Omar Mubin
email: o.mubin@uws.edu.au

Luke Vink

Pieter Oosterwijk
email: p.j.m.oosterwijk@student.tue.nl

Abdullah Al Mahmud
email: a.almahmud@tudelft.nl

Suleman Shahid
email: s.shahid@uvt.nl

Floffy: Designing an Outdoor Robot for Children

Keywords: Child-robot interaction, Arduino, Environment

In our research we utilized the domain of entertainment robotics to educate children on the principles of environmental awareness by playful means outdoors. Our research revolved around the iterative design of Floffy: the environmental robot, which was essentially a playful toy robot that would respond positively to interaction that was beneficial for the environment and the child's own well being and negatively to interaction or behaviour that was detrimental to the surroundings. We conducted an explorative, informal evaluation of Floffy with two small groups of children and they rated their experience with it positively. Our results show that there is potential in utilizing entertainment robots to educate children on serious and critical issues such as saving our environment and being sustainable.

Introduction

In today's world dominated by industrial, mechanical and technological production, slowly sustainability and environmental awareness are gaining importance. Great emphasis has been laid forward on developing ventures that can educate people in protecting and preserving their environment. Educating our children on the importance of caring for the world we live in is also imperative, as awareness needs to start bottom up. The use of entertainment, games and robots to educate children is an exciting research area [START_REF] Han | The educational use of home robots for children[END_REF][START_REF] Fisch | Making educational computer games educational[END_REF]. LEGO Mindstorms is a well renowned learning tool, combining the aspects of play, games, robots and education [START_REF] Mubin | Improving Speech Recognition with the Robot Interaction Language[END_REF].

The number of robots in our society is increasing rapidly and already in 2008 the sales of service robots outnumbered the sales of industrial robots [4]. Incorporating robots in behavioural revolutions therefore seems like an obvious choice. Gradually, users' interactions with robotic systems in their daily life will increase therefore there is great potential in utilizing those interactions to educate the users about various issues related to the betterment of the world. The notion of propagating environmental awareness with the help of robots is generally an untapped domain. An upcoming research stream is that of persuasive technology, where robots have been used to persuade users to save energy [START_REF] Midden | Using negative and positive social feedback from a robotic agent to save energy[END_REF]. However what is measured is the power of verbal persuasion by robotic agents but there is no physical interaction involved with the robot. In addition there is no effect of the act of saving energy on the robot itself. Therefore our focus was on creating a robot that could educate its users on environmental protection, such that the robot was at the source of the environmental consciousness behaviour. The use of technology in general to instil environmental awareness in people is not new [START_REF] Morgil | The influence of computerassisted education on environmental knowledge and environmental awareness[END_REF].

We wished to focus on child robot interaction for our research on creating a robot that would be environmentally friendly. Children of today will be the adults of tomorrow therefore any gradual behavioural revolutions in our society should also target children and not only adults [START_REF] O'brien | Increasing environmental awareness through children's literature[END_REF]. There has been extensive research on educating children on the importance of preserving their environment [START_REF] Brynjegard | School Gardens: Raising Environmental Awareness in Children[END_REF]. One relevant prior work within the domain of environmental education using robots is that of [START_REF] Yamazaki | Development of an eco-communication robot for enhanced environmental education[END_REF], where they developed an ecologically friendly robot. However their target group was university students and the results of their evaluation are fairly limited, as only a questionnaire was used. The choice of age of our target group was another key decision. From prior literature [START_REF] Markopoulos | Interaction design and children[END_REF], we deduced that at the age of 12 years old and more, children start to become more in touch with reality and develop a sense of reasoning and logic. In addition their cognitive thought processes become less egocentric and they start to think about their surroundings and the people in them. All in all, we felt that children of this age group would be willing to appreciate the principle of environmental awareness much better than younger children. This is further substantiated by the fact that children of the age of around 12 years would have probably gone through some environmental awareness programs at school or their local community. The intention of our research was not to replace such avenues but rather supplement them and provide a playful yet educational toy like product to children.

To summarize the design statement of our research was, "To design and evaluate an animated toy robot that in an organic form, represents appropriate animated behaviour to show a child around the age of 12 years old the importance of our natural environment." We realized that we would be unable to adapt a robot off the shelf (primarily because there is no such robot available that can effectively propagate environmental awareness to young children in a playful way). Our aim was to therefore indigenously create such a robot. In the following sections of the paper we first describe the iterative design process of Floffy and then the evaluation study that we carried out with children.

Design Process

Given that we were targeting a specific user group and that we had certain interaction trends in mind we outlined the following design decisions. These decisions were primarily informed from prior literature on entertainment robotics [START_REF] Graf | Entertainment Robotics: Examples, Key Technologies and Perspectives[END_REF] (design decisions 1 and 2) and also from the brainstorming sessions we conducted with the research team (design decisions 3 and 4).

1. The robot should display certain animations (or behavior) to inform how it is feeling at a particular moment.

2. The robot should allow for personal, playful and tangible interaction.

3. The robot should physically represent a toy or a playful creature. However its representation need not be very literal, to allow for children to associate with easily, as children in the age group of 12 years old are likely to discover abstract signals and icons [START_REF] Markopoulos | Interaction design and children[END_REF].

4. There must be elements of environmental consciousness built into the robot's interaction model. For e.g. aspects such as outdoors is better that indoors in a sustainable, environmental and general wellbeing sense (as evidenced in [START_REF] Coon | Does participating in physical activity in outdoor natural environments have a greater effect on physical and mental wellbeing than physical activity indoors? A systematic review[END_REF]), water is better than battery/water is renewable (as evidenced in [START_REF] Frey | Hydropower as a renewable and sustainable energy resource meeting global energy challenges in a reasonable way[END_REF]), etc. must relate back to the animations of the robot.

