, so it's very difficult for us to take time off to go there. But with that app, it is so much easier. They (BNUs) don't have to tell us to go there. Just use the app and we (JBIMs) are available to interpret from wherever we are. So, I think it's something that a lot of people, our peers, and even the Deaf would be very keen to use.\u0026rdquo; (JBIM 2, M)\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eFacilitating conditions\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 1: Previous experience with telecommunication\u003c/b\u003e \u003c/p\u003e \u003cp\u003e All participants had experience using other teleconferencing apps for video calls. During the COVID-19 pandemic where social distancing measures were in place, the use of teleconferencing apps surged, and this experience was deemed useful in easing the process of navigating the DITE app.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 2: Environment and supportive devices\u003c/b\u003e \u003c/p\u003e \u003cp\u003eA quiet and appropriate background was deemed necessary by the participants to fully optimize the use of the DITE app: \u003cem\u003e\u0026ldquo;I think the area that I was placed at was quite good, because first of all, it was quiet and then second thing which was very important for me was that it was a clear empty background behind me.\u0026rdquo; (JBIM6, M)\u003c/em\u003e Resources should also be available to support the use of the DITE app. This includes the availability of Internet access and additional devices such as headphones, especially when the surroundings are noisy.\u003c/p\u003e \u003cp\u003e \u003cb\u003eLimiting conditions\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 1: Lack of cultural competency among HCP\u003c/b\u003e \u003c/p\u003e \u003cp\u003e Participants found that there was a need to improve the cultural competency of HCPs, particularly when communicating with a Deaf-sign user in the presence of an interpreter. During the simulated consultations, participants noted that the HCPs were either speaking too quickly or too slowly. This made it difficult for the participants to interpret to the patient, as captured in the following comments:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;When the voice was tested just now, the doctor was speaking too fast. It's very difficult to catch up. (I had to ask the doctor), \u0026lsquo;What was it again, sorry\u0026rsquo;.\u0026rdquo; (JBIM 5, F)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I think (speaking) too slow also makes it very difficult because sometimes I want to listen to the whole sentence to know what else (the doctor) wants to say. I want to hear everything, before I sign, and the Deaf are waiting (for me to interpret).\u0026rdquo; (JBIM 3, M)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 2: DITE app not available on iPhone operating system (iOS)\u003c/b\u003e \u003c/p\u003e \u003cp\u003eAs the DITE app was not available on the iPhone operating system, participants stated that this was one of the major limiting conditions as they struggled to find and navigate an Android phone: \u003cem\u003e\u0026ldquo;I feel that because (the app is not available on) iOS (iPhone operating system) phones, so for me, I did face some problems because I need to look for another Android phone\u0026hellip; Besides, I am not so used to Android phones, this was the first time I have used an Android phone, so it also posed an issue to me.\u0026rdquo; (JBIM1, F)\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 3: Difficulty in signing medical terminologies\u003c/b\u003e \u003c/p\u003e \u003cp\u003eParticipants also revealed that they were challenged with medical terminologies that were difficult to sign as \u003cem\u003e\u0026ldquo;I find the medical terminologies difficult to spell. For example, in the (simulation) just now, we had to ask the doctors how to spell the names of the medications. We were not familiar with the (medical) terminologies\u0026rdquo; (JBIM5, F)\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eBehavioural intention\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 1: Promotion and use of the DITE app\u003c/b\u003e \u003c/p\u003e \u003cp\u003eWhen asked if they would use the DITE app frequently when it is available, participants unanimously agreed that they would. However, one participant mentioned that they would not use the app all the time, depending on the role they are playing in the consultation, \u003cem\u003e\u0026ldquo;For me, it\u0026rsquo;s 50\u0026ndash;50. It is all dependent on my role. If I know them personally, I prefer to go to them... because apart from interpreting, I\u0026rsquo;m also their friend, I also want to visit them. So, I can do two things at once. But for someone I do not really know, I prefer using this app. So, it depends on what the role that I\u0026rsquo;m playing is.\u0026rdquo; (JBIM4, M)\u003c/em\u003e Participants unanimously agreed that they would encourage other stakeholders such as doctors to use the DITE app.\u003c/p\u003e \u003cp\u003e \u003cb\u003eAreas for improvement\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 1: User guide\u003c/b\u003e \u003c/p\u003e \u003cp\u003eWith the aforementioned challenges in using the DITE app, the moderator suggested to establish a user guide, and this was positively accepted by participants. The user guide would clearly delineate practical approaches to maximize the benefits of the DITE app. This includes features that needed to be switched on, positioning of the device, and instructions on how to use the DITE app during physical examinations.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 2: Communication and setting expectations\u003c/b\u003e \u003c/p\u003e \u003cp\u003e Participants suggested that DITE app is designed so that the HCP, JBIM, and BNU can be seen on the screen to allow for three-way communication. However, this should not compromise the view of the BNUs. Hence, there needs to be a feature that allows JBIM to pin the BNU on their screen: \u003cem\u003e\u0026ldquo;I would prefer it if there were a three-way (communication), because, (during the simulation), it was just two ways (BNUs and JBIMs), but if we have three-way and pinning are there, then yeah it will be a lot better.