The validation and assessment of a curriculum based GAIT App used in teaching bachelor of physiotherapy students: a cross sectional study

Introduction There has been an advent in the use of Mobile Apps in the academic space. The pandemic hastened their usage, and forced us to rapidly innovate in order to meet the educational needs of our students. Also, Mobile Apps have been known to facilitate self-learning, make it enjoyable, and personalize the pace of learning of the individual. Given the level of skill-learning in Physiotherapy education, the use of Mobile Apps can pose a challenge, as well as offer an opportunity to explore its scope to enhance learning, and create innovative pedagogic strategies. There are a very few learning mobile apps that have been assessed in Physiotherapy education. Aim To develop, establish content validity and internal consistency of a curriculum based App on the kinesiology of normal Gait for bachelor of physiotherapy students, and to evaluate the App with regards to use, quality, engagement, and overall experience. Materials & methods In the first phase, a mobile app based on a bachelor of physiotherapy Gait curriculum was developed and validated using Delphi procedure, with 80% agreement criteria, by a group of experts. Subse-quently, the App was rated by 200 users on: engagement, aesthetics, information, subjective quality. Results The content validity index following 2 rounds of Delphi was found to be 0.88. Also, therapists found the App easy to use, and 80% gave it a rating of > 3 stars. Conclusion Creating, designing, implementing, and evaluating the efficacy of a Gait App as a means to teaching the GAIT component to physiotherapy students was found to be appealing and beneficial.


Introduction
Learning is described as an observable change in a student that leads to a quantifiable and measurable influence on student achievement.Educators have suggested novel techniques for establishing innovative teaching environments that promote efficient and effective student-centric learning [1].Communication technology, such as a mobile application (M App) is one such tool that has grabbed the attention of academicians, as well as students around the globe.Importantly, it has helped develop innovative learning strategies, by providing additional possibilities and experiences beyond the classroom [1].Furthermore, its use helps break down traditional classroom barriers, and hence can effectively boost student engagement in today's ever-evolving academic environment [2].
Mobile App learning provides an alternative teaching strategy that is appreciated by the current generation of college students, as it informally encourages self-learning at a customized pace that suits their busy lifestyle [3][4][5].In other words, the App allows for self-paced learning beyond the time-space constraints of a classroom and/ or Institution [6,7].However, it is imperative to understand this methodology and the extent and scope of its integration within the curriculum to achieve optimal results [2,8,9].
Physiotherapy is a profession that promotes function and enhances patients' quality of life by treating a wide range of diseases, impairments, and disabilities with movement-based solutions.To develop clinical expertise in physiotherapy that will help patients, or at the very least not hurt them, a wide range of theoretical and practical information must be understood and applied.This demands a great deal of practice.Therefore, exposure to knowledge beyond a formal didactic approach in a classroom setting, in clinics when examining patients, etc., would be extremely beneficial for physiotherapists in training.Because of this, it is essential that physiotherapy education go well beyond conventional teaching methods and incorporate substantial independent study as well as unrestricted practice in a structured environment.Mobile applications make it simple to do this kind of learning.They not only provide instant access to information but also encourage students to pay attention by engrossing them with text and images [10].Numerous mobile applications with a range of findings have been developed and assessed for use in educational settings.On the other hand, there is a dearth of research on their legitimacy, the precision with which the content is delivered, and how well they work to encourage learning clinical content [11,12].

Aim
The aim of this study was to develop an educational smartphone application that contain a valid curriculum module on the kinesiology of normal gait appropriate for students studying in Bachelor of Physiotherapy (BPT) program.

To develop physiotherapy educational mobile App on
GAIT, in accordance with Bachelor of Physiotherapy curriculum.2. To develop the content on Kinesiology of Normal Gait. 3. To establish the content validity of GAIT App. 4. To evaluate the developed App using the Mobile App Rating Scale.

Methodology
Following the Institutional Ethical clearance (EC/2015-16/003) the study was conducted from August 2018 to June 2021 in two (2) phases:

Phase I Preparation of content for Mobile App on GAIT
An extensive literature search was conducted to collect content on kinesiology of Gait to develop a mobile application.Content from multiple sources related to the Kinesiology of Normal Gait appropriate for students studying Bachelor of Physiotherapy (BPT) program was collected and content validity was established.

Study design to establish content validity
Content validity is the match between the content items and the subject matter.The content was evaluated by a panel of experts and validity was established using a Delphi method with an 80% agreement threshold [13,14].

Sample: content experts
Eleven experts who taught the Gait component to BPT students were recruited as volunteers.Faculty of different institutions from around the country as per the inclusion criteria were contacted and explained the proposal.The ones who agreed and met the inclusion criteria were recruited as experts for the study.

Inclusion criteria
1. Teaching faculty with a minimum of five (5) years teaching undergraduate BPT students.2. Experts from all across India teaching the same Gait curriculum to BPT students.3. Willing to participate in the study.