We followed an iterative process with the design of our robot. The first step of the design process was a series of several brainstorming sessions that we mentioned earlier. The following "physical attributes" of our robot were also brought forward as a result of our brainstorming sessions (along with the earlier mentioned design guidelines). The sessions were held within the research team (5 members) where one of the member took on the role of a facilitator and a second the role of the note taker. As part of the sessions we compared and contrasted existing entertainment products (toy robots) for children of our age group. Summarized below are the key attributes of our intended robot:

• The robot must move, i.e. leg/limb movement is an important design aspect to look into. A mobile robot would provide us with a richer array of interaction possibilities. • The display of colors and lighting is also very important to utilize interaction possibilities.

• The robot should have an option to change shape.

The choice of prototyping platform was also a key design decision. We went ahead with the Arduino prototyping kit, which is a low-cost kit that comes with a microcontroller and various props that function as sensors and actuators. It is used fairly extensively in design research to create robotic prototypes [START_REF] Alers | AdMoVeo: A robotic platform for teaching creative programming to designers[END_REF]. We acknowledged that focusing on a solitary robot would not be an intelligent design decision. What was imperative was that we followed an iterative process, merging beneficial features from sub-prototypes. We now briefly present some of our intermediate designs (built using Arduino) (see Figure 1) that eventually led to the creation of Floffy. Sub-prototype 1. The wagging tail. The Wagging Tail was an exploration of fluid movement to distinguish two opposing emotions (i.e. happy and sad) with two opposing movements, ultimately mimicking the shape dynamics of an animal tail. Sub-prototype 2. The triangular robot. The triangular robot was again an expression of two opposing emotions. The triangle would be content in its default state (as seen in the figure). When suddenly approached by an unknown object in its proximity, the triangle would get scared and fall on its point. Sub-prototype 3. Mr Googly. Mr Googly was an exploration of how the exterior of our robot could look like aesthetically and how it would feel in a material sense. We specially focused on its big eyes, inspired by characters in children's TV shows such as in Sesame Street. The inside of the eyes contained RGB LED's. The choice of what colors in the LED's would depict what emotions was inherited from [START_REF] Russell | Circumplex models of personality and emotions[END_REF]. Sub-prototype 4. Walter Cannon. The Walter Cannon robot combined emotion and mechanics successfully using a proximity sensor to alternate its position and stance. If a user would draw his/her hand towards the robot it would quickly retreat. Sub-prototype 5. Raffelsia. In order to explore techniques to portray the environment, we created the Raffelsia (flower like) robot. It consisted of an in-house built water sensor and an ultraviolet light sensor. The "petals" of the robot would open and shut depending on water intake and if it was outdoors or not.

Development of the Robot

Drawing on our experiences of creating the sub-prototypes we moved to the next stage of actually creating Floffy. We tried to incorporate facets of knowledge from the earlier design phase into our final design by utilizing the Questions, Options and Criteria Technique executed within the design team to decipher which features of the sub-prototypes would be the most critical for our final product. This led to for e.g. the water sensor mechanism of Raffelsia being retained for the final implementation. The first step was to sketch the prospective design of Floffy on paper (see Figure 2). We drew up several forms for the robot including 4, 5 and no legged creatures. Eventually, we decided on a robot with 3 limbs. This meant that whatever we worked out for the front two limbs, we could most likely make it move. The result was a gecko inspired creature.

The Personality of Floffy. Before creating the robot we agreed on an interaction scenario of Floffy based on its hypothetical personality: "Firstly, Floffy requires water to live. When Floffy is inside it responds with anger and sadness. It will jump and run away. When taken outdoors, its behavior changes and he begins to jump and play." Building Floffy. Once we had an initial sketch and initial persona of Floffy in mind, the next step was to build the main frame/body of the robot, followed by adding sensors and finally the last stage of the building process was to focus on the physical attributes such as the outer skin and the padding to give it volume. We will now briefly describe each stage of the building process. The frame of the robot was divided into modules, such as the two arms and the tail. While we built the individual modules we would predict the final shape of the robot with overlays to help in visualizing the outlook of the robot. Due to our success in the sub-prototype 5: Raffielsa, we wished to have arm movement in Floffy and we consequently arrived at the structure shown in Figure 3 (top). Due to a restriction on the number of ports on the Arduino board we used motors instead of servos.

We soon realized that due to a weight issue we could not achieve proper arm movements with the motors. They were unable to lift let alone move the robot. We also faced an issue with precise positioning of the continuous motor. Therefore our redesign involved the incorporation of wheels (see Figure 3 -bottom). The eyes of Floffy were adapted from sub-prototype 3: Mr Googly and the water sensor and solar panel from sub-prototype 5: Raffelsia. The movements of Floffy were based on our subprototype 4: Walter Cannon. The fur was also fairly complex to integrate because every part of the robot that moved had to be considered in conjunction with the placement of the water sensor and the solar panel.

The behaviors of Floffy. Floffy, used a proximity sensor to determine in combination with a solar panel and water sensor, 9 different behavioral states. These were categorized into 3 groups determined by the current status of the robot. The 3 major states, 'near death', 'inside' and 'outside' were guided functionally but the existence of water (as food/energy) and then further broken down into 3 levels based on the proximity of the user. In the first major state; 'near death', Floffy would 'writher' in desperation (see Figure 5), if a user was in range (roughly 30 cm). As the person drew closer, Floffy would show a heightened and excitable desire for water by jumping swiftly.

The second state, where Floffy was fed but inside, the robot would show negative behaviors, as an inclination to go outdoors. The closer the user got, the more Floffy would retreat and move away. In the final state; 'Outside', Floffy would show greater interest the more closer a user was by drawing itself towards the user. All the while, the robots eyes were changed in attempt to display these behavioral states. For example in a state of anger, Floffy would flash his eyes red, while joy or happiness showed the flashing of green eyes and desperation with orange.