\u0026rdquo; (JBIM2, M)\u003c/em\u003e\u003c/p\u003e \u003cp\u003eAdditionally, participants also found that there was a need to communicate with BNUs and HCPs before the consultation. It was noted that communicating with HCPs would be a method to overcome the lack of Deaf culture awareness among HCPs. This provides an opportunity for JBIMs to inform HCPs that they are not medically trained and to avoid medical jargons. Privacy and confidentiality of information could also be reassured to HCPs during this process, with one noting: \u003cem\u003e\u0026ldquo;\u0026hellip;if I (am interpreting in a) medical setting, I would want to meet up with the doctor first. Why? Because I'm going to tell them that I am representing the Deaf, so that they know that certain P\u0026amp;C (privacy \u0026amp; confidentiality) thing I am allowed to do. Number 2, they also know that I am not a medical trainee. They have to cut short some of the some of the medical terms by using very laymen language. Otherwise, whatever word you say to me, I have to spell it to the Deaf. If I don't understand, the Deaf definitely don\u0026rsquo;t understand. It\u0026rsquo;s just a word, but what is that word? So, that is the preliminary meeting with the doctor which is compulsory. And from there, if you want to talk about the speed and if the app allows us to have just a two-minute talk to the doctor, then it will be fantastic.\u0026rdquo; (JBIM4, M)\u003c/em\u003e\u003c/p\u003e \u003cp\u003eCommunicating with BNUs before the consultation was also necessary to understand the literacy level of the patient and their fluency in BIM: \u003cem\u003e\u0026ldquo;we have to know who our clients are, and their respective background in sign language before the consultation. Sometimes, for Deaf people, their level of (expertise) in sign language differs. So I think before the call, interpreters can first meet up with the client, so we can check with the client on their level of comprehension in sign language, and whether they can keep up with the interpreters\u0026rdquo; (JBIM5, F)\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 3: Notification for calls and emergency bookings\u003c/b\u003e \u003c/p\u003e \u003cp\u003eWith regards to the lack of notification when participants received bookings, participants suggested the DITE app should include ringtones as a notification and to have a special ringtone for emergency bookings. Participants also mentioned a need for pop-up notifications for emergency bookings to make it more eye-catching, with one saying \u003cem\u003e\u0026ldquo;\u0026hellip;those in emergency cases, those (who are calling) on demand, (the ringtone should be) something that really catches our attention, telling us that: \u0026ldquo;Hey, the app requires our attention now\u0026rdquo;. Yeah, it could be a siren or something. Something that is not a common ringtone that people would be using. Yeah, because if it's a normal ringtone we would... like... just ignore it. But if it is something that alerts us, that the app requires our attention, yeah, (we would attend to the app).\u0026rdquo; (JBIM2, M)\u003c/em\u003e\u003c/p\u003e \u003cp\u003eParticipants also hope to see the incorporation of emergency booking status in the DITE app. Whenever BNUs request for an emergency booking, JBIMs hope to receive an update on whether the request has been fulfilled, especially when they are unable to attend to them: \u003cem\u003e\u0026ldquo;I think, especially when they apply for the \u0026lsquo;on demand\u0026rsquo; (emergency booking), (I want to know) whether another interpreter accepts it. (If) I'm not able to pick up, at the back of my mind, \u0026ldquo;Oh my gosh, did somebody pick it up or not, or is that Deaf person left hanging there without anybody assisting,\u0026rdquo; because I have no idea whether it\u0026rsquo;s picked up or not.\u0026rdquo; (JBIM2, M)\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 4: DITE app logo and icons\u003c/b\u003e \u003c/p\u003e \u003cp\u003eParticipants suggested that the logo of the DITE app should include components that represent Deaf and health. This would inform users that the app was meant for the Deaf and healthcare consultations, saying \u003cem\u003e\u0026ldquo;The sign (logo) will be related to Deaf and medical, so at least when they look at it, they know that this is helpful for the Deaf in medical consultations.\u0026rdquo; (JBIM1, F)\u003c/em\u003e One of the participants also revealed that some BNUs may navigate the app through graphic representations rather than words. Hence, the app should incorporate graphic icons to improve its user-friendliness as \u003cem\u003e\u0026ldquo;\u0026hellip;we know that Deaf is the eye person (uses their eyes to navigate). So instead of putting words in the icon there, it would be better (if) you could change it to an emoji.\u0026rdquo; (JBIM4, M)\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 5: Additional features\u003c/b\u003e \u003c/p\u003e \u003cp\u003eParticipants identified multiple features that could be included in the DITE app to improve its effectiveness and user experience. Firstly, a suggestion was made to include the data of interpreters available in Malaysia into the DITE app. This allows BNUs to easily search for their preferred interpreters and make bookings for their healthcare consultation. Participants found that there were safety concerns regarding the identity of the users. Hence, a suggestion to have identity verification in the DITE app was made. This would ensure that bookings were made by those who truly needed it: \u003cem\u003e\u0026ldquo;\u0026hellip;in order to use the app, them (users) needing to at least upload their profile and a picture of themselves before they can actually start using it, so at least when you (JBIMs) accept it, you can identify the person. They are legit, not something like (a robot or spam).