Abstract
Medical devices designed for use in low-resource settings require unique and thoughtful design considerations to facilitate successful implementation and adoption. Usability testing is critical for good design but conducting research in international locations with intended target users is challenging and costly. Proxy user groups have been proposed as a reasonable solution when travel is impractical or wholly restricted, as it was during the Covid-19 pandemic. This study explored the viability of utilizing a proxy user group in Houston, TX, USA, to represent nurses in Blantyre, Malawi, to assess the usability of neonatal medical devices designed for use in sub-Saharan Africa. Seven devices were tested with 13 clinicians in Houston, Texas, and 17 clinicians in Blantyre, Malawi. Participants in Houston were carefully selected to mirror Malawi's expected demographics, particularly educational background and years of experience. This analysis compared the rates and types of use errors that occurred within each group. Results indicated that the Houston nurses recruited were an insufficient proxy to represent Malawian nurses in usability studies, with only 53.7% of errors observed in both groups. Furthermore, common errors identified tended to be more severe in Blantyre than in Houston, indicating that caution should be exercised when relying on proxy users. Future work should explore these observed differences further, and larger sample sizes should be utilized to assess the viability of a proxy group. Although proxy usability testing can be advantageous, testing with target users remains the gold standard.