Evaluation

Method. In order to evaluate our design of Floffy, we conducted a series of exploratory qualitative evaluation sessions with a group of children using the think aloud methodology. The think aloud protocol has shown to be effective with children [START_REF] Donker | A comparison of think-aloud, questionnaires and interviews for testing usability with children[END_REF] as compared to other standard evaluation methods such as questionnaires. The evaluation was spread across two separate sessions, each involving 3 children (3M, 3F, average age: 12.2 years). Appropriate consent was gathered from their parents. The objective of the evaluation was to ascertain if the children could understand the rationale behind Floffy and interact and engage with it. The sessions started off by giving a small introduction of Floffy while indoors. The children were allowed free and open interactions (for 20 minutes) by bringing their hands close to Floffy (see Figure 6). They were also allowed to interact cooperatively with the robot and figure out how it all worked. At this juncture, the facilitators monitored what the feedback was from the children and also encouraged the children to elicit what they felt about each interaction step with the robot. The children were then given a water feeder without letting them know what they must do with it. The children would sooner or later discover that water would need to be dropped into Floffy (see Figure 6). As the facilitators we observed the reactions and thoughts of the children throughout the whole process. Floffy was then taken outside and the actions were repeated (free explorations for 20 minutes). We would like to share some interesting anecdotal notes from the evaluation.

Results. In the first session, one child attempted to pat Floffy from the front and due to Floffy's reaction with the proximity sensor, coupled with the robots lack of sunlight, it began to move fast and wildly (signifying an angry movement). The child became reluctant and took his hand away only to be later calmed by our explanation that Floffy is safe. In the second session, one of the girls exclaimed to us: "He (Floffy) likes it better outside!" When we questioned further as to why, the girls responded with, "Because his eyes are red inside and green outside". The children enjoyed playing with Floffy and 5 out of 6 children were able to correctly deduce what the purpose and intention of Floffy and its interactions was.

Discussion and Future Work

With our research we have investigated the impact robots can have on educating children in a fun and enjoyable way. We would like to summarize the key novel aspects of Floffy":

• Floffy is unique. No other robot on the market is "fed water" or "desires the sun". This robot is designed to teach children to love the environment via its unique interaction mechanisms.

• Designed to be happier outside, children will prefer to play with Floffy outside at the same time learning to appreciate the environment the way Floffy does.

• Floffy convinces children into thinking it is powered by water, which is both inspiring for children and possible in the future. Floffy subtly suggests that the future of power is alternative energy. One of the limitations of the work presented in the research so far is that to fully validate our claims we would need to carry out a large-scale evaluation with a substantial number of children. Therefore as part of our future work we would like to carry out extensive user evaluations with Floffy and children of 12 years old, which will help us in finalizing the granularity and specifications of the behavioral variations that we have implemented and also contemplate any redesign and structural modifications. We wish to conduct empirical evaluations of quantitative nature, enabling us to confirm the connection and link between the behavior of the Floffy and the interpretation of the child. We will also be able to establish what kind of actions and responses stimulate interaction between children and robots.

Fig. 1 .Fig. 2 .

 12 Fig. 1. Sub prototypes (from L-R): The wagging tail, the triangular robot, mr googly, walter cannon and raffelsia

Fig. 3 .

 3 Fig. 3. Floffy showing desperation for water in the state of 'near death' (left most); Children interacting with Floffy

Acknowledgements. We thank the children and their parents for the cooperation.


Abdullah Al Mahmud
email: a.almahmud@tudelft.nl

David V Keyson
email: d.keyson@tudelft.nl

Supporting Improved Maternity Care by Midwives: Design Opportunities & Lessons Learned

Keywords: Prenatal care, midwives, Information Technology (IT), maternal health, Human-Computer Interaction (HCI)

In this paper we describe a study about the role of Information Technology (IT) on the quality of maternity care in the midwifery centres in the Netherlands. We conducted an interview study with midwives in the Netherlands. The objective was to understand the current situation, challenges and design opportunities that could help to provided improved healthcare. The results of the interview study show that the current prenatal care system suffer from some challenges such as proper IT support, lack of IT training for the midwives, lack of integrity between different software systems used in the midwifery centres and hospitals and attitude of the pregnant mothers. Based on our findings we provide some recommendations and design implications to support improved care provided by the midwives.

Introduction and background

A key aspect to improve maternal health is to make use of the role of skilled health professionals, specifically midwives. Women around the world depend on the expertise of midwives for both prenatal and neonatal care. In the Netherlands, midwives are independent medical practitioners who work either in a midwifery practice centre or in a hospital. Approximately 78% of pregnant women start their maternity care with a primary care setting where 44% start labour in primary care, and finally 33% of women give birth under supervision of a primary care midwife [START_REF] Manniën | Evaluation of primary care midwifery in the Netherlands: design and rationale of a dynamic cohort study (DELIVER)[END_REF]. Midwives are trained to provide maternity care to women whose pregnancy and childbirth are uncomplicated including antenatal, intrapartum and postnatal care to mother and child [START_REF] Anthony | De thuisbevalling in Nederland 1995-2002[END_REF]. The first appointment at the midwifery practice usually takes place around the 8th week of pregnancy. On average one pregnant woman visits midwives 10-13 times over 9 months. Due to the frequent visits throughout pregnancy and because of their expertise, midwives are treated as dependable providers of pregnancy related health education and advice for pregnant women.

Maternity care in the Netherlands is known for its high percentage of home births and for the independent situation of midwives [START_REF] Smeenk | Have: Medicalization and obstetric care: an analysis of developments in Dutch midwifery[END_REF][START_REF] Wiegers | Variation in home birth rates between midwifery practices in the Netherlands[END_REF]. In the Netherlands about 175,000 births occur annually [START_REF] Bais | The basis of the Dutch obstetric system: risk selection[END_REF]. Obstetric care in the Netherlands is provided by primary caregivers: midwives or general practitioners (GPs), and by specialist obstetricians. Women with low-risk pregnancies receive antenatal care from midwives. When they remain low risk throughout pregnancy they are free to choose to give birth either at home or in hospital. Their midwife (or GP) will support them in their choice and attend the birth in the chosen place. Referral to specialist care only happens in case of complications [START_REF] Anthony | De thuisbevalling in Nederland 1995-2002[END_REF].