\u0026rdquo; (JBIM6, M)\u003c/em\u003e\u003c/p\u003e \u003cp\u003e Additionally, participants also noted the need for close captioning during the healthcare consultations, especially for medical terms. This is highlighted in the following comment: \u003cem\u003e\u0026ldquo;If we can see what the doctor said on the screen, (that would be good). Because for some medical terms, we may not be very familiar. If it can appear at the bottom of the screen, we don't have to ask the doctor what he was trying to say or how to spell the word. It may not be accurate, but at least, we already know, more or less, what it is.\u0026rdquo; (JBIM4, M)\u003c/em\u003e There was also a suggestion to record the healthcare consultation to cross-check whether the interpretation was accurate, as \u003cem\u003e\u0026ldquo;For me, (the recording is) not for the doctor, (it is) only for the Deaf, to see whether what they are signing is correct or incorrect, (or) if the voice-over is correct or incorrect. We need the recording (of the consultation) for the Deaf.\u0026rdquo; (JBIM5, F)\u003c/em\u003e\u003c/p\u003e \u003cp\u003eTo improve the convenience and user experience of the DITE app, the moderator explored the feasibility and benefits of syncing the bookings in the DITE app to the participants\u0026rsquo; personal calendars such as Google Calendar. Participants agreed that this would be a good feature to have. Finally, participants believed that the potential of the DITE app could be expanded beyond the limits of medical consultations: \u003cem\u003e\u0026ldquo;In terms of using it in a medical setting, I think it can be expanded from medical settings because I think the \u0026lsquo;on demand\u0026rsquo; and the \u0026lsquo;booking\u0026rsquo; features, are not just limited to medical settings.\u0026rdquo; (JBIM6, M)\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe discussion section delves into the multifaceted implications and potential of the DITE app in bridging communication barriers between HCPs and Deaf patients. Key themes explored include the significance of communication in patients' preferred languages, the scarcity of certified JBIMs in Malaysia, the importance of diversity and inclusivity in JBIM selection, assurance of accuracy and confidentiality, logistical benefits, impact on doctor-patient relationship, cultural competency in HCPs, extended consultations with the app, medicolegal issues, limitations in internet access, and avenues for future research and enhancement. The analysis underscores the promising role of the DITE app in facilitating effective healthcare communication for the Deaf community in Malaysia, while emphasizing the imperative for ongoing research, refinement, and strategic implementation to maximize its impact on healthcare accessibility and outcomes.\u003c/p\u003e \u003cp\u003e \u003cb\u003eEnabling communication in patient\u0026rsquo;s language\u003c/b\u003e \u003c/p\u003e \u003cp\u003eDuring the FGD, it was emphasized that a significant benefit of the DITE app is its ability to enable communication for Deaf patients using sign language, which is their native and preferred mode of communication. Both the BNUs and HCPs concur that this dynamic interaction between healthcare providers and patients is pivotal in shaping the quality of patient care.\u003c/p\u003e \u003cp\u003eThis importance is further underscored in an article by Ranjan et al which stresses the necessity for HCPs to communicate in their patients' preferred language to strengthen the practitioner-patient relationship [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. In addition to enhancing patient comfort and facilitating information sharing, effective communication in the patient's language has the potential to improve treatment adherence significantly [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBesides facilitating healthcare consultation, the importance of popularizing sign language communication in healthcare to enhance the overall health of the Deaf population must be emphasized. Deaf patients exhibit lower health literacy levels compared to their hearing counterparts with equivalent formal education levels for several reasons [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Firstly, while hearing individuals acquire knowledge through incidental learning opportunities such as overhearing conversations and media broadcasts, Deaf signers are deprived of this exposure, hindering their acquisition of health-related information [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Additionally, the reliance on visual language makes written health education materials less accessible to Deaf individuals, compounded by materials often being written at a reading level above their literacy level [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Moreover, the scarcity of health resources available in sign language further limits Deaf patients' access to vital health information [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Consequently, these factors contribute to the diminished health literacy levels observed in Deaf signers compared to their hearing peers with similar educational backgrounds. For instance, in a study assessing cardiovascular risk knowledge among 203 Deaf signers in the United States, 40% failed to mention any symptoms of a heart attack, while 60% were unable to list any symptoms of a stroke. This increases their susceptibility to health issues and leads to inferior health statuses and outcomes compared to the general population [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHence, facilitating and promoting healthcare communication in sign language stands as a crucial measure to ensure effective healthcare accessibility for the Deaf community, thereby enhancing their healthcare literacy and, consequently, improving health outcomes. The DITE app's provision of SLIs addresses the critical need for effective communication in the native language of the Deaf community in Malaysia, emphasizing the cultural and linguistic competency required for accurate healthcare communication.\u003c/p\u003e \u003cp\u003e \u003cb\u003eImproving productivity and accessibility of JBIMs\u003c/b\u003e \u003c/p\u003e \u003cp\u003eDuring the FGDs, both BNUs and JBIMs unanimously emphasized that the DITE app has the potential to enhance the efficiency and accessibility of JBIMs. As mentioned earlier, there is a notable shortage of JBIMs in Malaysia. As of 2021, only 95 certified JBIMs were registered with the Malaysian Federation of the Deaf, predominantly concentrated in Kuala Lumpur, the capital of the country [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. This scarcity of interpreters poses a substantial obstacle to effective healthcare communication between Deaf patients and HCPs, resulting in limited access to healthcare services for many Deaf individuals. The DITE app shows promise in addressing this scarcity by potentially enhancing the efficiency of SLIs, a critical factor in overcoming this challenge. However, it is essential to acknowledge potential limitations in rural areas, where limited internet access may impact the app's accessibility.\u003c/p\u003e \u003cp\u003e \u003cb\u003eEquality, diversity, and inclusion in JBIM selection\u003c/b\u003e \u003c/p\u003e \u003cp\u003eIn the FGD, JBIMs highlighted a potential benefit of the DITE app for the Deaf community in that the app offers a unique feature allowing patients to select JBIMs based on preferences related to race, gender, and potentially religion. This ensures that Deaf patients can choose interpreters who resonate with their own backgrounds, fostering a sense of representation and inclusivity [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. This dedicated effort to promote equality, diversity, and inclusion within the Deaf patient community is particularly crucial in Malaysia's diverse, multiracial, and multireligious context.\u003c/p\u003e \u003cp\u003eThe importance of representation and diversity in healthcare is paramount, especially in the private and sensitive nature of the healthcare setting. A qualitative survey investigating the importance of interpreter gender across the United Kingdom, Finland, and Spain highlighted that nearly 60% of participants recognized the significance of interpreter gender, specifically within healthcare settings. Clients feel more comfortable sharing their symptoms and concerns with an interpreter of the same sex, especially in mental health contexts. Furthermore, female interpreters are perceived as less intimidating, particularly in social work, such as child protection cases [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRecognizing this importance, the DITE app not only addresses the scarcity of JBIMs but also emphasizes the significance of a diverse JBIM community and the ability for patients to choose their preferred interpreter. This approach aligns with the broader goal of respecting patients' autonomy in healthcare, ultimately improving compliance and overall health outcomes [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cb\u003eAssurance of accuracy and confidentiality\u003c/b\u003e \u003c/p\u003e \u003cp\u003eDuring both FGDs involving BNUs and HCPs, it was observed that the utilization of DITE apps could eliminate the need for family members to act as intermediaries between Deaf patients and HCPs, a factor regarded positively by participants. This is supported by research which underscores the suboptimal nature of relying on family members for interpretation within healthcare settings due to their potential emotional involvement, untested language proficiency, and lack of proficiency in medical terminology [\u003cspan additionalcitationids=\"CR39\" citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. For example, in a study on errors in medical interpretation and their potential clinical consequences in paediatric encounters, it was found that errors made by non-professional interpreters were notably more likely to have potential clinical consequences compared to those made by professional interpreters (77% vs. 53%) [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Additionally, utilizing family members for interpretation also poses a risk to patient confidentiality, with no assurance of impartiality or adherence to professional conduct [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. The DITE app, by facilitating professional interpretation, aligns with established best practices for upholding patient confidentiality and fostering effective communication.\u003c/p\u003e \u003cp\u003e \u003cb\u003eLogistical benefits and time efficiency\u003c/b\u003e \u003c/p\u003e \u003cp\u003eDuring the FGDs with HCPs, the DITE app was commended for its ability to streamline SLI services, which was seen as a key advantage for its adoption. Specifically, the app simplifies the process of acquiring interpreters, addressing challenges associated with lengthy waiting times. This aligns with the broader objective of enhancing interpretation services for the Deaf community and improving overall efficiency.\u003c/p\u003e \u003cp\u003eThese benefits of mobile applications offering video remote interpreting (VRI) services were illustrated in an observational study assessing the integration of VRI in a hospital that previously relied on in-person and over-the-phone interpreting services, where it was observed that VRI implementation led to several notable improvements. These included enhanced utilization of interpreters, a reduction in over-the-phone interpreting, shortened wait times (from 60 minutes to 5 minutes), and facilitated access to interpreters in clinics where in-person interpreting services were previously unavailable. Additionally, the adoption of VRI resulted in an increase in the overall number of interpreting encounters conducted annually [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOverall, the findings underscore the potential of applications offering VRI services, such as the DITE app, in improving logistical efficiency and accessibility in healthcare interpretation services.