Each year worldwide 529000 maternal death occur [START_REF] Bullough | Review: Current strategies for the reduction of maternal mortality[END_REF]. The target set for MDG-5 is a 75% reduction of maternal mortality ratio between 1990 and 2015. Developing countries are mainly struggling to achieve the Millennium Development Goal (MDG). There are three main approaches of safe motherhood strategies which are developed based on different stages in a women's reproductive cycle. The stages are categorized as pregnancy, antenatal, delivery and postpartum period [START_REF] Herz | The safe motherhood initiative: Proposals for action[END_REF]. Antenatal care consists of a number of interventions administered to women during pregnancy, containing screening tests, immunizations, and treatment for recognized complications. It has been established that the detection of early signs or threat factors for morbidity and mortality can be spotted and effective interventions are possible [START_REF] Rooney | Antenatal care and maternal health: how effective is it? A review of the evidence Maternal Health and safe Motherhood Programme division of Family Heath[END_REF]. The main aim of antenatal care is to produce a healthy mother and baby. Midwives have a significant impact on the wellbeing of women and new born babies.

Our aim is to identify needs and desires of midwives about the tools they need to deliver the best possible care for both mothers and infants. We need to get a clear picture of maternity care and their providers in developed countries though it is assumed that developed countries have better maternal care. There has been ample literature on midwives and maternal care in low resource environments for example see [START_REF] Herz | The safe motherhood initiative: Proposals for action[END_REF][START_REF] Rooney | Antenatal care and maternal health: how effective is it? A review of the evidence Maternal Health and safe Motherhood Programme division of Family Heath[END_REF][START_REF]The state of world's midwifery[END_REF]. Furthermore, Human-Computer Interaction (HCI) community is working with midwives to design better systems such as improved ultrasound [START_REF] Havukumpu | Midwives experiences of using HMD in ultrasound scan[END_REF]. There are few studies which explored role of computer and Information Technology for midwives in developed countries. For example, one study conducted in Australia to understand the use of Internet among midwives [START_REF] Mckenna | Midwives' use of the Internet: an Australian study[END_REF]. It was revealed that midwives had insufficient Internet competence. We are not aware of any study that investigates workflow of midwives and the role of IT. Therefore, we explore maternity care issues and challenges in the Netherlands with respect to use of Information Technology (IT) in the midwifery centres. To better comprehend and support the workflows of midwives we conducted an interview study to discover the needs of midwives, and to develop technologies that will help them to better serve their patients. The specific objectives of the study are: a) identifying the role of IT and point-of-care testing (POC) devices b) identifying the purposes of Information Technology (IT) and POC for midwives, c) understanding the barriers to using IT and POC devices in the midwifery centres, d) recommendations to overcome these barriers to improve maternal care.

Interview study and results

In total 15 midwives participated in a semi-structured interview. They were contacted via the Royal Dutch Organization of Midwives (KNOV) [START_REF]Dutch midwifery association[END_REF]. The selection criteria were: the midwives should have active participation in midwifery centres and they should have minimum 5 years of working experience. The participation was volun-tary. The preliminary questions for the interviews were a) key issues related to providing basic prenatal care, b) managing information to support prenatal care, c) prenatal visits and quality of care, d) barriers and facilitators to the prenatal care and role of Information Technology. Each interview session was one hour long. Interview data were audio recorded and later transcribed. The data were thematically analysed by the first author and one external researcher and the qualitative data analysis method described in [START_REF] Strauss | Basics of qualitative research: grounded theory procedures and techniques[END_REF] was followed. The key themes that emerged from the interviews are explained below:

Protocols for midwives. Generally midwives (MW) follow written protocols in the midwifery centres; however midwives with several years of experience do not need those very often. One midwife (MW3) mentioned, "some are written and some are in my head, it is in my head as I am experienced and for new colleagues it is on paper as well. We have several booklets in different languages.' Protocols are written by the Dutch organization of midwives (KNOV). It is a manual to inform how a usual prenatal care should be carried out. However, midwives are not forced to do that. One midwife (MW1) mentioned, 'You have your own responsibilities and you can decide based on your experiences and judgment when to see the patient in two week or four weeks. However, the rules are means and they are not aims'. There are several protocols that are suitable for midwifery centres and regular hospitals where prenatal care is given as well. One midwife (MW9) mentioned, 'we work together with hospitals and we need to know the protocols of the hospital. We have not put the protocols on paper; they change a lot so it is in digital format as PDF files'. Patients and communication. Midwives use both paper and electronic forms to manage patient information. During or before the first visit a prenatal registration form is given to the pregnant women and later those are used to keep online record with the help of the software systems that midwives use. One midwife (MW7) mentioned, "when I take a blood sample for testing, I fill out a form, the results come back online and I decide if this is ok or not. If it is not OK the patients are referred. If I have to go an urgent consultation I call the obstetrician". Furthermore, electronic agenda are quite often used to manage and provide care which helps them to work efficiently. Another midwife (MW5) mentioned, "we have agenda per location and we also travel in the 5 locations to provide care so that pregnant women can easily reach. The agenda helps us to keep track of all the appointments". During the first prenatal visit midwives collect the history of the patients and keep in their software systems. They also provide information to pregnant women about their practice and give lot of information about pregnancy such as diet, exercise and follow up visits Therefore, it is important that the provided information given to pregnant women are easy to remember and manage during the 9 months. Managing information and supporting prenatal care. We identified that all the midwives complained about the software systems that they use to manage patient information. There are numerous major advantages of the software systems as well as reported by the midwives. The key advantages are a) patient summary information such as pregnancy history, disease history, family history are easily available, b) an agenda in the software system to manage appointments with the pregnant women. The other things are, a) counselling information: smoking and drinking, b) provides summary of the health situation of the pregnant women based on self-reported data. One midwife (MW12) mentioned, "If my colleague fills it I can just access the data. I always read the whole journal and it helps me to get an overall impression about a patient's condition". Therefore, the software systems help to maintain a good workflow of midwives. Some key issues reported my midwives are, a) the software do not provide a notice if wrong information is added, b) the software systems do not let midwives know that the blood pressure is high. For example, one midwife (MW8) mentioned, "the other program [name of the software program] gives me some jokes. If I type 11 children it gives me a joke. If the baby's blood type is O negative and we have to give medication. The software systems do not provide much intelligence. The whole thinking part is from the midwife. Though I believe that it cannot be fully taken over by the computer. The person who enters the data needs to take the decision".