\u003c/p\u003e \u003cp\u003e \u003cb\u003eImpact on doctor-patient relationship\u003c/b\u003e \u003c/p\u003e \u003cp\u003eAn issue highlighted regarding the utilization of the DITE app revolves around the limited interaction between HCPs and patients. During consultations, patients directed their focus towards the JBIM rather than the HCPs, primarily due to the constraints within the user interface of the DITE app. The HCPs in the study mentioned finding this challenging for them to effectively convey and interpret non-verbal cues.\u003c/p\u003e \u003cp\u003eNon-verbal cues such as haptic communication (via touch), kinesics (gestures, head movements, eye contact, and facial expressions), and proxemics (use of space and distance) are essential in ensuring effective communication[\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Research suggests that the non-verbal communication behaviours of HCPs are pivotal in doctor-patient interactions, playing a significant role in establishing rapport and trust between HCPs and patients. This importance is underscored in a review by Chandra et al which highlights a positive correlation between trust, communication, and patient satisfaction [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Indeed, improved communication has been shown to enhance adherence to medication and to medical advice, both in developed and developing countries [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Further supporting this, a meta-analysis examining the relationship between physician communication and patient adherence revealed a substantial impact of communication skills on patient adherence to treatment regimens across various medical conditions. Patients whose physicians communicate poorly face a 19% higher risk of non-adherence compared to those whose physicians effectively communicate [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Given these findings, addressing the limited interaction between HCPs and patients on the DITE app remains a crucial priority for enhancing its effectiveness and ensuring optimal patient care.\u003c/p\u003e \u003cp\u003e \u003cb\u003eCultural competency in HCPs\u003c/b\u003e \u003c/p\u003e \u003cp\u003eDeaf culture competency stands as a pivotal factor in enriching the healthcare experiences of Deaf patients, as highlighted by JBIMs in this study. Despite advancements like the DITE app designed to streamline healthcare consultations for the Deaf community, significant barriers remain if HCPs lack sufficient training in Deaf cultural competency [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In the United States, HCPs were observed to treat Deaf patients paternalistically, offering treatment without ensuring patients fully comprehended their health condition or provided informed consent, leading to nonadherence and undermining patients' autonomy rights [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. This underscores the urgent need for HCPs to understand and address the specific needs of the Deaf to optimize healthcare outcomes.\u003c/p\u003e \u003cp\u003eNevertheless, despite legislative mandates for equitable access and communication, culturally incompetent healthcare practices endure, exacerbating disparities within signing Deaf communities. Many HCPs are unaware of Deaf cultural norms and linguistic rights, impeding effective communication and comprehensive care [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In a survey involving pharmacists in Malaysia, less than 5% had utilized the services of a JBIM during consultations and more than 80% relied on written communication when interacting with the Deaf [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e].Bridging these divides necessitates thorough cultural competency training for HCPs, emphasizing critical self-awareness and reflection in cross-cultural situations. Research indicates that culturally-competent care can bolster healthcare accessibility for Deaf patients. For instance, medical students trained in American Sign Language (ASL) and Deaf culture displayed a deeper understanding of the challenges faced by Deaf patients within the healthcare system [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. Similarly, workshops on ASL and Deaf culture for osteopathic medical students bolstered their confidence and understanding in engaging with Deaf patients [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePositive healthcare experiences for Deaf patients often hinge on the presence of medically-certified interpreters and HCPs proficient in sign language. However, cultural competence education should extend beyond interpreters and be integrated into the early stages of HCP training. By reshaping attitudes and behaviours, HCPs can cultivate enhanced communication and patient involvement, ultimately diminishing healthcare disparities among Deaf patients [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Therefore, the development of the DITE app and the qualitative research on its usability extend beyond merely creating a communication tool; they also aim to raise awareness of Deaf culture among HCPs.\u003c/p\u003e \u003cp\u003e \u003cb\u003eExtended healthcare consultations and long-term benefits with the DITE app\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe utilization of the DITE app was observed to result in extended healthcare consultations, as both HCPs and Deaf patients engaged in more in-depth communication. While this may be perceived as a drawback due to the prolonged consultation duration, it is imperative to recognize potential long-term benefits, particularly the enhancement of patient comprehension. Research indicates that sufficient consultation time is crucial for ensuring that patients receive comprehensive assistance, treatment, and education, thereby promoting equal access to and quality of healthcare [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. The reality is that Deaf patients often face challenges in effectively communicating with HCPs, leading to shorter and less effective consultations [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. The improvements facilitated by the app have the potential to alleviate these issues and, in turn, contribute to a reduction in future healthcare burdens. This underscores the app's significance in facilitating accessible and effective healthcare communication for the Deaf community.