Furthermore, the questionnaire data for prenatal registration collected from the pregnant women stays at the midwifery practice during the 9 months, when a baby is born and care has been finished, it goes to the national database anonymously [START_REF]Netherlands Perinatal Registry (PRN foundation[END_REF]. For example, when someone has a miscarriage, midwife has to fill in a special form with all the information: there is no option in the software systems to do the same task. Midwives also use some point of care diagnostic devices such as blood pressure machine, Doppler machine, ultrasound in some practices and then sterilizing instruments are used for home delivery. These point-of-care (POC) testing devices are usually independent and each measurement data needs to enter into the software systems of the midwives. Prenatal visits and quality of care. The quality of care depends on the attitudes of the pregnant women and midwives. Sometimes some pregnant women have difficult behaviour. Some pregnant women do not even come for a follow up visit and they do not even keep their appointments up to date. One midwife mentioned (MW10), "though we have a booklet for the pregnant women and we note down their follow up appointments, still they miss the appointments". In the regions where low social status people do not come to a prenatal visits regularly. Midwives need a lot of interaction with the pregnant women. Sometimes people do not show up and midwives have to call them. It would be nice to have a reminder system for those pregnant women. One midwife mentioned, "the main part of our work is the relation with the pregnant women. If you do not have a good relation, you cannot give a good care. We do a lot of talking and listening. One of the basic competencies of midwives is making and building relations, maintaining relations and finishing the relations". Barriers and facilitators to prenatal care and IT. Four software systems are used in the midwifery centres such as a) MicroNatal (http://www.micronatal.nl/), b) Orfeus (http://www.orfeus.nl/), c) Onatal (http://www.onatal.nl/), and d) Vrumun (http://www.vrumun.nl/) and each midwifery centre uses only one of them. These software systems provide a wide range of support and generally the software system are secured and require secure log in credentials. One midwife (MW5) mentioned, "we have a system everybody has different discipline, I do not know the finance section of the software so I cannot access that part. You get a user name and a special password to log on to the system". The positive aspect is that the software allows midwives to provide direct feedback to the developers and helps to provide better care to midwives by giving overview of the finished tasks. However, midwives had mixed reaction about the current software systems. One of the key issues is the broken link among the different software systems of midwives and gynaecologists. One midwife mentioned, "I have my software and the gynaecologists have their own software. However, due to privacy reasons those are not connected. I want to check my patient within the system of the gynaecologists who is in a hospital".

Other wish list from the midwives were a) a touch program to input data while visiting a patient, b) easy customization of the menu items and other functional features where more frequent menus to be appeared only. One midwife mentioned, "when I have to visit a patient who cannot come to our midwifery centre, I use a diary to keep notes and patient data. I cannot access the patient data which are in my computer at the midwifery centre. It is a pity and I have to enter the notes and other information when I am back at my office". Fig. 1. Our proposed conceptual model to support improved prenatal and postnatal care. The keys issue is to repair the broken link among three care providers that is create an access to the patient data from each care location when required. Furthermore, mobile apps are proposed for midwives and nurses when they need to visit pregnant women and need to access the patient data. An integrated knowledge base is also proposed for improved care.

Midwives work closely with nurses (in Dutch they are called 'kraamzorg') and the nurses very often need critical information from midwives or specialists. For example, if a baby is born with high bilirubin which needs to be checked and very often nurses call midwives or specialists to know whether the bilirubin level is within normal range. One midwife mentioned (MW12), "this is really critical information and an assistive mobile application would certainly help the nurses and midwives to take a decision and reduces their burden".