\u003c/p\u003e \u003cp\u003e \u003cb\u003eMedicolegal Issues\u003c/b\u003e \u003c/p\u003e \u003cp\u003e HCPs participating in their FGD have expressed concerns regarding the medicolegal acceptance of using the DITE app, particularly in obtaining patient consent. The issue arises from the interpretation process not being conducted by an official hospital translator, leading to doubts about the validity of the consent obtained. One suggested solution to address this challenge is to explore the possibility of including the SLI's name on the consent form as a legal translator, ensuring proper documentation for potential legal actions involving Deaf patients.\u003c/p\u003e \u003cp\u003eThis concern is indeed valid and supported by existing literature. A literature review of current practices in the utility of mobile technology in medical interpretation highlights the danger of inaccurate application translations and discussed the importance of having trained, professional interpreters present in medico-legal discussions, such as obtaining informed consent [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. Additionally, a study comparing informed consent scores between consultations requiring a medically trained interpreter and those without language barriers highlights the significant hindrance posed by the absence of medically-trained interpreters in obtaining informed consent, which is a crucial aspect of medicolegal discussions. While nearly two-thirds of consultations without language barriers achieved high information scores, only about a quarter of those requiring professional medical interpretation attained similar levels of understanding [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe crux of the matter lies in determining the medicolegal validity of interpreting services provided by SLIs who are not certified in medicolegal consultations. There is a pressing need to assess the risks and benefits associated with allowing them to testify in consultations of this nature. One potential solution to mitigate these challenges is to invest in training more SLIs in medical and medicolegal consultations, which will be further elaborated on below. By equipping them with the necessary skills and knowledge, healthcare systems can better meet the demands of the Deaf community while ensuring compliance with medicolegal standards.\u003c/p\u003e \u003cp\u003e \u003cb\u003eLimitations in internet access\u003c/b\u003e \u003c/p\u003e \u003cp\u003eIt is crucial to tackle the constraint of the DITE app in regions with inadequate internet connectivity. Amid the COVID-19 situation, where the reliance on online platforms has become imperative, there is an opportune moment to enhance the prevalence and acceptance of telehealth, including accessing healthcare interpreting services [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. Resolving this challenge necessitates concerted efforts on a broader scale, particularly in addressing internet coverage issues in Malaysia. In our pilot study assessing the feasibility and acceptability of DITE among Deaf and JBIM participants, the majority acknowledged having adequate internet speed. However, some encountered difficulties accessing internet data, emphasising the necessity of reliable internet access for seamless connectivity. One proposed solution was to incorporate the cost of data into the DITE app, guaranteeing at least an hour of free data or credit for emergency use to enhance accessibility [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cb\u003eStudy limitations and future research\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis study is the first such study of its kind involving three key stakeholders to assess the feasibility of an app for healthcare consultations for the Deaf. The study is not without limitations. Most of the JBIMs involved did not have prior experience translating in healthcare settings. The study was also conducted in an urban setting where internet connectivity was good, and involved participants who were technologically-capable. In addition, it was not conducted in the real-world setting i.e. an actual healthcare setting, where various other factors could have affected the use and functionality of the app, as mentioned by participants above. The study's sample size was relatively small and the sample might not have adequately reflected the diversity present within each stakeholder group, which could restrict the broader applicability of the results. The inclusion criteria requiring participants to have Android phones may have also excluded individuals who use other types of devices, potentially biasing the sample towards a particular demographic.\u003c/p\u003e \u003cp\u003eParticipants were recruited through the research team's networks, which may introduce bias towards individuals who are more familiar with or supportive of the project, potentially skewing the results. In addition, participants were only given access to the DITE app for a week before engaging in simulated medical consultations. This short duration may not have allowed participants sufficient time to fully explore and become accustomed to the app's features, potentially affecting their perceptions and feedback. The study primarily focused on evaluating the feasibility and acceptability of the DITE app, through the lens of the UTAUT2 framework. While this approach provides valuable insights into users' behavioural intentions, it may not capture all relevant factors influencing the adoption and utilisation of the app. Finally, despite efforts to ensure accuracy in transcription and thematic analysis, interpreting sign language and capturing its nuances in written form can present challenges. This may introduce potential limitations in the analysis and interpretation of data from Deaf participants.