Recommendations and design implications

In this following section we provide recommendations to help midwives to provide better prenatal care. Interoperability and centralization of software for midwives. Too much information is provided to the pregnant women, therefore pregnant women either forget or they ask midwives repeatedly in upcoming visits. Therefore, it would be helpful if that information could be shared for both pregnant woman and midwives in an easy and accessible manner. For example, an interactive application/mobile app where it would be easy to interact with and pregnant women will get support over the nine months and post natal care would be really helpful. It would be beneficial to have an integrated software system with doctors, midwives and other caregivers. The current system in the Netherlands does not allow different stakeholders to access the same patient data from their own software terminals. Therefore, creating an integrated health care system is a crucial need where privacy of the end user data will be preserved. The short term solution would be to make a viable link with the existing software systems operating in the midwifery centres and hospitals. We have observed that some of the software systems are not possible to use if the midwives need to visit a patient since the application can only be used at the computers of the midwifery centres. Therefore, a mobile application which could help to integrate with the local software system would be really helpful for the midwives. We recommend having a mobile app that would help to access the software systems while midwives have to visit a patient. The mobile app should be able to synchronise the gathered data later on. Accessible protocols. Since the maternal care system is based on protocols, and the obvious advantage would be to create some means to access the protocols based on the specific situation of pregnant women. Furthermore, creating a central knowledge base for the midwives would be helpful to reduce the burden for the new midwives. Usability and features of the software for midwives. We have found that there are four kinds of software systems and they have positive aspects while providing care by the midwives. All the software provides reasonable support to midwives despite some usability issues. The adoption process is based on price, and recommendations from other colleagues and the associated midwifery centres who work together. Improving the usability of the current midwifery software systems used in the midwifery centres will certainly help the workflow of the midwives. The major problems that we encountered were divided in two sides: a) lack of usable software system, and b) lack of financial support of the midwifery centres. One of the software was developed by individual initiative and no formal usability was measured. Furthermore, some manufacturers of the software systems started to get feedback from the midwives however since the community who use the systems are not very large the investment that is required to improve usability is less than the predicted return. We would like to stress that opinion of midwives should be taken into account while developing the software and support from the government is required for the software development firms. Virtual midwives. Two types of user groups were identified who ask care from the midwives. One group is motivated to visit the midwifery centre and the other group often misses their appointments. We also found that midwives find their task harder due to attitude of the people which is hard to control. However, it would be helpful if midwife could be virtually connected with the patients which could reduce their workload. Most of the time midwives are overloaded with so many queries of the women who are first time pregnant. Therefore, creating a virtual community and getting regular reminders about appointments could help to bridge the situation. It has also been observed that some user groups are very motivated and eager to know the growth of their expected baby. Since the midwives check the growth once in a month and sometimes it is hard to follow some appointments it would be beneficial to have a software system that will inform pregnant women about the growth of their baby. Furthermore, the will help pregnant women to get a piece of mind and will lower the burden from the midwives for example they will receive less worrying question from the pregnant women. It is evident from existing literature that the workload for primary care midwives are huge [START_REF] Wiegers | A: Workload of primary-care midwives[END_REF]. Training for midwives. Providing regular training to midwives about the usage of IT or existing software systems will improve their workflow. We observed that some midwives are not well aware about the capability of the IT systems. Therefore, regular training to make them competent will result in delivering improved care. These findings are also in line with the existing findings mentioned in [START_REF] Gerrish | Factors influencing use of information technology by nurses and midwives[END_REF][START_REF] Hillan | Computers in midwifery practice: a view from the labour ward[END_REF]. Tools to support postnatal care. One of the issues midwives mentioned that they have problems in postnatal care support as well. The main reason was that the nurses involved in postnatal care are not sure about different measurements such as high bilirubin of the new born child. Most of the time the nurses call the midwives or doctors to consult. In some cases they have to calculate the bilirubin in every two days and calling nurses or doctors is very cumbersome. Therefore, a mobile application where nurses could measure the level of severity of the bilirubin would help to improve their workflow.

Conclusion and future work

In this paper we have presented a qualitative study to understand the work process and tools used to provide maternity care by midwives. The findings are encouraging though the prenatal care in the Netherlands is considered very good and some of the findings are due to the nature of the Dutch healthcare system. We are working with local midwives to design improved services for midwives and pregnant mothers. For example, we are designing an app for the peace of mind of pregnant mothers. The objective is to help pregnant mothers to get useful information and make them aware about the growth of the baby over 9 months. The app will also be able to document each visits to the midwifery centres and will provide recommendations on food and nutrition, exercise etc. Moreover, we believe that in order to bridge the different care providers, privacy of the information was an issue. KNOV is working to solve the issues so that each stakeholder can access each other's data to provide better pre and post natal care. In this study, we have interviewed the midwives from 12 different midwifery practices in the Netherlands. The experiences of the midwives varied in terms of software use, prior familiarity with IT and training. However, the findings led us to discover a better information system to improve maternal care in the Netherlands which may be suitable in similar other countries as well.

Acknowledgments. We thank the midwives and KNOV for their cooperation.


Stanislaw Zabramski
email: stanislaw.zabramski@im.uu.se

Wolfgang Stuerzlinger

Did We Miss Something? Correspondence Analysis of Usability Data

Keywords: shape, freehand, tracing, drawing, mouse, pen, stylus, touch, evaluation, comparison, error, measurement, subjective

We have applied a multivariate exploratory technique called Correspondence Analysis (CA) to create and analyze a model of the dataset of experiment results. The dataset originates from a comparative usability study of tracing with the use of mouse, pen, and touch input and contains both categorical and continuous datai.e. results of questionnaires and task measurements. CA allowed to visually and numerically assess the main variables in the dataset and how they interact with each other. In our study, pen input had the best measured performance and was preferred by the users. Touch input was the least accurate of all input methods tested but it was preferred by users over mouse especially in the conditions lacking of visual feedback of drawing. CA helped to detect that secondary effect even though it cannot be explained by the performance results alone. The importance of the influence of user's previous experience is also noted. We conclude that CA helped to identify all major phenomena known from previous studies but also was sensitive to minor and secondary effects, what makes it a well suited method to quickly evaluate usability data.

Introduction

Usability of any technical solution can be perceived from the pragmatic point of view that focuses only on "getting things done". However, there is a variety of users' beliefs, preconceptions, preferences, perceptions, and physical and psychological responses that affect the whole experience before, during and after use of the technique tested. Therefore the subjective and objective approaches should be used in usability evaluations and the results should be integrated into one consistent picture [START_REF]Ergonomics of human-system interaction -Part 210: Human-centred design for interactive systems[END_REF]. Even though subjective perceptions of usability are generally not correlated with objective measurements [START_REF] Frøkjaer | Measuring Usability: Are Effectiveness , Efficiency , and Satisfaction Really Correlated[END_REF] their comparison is done rarely in practice [START_REF] Barkhuus | From Mice to Men -24 years of Evaluation in CHI[END_REF]. The reason for that might be that it is hard and time consuming to get a holistic view on the experiment from results obtained from a number of different methods of data analysis suitable for particular types of data. Correspondence Analysis (CA) is a multivariate exploratory technique similar to Principal Component Analysis (PCA). In this study we apply CA and analyze objective measurements of users' performance i.e. task time and error, together with subjective evaluations of users' satisfaction in shape-tracing task.

Artistic drawing involving computer as a tool may be negatively influenced both by inaccuracies in the input method and by spatio-temporal constraints imposed on the user e.g. by task formulation. Unfortunately, there is no suitable model to describe spatially and temporally unconstrained freehand drawing when the path is unknown a priori and typical user errors are not characterized mathematically. Therefore, an exploratory study based on a standardized method [START_REF]ISO: 9241-9 Ergonomic requirements for office work with visual display terminals (VDTs) -Part 9: Requirements for non-keyboard input devices[END_REF] was performed to comparatively evaluate three popular input methods (mouse, pen, and touch input) in a simple shapetracing task [START_REF] Zabramski | Careless touch: A comparative evaluation of mouse, pen-and touchinput in shape tracing task[END_REF]. Previous research points to a positive influence of visual feedback. Therefore, the visual feedback of drawing was controlled in analyzed study through the presence or absence of solid black ink trace.

We use CA in an attempt to get a quick and simplified view on the experimental data-set and use it to evaluate if drawing performance can be a predictive criterion of users preferences [START_REF] Nielsen | Measuring usability: preference vs. performance[END_REF] towards input methods tested with controlled visual feedback.

Procedures and Methods

We used CA to analyze the data-set of results from experimental study that aimed to evaluate the influence of mouse, touch and pen input on user performance in an unconstrained free-hand tracing task [START_REF] Zabramski | Careless touch: A comparative evaluation of mouse, pen-and touchinput in shape tracing task[END_REF]. It also included the user experiences and preferences expressed towards these devices.

Experiment Design

The experiment featured a mixed design. Sixteen student volunteers (4 females) with average age 24 (SD = 2.3) were selected through convenience sampling from the local university campus. All except one were right-handed and had normal or corrected to normal vision. Half of the participants were randomly assigned to the visible drawing line condition and the other half had no feedback of drawing. Each participant used the mouse, pen and touch input on a Windows7 based HP Touchsmart TM2-1090eo Tablet PC to draw over a semi-randomly generated contour shape displayed on the screen once with every input device. Devices were assigned in a counterbalanced order in a within subject design. They were required to use the same starting point and direction to draw over the same nonsense closed contour shape presented, using a single continuous and uninterrupted stroke. Timing data was collected for each task. User error was calculated via a method that computes the average deviation of the user-generated shape from the original version [START_REF]ISO: 9241-9 Ergonomic requirements for office work with visual display terminals (VDTs) -Part 9: Requirements for non-keyboard input devices[END_REF][START_REF] Zabramski | Careless touch: A comparative evaluation of mouse, pen-and touchinput in shape tracing task[END_REF].

2.2

Questionnaires

All the participants filled pre-test questionnaires and provided basic screening information about demographics as well as their familiarity with the investigated computer input methods in the last 3 years. After the experiment, post-test questionnaires were used to collect information about participant experience and opinions regarding three following aspects:

 input device of preference (statement S1)  perceived ease of use (statements S2 and S4)  perceived learnability (statements S3 and S5)

To avoid potential distortions originating from acquiescence bias the scale was balanced by offering equal number of positive and negative statements regarding the most important aspects [START_REF] Schriesheim | Controlling Acquiescence Response Bias by Item Reversals: The Effect on Questionnaire Validity[END_REF]. The users' ratings of negative statements were later inverted and the final ratings then computed as the median of the responses to the paired questions (S2&4, S3&5). The questionnaire included:  S1 -I think that I would like to use this input device frequently for sketching.  S2 -I thought that the input device was easy to use.  S3 -I would imagine that most people would learn to sketch with this input device very quickly.  S4 -I found the input device very cumbersome to use.  S5 -I imagine I would need to practice a lot before I could sketch efficiently with this input device.

Participants were asked to evaluate five statements on a symmetric Likert-like psychometric scale. The choices offered were: strongly disagree, somewhat disagree, indifferent, somewhat agree, strongly agree. Every statement was evaluated for each input method separately.

Correspondence Analysis

CA identifies a set of synthetic variables (factors) that summarize the original data set. In this study, CA is expected to reveal frequency-based associations between the categorical data from the questionnaires and the data from the measurements [START_REF] Greenacre | Correspondence Analysis in Practice[END_REF]. CA creates a model for data with fewer factors by decomposition of inertia describing the degree of variation or eigenvalue. Similarly to PCA, the calculation gives the factors and correlations (loadings) with each factor for each variable. The optimal number of factors can be decided with the scree-test or the Kaiser criterion. Then significance tests can be used to indicate that the occurrence of certain values is significantly more common than chance. CA also enables the visualization of associations between variables in question, to simplify their identification, and to isolate relations between them. That can be done through two-dimensional configuration bi-plots, which show the relative proximity of data points and depict degrees of correlation and variation (inertia). Each dimension of a plot explains a certain percentage of the variation in the data. Normally, the first two dimensions capture a large percentage of the variation [START_REF] Greenacre | Correspondence Analysis in Practice[END_REF].

Results

3.1

Pre-test Questionnaires

The participants reported their average daily experience: 8.2h (SD = 5) of with computers in general, 3.7h (SD = 4.7) with a computer mouse, 0.8h (SD = 1) with pen devices (incl. mobile phones), and 3.3h (SD = 5.3) with touch devices (incl. mobile phones). These values have been called experience and were used in the analyses.

Time and Error

The ANOVA of task time and user error data showed no main effect for the visibility of visual feedback during drawing, nor any interaction between feedback visibility and input device used [START_REF] Zabramski | Careless touch: A comparative evaluation of mouse, pen-and touchinput in shape tracing task[END_REF]. There was no significant difference between the visibility of feedback conditions either for time (Cohen's d = 0.3) or error (Cohen's d = 0.14).

Power analysis revealed that in order for an effect of this size to be detected (90% chance) as significant at the 5% level, a sample of 238 and 1111 participants would be required for time and error respectively. However, there was a main effect of input device on task time and a post-hoc analysis identified significant differences between touch input and mouse. The mean times were: mouse = 40 sec. (SD = 16.6 sec.), pen = 30.1 sec. (SD = 15.3 sec.), and touch = 21.5 sec. (SD = 9.3 sec.). User error data indicated also a main effect of input device. A post-hoc analysis showed that mouse and pen are not significantly different. The mean errors were: mouse = 5.84 px (SD = 2.21 px), pen-input = 4.98 px (SD = 1.92 px), touch-input = 7.95 px (SD = 2.94 px), with the grand mean error = 6.25 px.