\u003c/p\u003e \u003cp\u003eMoving forward, our research points towards key avenues for future exploration and enhancement of the DITE app. To address limitations highlighted by participants, we propose conducting larger scale testing over a longer period, particularly in rural areas, to ensure a comprehensive understanding of the app's effectiveness across diverse settings. Potential biases in recruitment and analysis methods should also be mitigated. Real-world evaluations in healthcare settings will provide insights into the practical utility of the app in routine patient care.\u003c/p\u003e \u003cp\u003eTo address the challenges faced by HCPs in effectively communicating with deaf signers, it is imperative to implement training programs focused on Deaf cultural competency. These programs should aim to educate HCPs about the linguistic and cultural norms of the Deaf community, emphasizing the importance of recognizing and respecting Deaf identity. Moreover, training should include practical strategies for facilitating communication with deaf signers, such as learning basic sign language phrases and understanding the significance of visual communication in Deaf culture. By enhancing HCPs' cultural competence, healthcare settings can become more inclusive and responsive to the needs of deaf signers, ultimately improving patient-provider interactions and health outcomes [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAdditionally, SLIs play a crucial role in facilitating communication between HCPs and deaf signers, yet many lack systematic, in-depth medical training. To address this gap, comprehensive training programs tailored specifically for SLIs in medical settings are essential. These programs should cover a wide range of topics, including medical terminology, ethics, and cultural sensitivity. Additionally, SLIs should receive hands-on experience and guidance on navigating complex medical situations, ensuring they are well-equipped to accurately convey information between HCPs and deaf patients. By providing SLIs with specialized medical training, healthcare facilities can enhance the quality and effectiveness of interpreter-mediated healthcare interactions, ultimately improving accessibility and outcomes for deaf signers [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThese initiatives collectively aim to fortify the DITE app's functionality, advancing SLI service accessibility and cultural competency in healthcare settings.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe DITE app's potential in bridging communication barriers for Deaf patients in Malaysia unveils crucial insights. Key themes explored include the significance of communication in patients' preferred languages, scarcity of certified interpreters, diversity and inclusivity in interpreter selection, assurance of accuracy and confidentiality, logistical benefits, impact on doctor-patient relationships, cultural competency in healthcare providers, extended consultations, medicolegal issues, and limitations in internet access. The analysis emphasises the promising role of the DITE app in facilitating effective healthcare communication for the Deaf community in Malaysia. However, it also highlights the imperative for ongoing research, refinement, and strategic implementation to maximize its impact on healthcare accessibility and outcomes. Future efforts should focus on larger-scale testing, particularly in rural areas, real-world evaluations in healthcare settings, and the implementation of training programs for healthcare providers and interpreters to enhance cultural competency and medical expertise. By addressing these challenges, the DITE app can truly revolutionize healthcare accessibility and outcomes for the Deaf community in Malaysia.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eBI\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBehavioural intention\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eBIM\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMalaysian Sign Language\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eBNU\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBIM native users\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eDITE\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDeaf In Touch Everywhere\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eFGD\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFocus group discussion\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eHCP\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHealthcare provider\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eJBIM\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBIM interpreter\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eSLI\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSign language interpreter\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eUTAUT\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUnified Theory of Acceptance and Use of Technology\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was granted by the Monash University Human Rights and Ethics Committee (Ref no: 2021-20452-53435)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was funded by the Network for Equity through Digital Health (NEED) Platform, Monash University\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003eNES undertook transcribing, coding and thematic analysis on the interview transcripts and was a major contributor in writing the manuscript.\u003c/li\u003e\n\u003cli\u003eWRX undertook transcribing, coding and thematic analysis on the interview transcripts and was a major contributor in writing the manuscript.\u0026nbsp;\u003c/li\u003e\n\u003cli\u003eWNJEF undertook coding and thematic analysis on the interview transcripts and contributed to writing the manuscript.\u003c/li\u003e\n\u003cli\u003eAD was involved in the conception and design of the work and data acquisition.\u003c/li\u003e\n\u003cli\u003eVR was involved in the conception and design of the case scenarios.\u0026nbsp;\u003c/li\u003e\n\u003cli\u003eAC was involved in facilitating the FGD, drafting the manuscript based on the findings from the interview and providing relevant inputs/feedback in the manuscript.