Post-test Questionnaires

All the questionnaire responses were coded between 1 and 5 reflecting the level of expressed agreement or disagreement on an ordinal scale. Some of the scales were inverted to deal with acquiescence bias. We illustrate this inversion by adding a "-" sign in front of the statement number (e.g. -S4). The paired statements, S2&-S4 and S3&-S5, were compared to check for acquiescence bias. Polychoric correlation coefficients (pcc) were calculated and used in the analyses. To investigate the significance of potential differences between groups of responses a Wilcoxon matched-pairs test was used.

We found that the overall replies to statements S2 and -S4 for all input methods and all feedback visibility conditions have strong positive correlation (pcc=0.68) with insignificant differences between their medians. Similarly, in case of statements S3 and -S5, strong positive correlation was observed (pcc=0.74), but this time with significant differences between their medians (p<0.05).

Figure 1 presents the summary of responses to post-test questionnaires. In following analyses the median value of replies to S2 and -S4 is referred to as ease of use, and the median value of replies to S3 and -S5 as learnability. Replies to S1 are termed preference. The correlation matrix of responses of all these three aspects illustrated positive correlations to each other (pcc>0.5).

Correspondence Analysis

For extracting common explanatory factors a CA was calculated and analyzed. The first analysis compared the experience in using various input methods against the measurements and the post-test results, such as preferred input device and perceived ease of use. The bi-plot generated from the CA (see Figure 2 -left) shows that experience has a strong influence on all other variables. It shows potential strong relation to task time, but neither the correlation nor regression analysis gave any significant or consistent results. The experience factor was removed from data for the following analyses to better contrast the remaining variables (see Figure 2 -right).

Some differences between the visibility of the drawing feedback conditions have been noticed in the post-test responses within each input device (see Figure 1). The bi-plot generated from the CA confirmed that observation (see Figure 3). A Mann-Whitney-Wilcoxon test identified significant differences for preference and ease of use only for touch input (p<0.05). In case of learnability that effect was not so strong for touch but a significant difference has been found in case of mouse (p<0.05). Table 1 summarizes these results. Table 1. Input methods ordered by users preference in each visual feedback condition for each aspect. "≥" marks insignificant differences and ">" marks significant differences (p<0.05) after Mann-Whitney-Wilcoxon test.

Aspect

Discussion

The multidimensional dataset generated by an experiment is challenging to analyze. Thus, it is essential to use a suitable analysis method, such as CA, which can identify the most influential variables. Previous experience strongly varied between participants due to the lack of homogeneity in the participant's group. As the most influential variable, it biased both the measurements and subjective factors, but unfortunately not in a way that can be easily interpreted in a meaningful way. E.g. experience did not correlate with error or task time. Therefore it was excluded from the analyses.

CA suggested to contrast time with error (see Figure 2 -right). This is the evidence that the well-known speed-accuracy trade-off [START_REF] Zabramski | Careless touch: A comparative evaluation of mouse, pen-and touchinput in shape tracing task[END_REF] took place in this study.

Subjective evaluations did not show meaningful differences between the aspects of user satisfaction addressed in questionnaires and strongly correlated to each other. The pen supports better performance and overall results for device of preference identify the pen as the best choice for frequent sketching. It is followed by touch and mouse with a non-significant difference between the two. However, this difference changed to significant when no feedback of drawing was provided (see Table 1) making touch more preferred when the feedback was absent. That trend is also present in the case of perceived learnability and even more visible for perceived ease of use. None of these however, correspond to significant differences of performance [START_REF] Zabramski | Careless touch: A comparative evaluation of mouse, pen-and touchinput in shape tracing task[END_REF].

Conclusion

Correspondence Analysis is a frequently used technique e.g. in linguistics, sociology, or biology. When applied in HCI, CA helped to quickly analyze the results and identified all major phenomena in the studied experiment that mostly have confirmation in previous research. But, CA was also sensitive to secondary effects that might be harder to notice when the results are spread among multiple methods of data analysis.

In the experiment analyzed here the lack of visual feedback significantly improved the overall users' attitude towards touch as an input method for drawing (see Table 1 and Figure 1)while having no significant effect on performance. The result is opposite for learnability for the mouse. The pen stays an obvious choice for drawing task both from performance and preference point of view. However, we think that more attention should be directed towards user biases favoring touch input over mouse observed in cases lacking of visual feedback. Also, the huge influence of user's familiarity with these input methods is worth of being investigated even more. Potentially, technical properties of the input methods, such as directness, occlusion effect, or latency may also contribute to the observed mismatch between the performance results and subjective evaluations.

Obviously, we have to assume that the results of the experimental study used here are true only for the particular shape investigated. Nevertheless, CA appears to be an available [START_REF] Nenadic | Correspondence Analysis in R, with Two-and Threedimensional Graphics: The ca Package[END_REF] and convenient method that might be appropriate also for exploratory analyses of multi-dimensional data-sets with results from other kinds of studies in-volving mixed data-types, also with much higher sample size -what makes it worth being promoted more widely in HCI community.

Fig. 1 .

 1 Fig.1. Median responses to post-test statements for each input method and visibility of feedback mode (white bars for feedback "off", grey bars for feedback "on"). Whiskers represent the interquartile range.

Fig. 2 .

 2 Fig. 2. Bi-plots from Correlation Analyses with (left) and without users' experience as variable in the dataset (right).

Fig. 3 .

 3 Fig.3. Bi-plot from Correlation Analysis. The datasets with (marked with apostrophes) and without visible drawing feedback (marked with asterisks) were considered separately.

Acknowledgments

I thank Dimitrios Gkouskos and Sarathkumar Neelakannan for their respective input.