\u0026nbsp;\u003c/li\u003e\n\u003cli\u003eJN was involved in the design of the study, data acquisition, and transcribing of transcripts and video recordings.\u0026nbsp;\u003c/li\u003e\n\u003cli\u003eUD was involved in the app development, conception, design, data acquisition of the study as well as writing, and editing the manuscript.\u003c/li\u003e\n\u003cli\u003eSAJ was involved in the conception and design of the study, data analysis and interpretation, and writing, reviewing, and editing the draft and final version of the manuscript.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank all study participants for their time and feedback.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e[WHO] WHO. 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Challenges that healthcare practitioners experience in the comprehensive assessment of patients with non-communicable diseases: a preliminary investigation. Afr Health Sci. 2021;21(3):1282\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJi X, Chow E, Abdelhamid K, Naumova D, Mate KKV, Bergeron A, et al. Utility of mobile technology in medical interpretation: A literature review of current practices. Patient Educ Couns. 2021;104(9):2137\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHunt LM, de Voogd KB. Are Good Intentions Good Enough? Informed Consent Without Trained Interpreters. J Gen Intern Med. 2007;22(5):598\u0026ndash;605.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLoo JS, Yow HY, Ten YY, Govindaraju K, Megat Mohd Zubairi MH, Oui HC, et al. Exploring the rise of telehealth services in Malaysia: A retrospective study. Digit Health. 2023;9:20552076231216275.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRabanifar N, Abdi K. Barriers and Challenges of Implementing Telerehabilitation: A Systematic Review. Iranian-Rehabilitation-Journal. 2021;19(2):121\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Deaf, UTAUT, mHealth, PPI, patient and public involvement, participatory design, sign-language interpreters, Malaysia, healthcare","lastPublishedDoi":"10.21203/rs.3.rs-4392408/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4392408/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eDeaf individuals confront healthcare disparities from communication barriers, aggravated by Deaf culture ignorance and limitations of lip-reading. While medically-trained sign language interpreters (SLIs) offer solutions, shortages persist. Thus, the Deaf in Touch Everywhere (DITE\u0026trade;) app was developed to provide virtual SLI services through teleconferencing. This study investigates the app's feasibility and factors influencing the adaptation and utilization by the stakeholders.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003e This study adheres to the Consolidated Criteria for Reporting Qualitative Studies (COREQ) guidelines. Participants (\u0026ge;\u0026thinsp;18 years) were purposively sampled and comprised of three stakeholder groups: Malaysian sign language (BIM) users (BNUs), BIM interpreters (JBIMs), and healthcare providers (HCPs). They were involved in simulated medical consultations via video conferencing using the DITE\u0026trade; app. Following this, three focus group discussions (FGDs) were conducted. Interview questionnaires were designed using the extended Unified Theory of Acceptance and Use of Technology (UTAUT); encompassing performance expectancy, effort expectancy, social influence, facilitating conditions, and behavioural intention. Recorded interviews with JBIMs and HCPs were transcribed verbatim, while transcripts from BNUs were derived from video recordings. Results were imported into NVivo 12 software, and thematic analysis was performed.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eNineteen participants, comprising six BNUs, six JBIMs, and seven HCPs, participated in three FGDs. The findings were categorized according to the five UTAUT categories and were explored within each participant group. Within the \u003cem\u003eperformance expectancy\u003c/em\u003e, themes relating to the strengths and limitations of DITE app emerged. \u003cem\u003eEffort expectancy\u003c/em\u003e themes encompassed adaptation/adjustment, challenges/setbacks, and navigation/interface of the app. \u003cem\u003eSocial influence\u003c/em\u003e themes included concerns about data privacy/confidentiality, medicolegal acceptance, and encouragement to use app from relevant stakeholders. \u003cem\u003eFacilitating conditions\u003c/em\u003e encompassed themes like confidentiality, support availability, prior relationship with interpreters, previous consultation experiences, and familiarity with telecommunication tools. Regarding \u003cem\u003ebehavioural intention\u003c/em\u003e, themes that emerged were app usage and promotion and comparing telemedicine and face-to-face consultations with DITE app. In addition, limiting conditions and areas for improvement were discussed.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe DITE app holds the potential to tackle communication barriers between Deaf individuals and HCPs. However, ongoing research, fine-tuning, and strategic deployment are vital to maximize its effectiveness in enhancing healthcare accessibility and outcomes for the Deaf community in Malaysia.\u003c/p\u003e","manuscriptTitle":"Assessing the Feasibility and Acceptance of the Deaf-in-Touch Everywhere (DITE™) Mobile App: Insights from Healthcare Simulations and Stakeholder Discussions (HEARD Project)","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-28 17:49:24","doi":"10.21203/rs.3.rs-4392408/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f4aba05c-b279-42a7-a011-093b05763834","owner":[],"postedDate":"May 28th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-02-18T11:09:00+00:00","versionOfRecord":[],"versionCreatedAt":"2024-05-28 17:49:24","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4392408","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4392408","identity":"rs-4392408","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}