Procedure
The content was prepared and given to the panel of experts to test for its quality and validity on the parameters of clarity and essentiality through the Delphi procedure.Consent to participate in the study from each panel expert was taken prior to the start of the study.In a Delphi survey, several evaluative rounds need to be completed to achieve a consensus among panelists, who were selected based on expertise in the relevant field.The content items to be included in the App were mailed to all the experts in the form of a 'Google form' , and each panelist was asked to rate each item on two parameters, namely essentiality, and clarity.
Responses from all the panelists were then pooled and the number indicating "essential" and "clarity" for each item was determined, following which, the content validity ratio (CVR) was computed for each item.
Panelists were also asked to suggest additional items, if not included in the proposed content.
The suggestions that were considered valid were then selected for further analysis.After the first round, the comments made by the panelists and the additional content they suggested were evaluated and the content if needed were modified for inclusion in the App.In addition, items that did not meet the 80% agreement were modified for content and clarity, and re-sent to the panelists for a second round until 80% agreement was achieved for clarity and essentiality.Following 80% agreement, a Content validity index (CVI) was calculated [15].In addition, Cronbach's alpha was calculated to establish internal consistency or reliability of the content.
In this manner, the content validity of the content items included in the GAIT App was established and finalized.The validated content was then built into an android based App with the following architecture: Chapters as mentioned below were included.

Phase II
Evaluation of the App using the Mobile App Rating Scale.
The content thus established, was introduced into an android mobile application with the help of an app developer.Java was the programming language used to prepare the android app.

Study design
A descriptive survey design was used to rate the App, using a Mobile App Rating Scale [16].With outstanding internal consistency (alpha = 0.90) and interrater dependability intraclass correlation coefficient (ICC = 0.79), the MARS is an easy, impartial, and trustworthy method for categorising and evaluating the quality of mobile health apps.The 23-item MARS is a refined version of five main areas of criteria, each including four objective quality scales (engagement, functionality, aesthetics, and information quality) and one subjective quality scale.

Sample size
Slovin's Formula [17] was used to calculate the sample size.If we don't have the idea of population, we use this formula to calculate the sample size.The Slovin's formula is as follows: Where: We have used 95 percent confidence level (alpha level of 0.05) with a population size of 350 (7 Delhi Institutes with 50 students each).
Adjusting and adding for an attrition of 10%, n = 203 Consent was taken from Institutional heads/ faculty members of the physiotherapy colleges, who helped in reaching out their undergraduate and post graduate students.The students and faculties were explained the proposal and those who agreed were recruited as users of the App.Two hundred and three (203) volunteered as app users for rating the app.

Procedure
The volunteers to rate the app was selected as per the inclusion criteria and was oriented to the mobile app after taking their consent to participate in the study.The link of the app was shared with them free of cost along with the Mobile App Rating Scale after receiving their consent to participate in the study.The responses were recorded and analysed in MS excel.A total of 203 responses were recorded.

Content validation
The content thus developed underwent two rounds of the Delphi process in order for it to achieve 80% agreement.In addition, the content validity index (CVI) was calculated using the following formula in SPSS.CVI = Sum of CVR/No. of questions.CVR = (ne-N/2)/N/2.ne-Experts in agreement.
N-Total Experts.
The draft content was sent to the panel of 11 experts across the country belonging to both government and private institutions/universities in the Google form.The items were reviewed and scored for essentiality and clarity.The responses from the experts helped in rewording, rephrasing, and improvising the content.The CVI calculated on the parameter of essentiality was found to be 0.88.On the parameter of clarity five (5) topics out of total of 52 did not meet the 80% agreement criteria and hence all these topics were modified as per suggestions given by panel of experts.The modified content was sent for round 2 for meeting 80% Delphi agreement.In Round 2 an 80% threshold consensus was achieved, and hence the items accepted to be included in the final App on Gait.

Rating the App
The mobile app named GAIT was then rated by sample of 203 physiotherapy students and faculty.There were 65% fourth year undergraduate students, 28% postgraduate students, and 6% academicians.There were 154 females and 49 males.Of the 12 academicians, three (3) belonged to Sports Specialty, sic (6) orthopedics and three (3) Neurology (Fig. 1).
The App was rated on Engagement, Functionality, Aesthetics &Information, and Subjective Quality, using Mobile App Rating Scale.76% of the respondents found it to be entertaining, encouraging its repetitive usage (Fig. 2), 86% of the respondents found it interesting (Fig. 3), 63% agreed that the app had all the necessary settings required to run the app (Fig. 4), 62% found it to be interactive (Fig. 5) and 82% (52% + 30%) felt that the app content is appropriate for the target Undergraduate Physiotherapy Students (Fig. 6).b.Functionality: This parameter measures the app functioning, ease to navigate and the overall flow of the app.It has four sub dimensions Performance, Ease of Use, Navigation and Gestural design.
30% of the users agree that the app is perfect with no technical bugs (Fig. 7), 43%) of the users found the app to be used immediately (Fig. 8), 43% of the users say that the app is perfectly logical, easy and clear (Fig. 9) and Fig. 2 Percentage distribution of respondents on the Criteria of "Entertainment" under the section "Engagement".(Source: Graphical representation of the data collected) Fig. 3 Percentage distribution of respondents on the Criteria of "Interest" under the section "Engagement".(Source: Graphical representation of the data collected) 37% users rate the app as perfectly consistent and intuitive (Fig. 10).c.Aesthetics: This parameter which measures the stylistic consistency has three dimensions, Layout, Graphics and Visual Appeal.
32%) of the users rate the app as professional and simple (Fig. 11), 47% found it to be of high quality and stylistically consistent (Fig. 12) and 48% found it to be very visually appealing (Fig. 13).

d. Information: It measures the app on seven sub
dimensions, Accuracy, Goals, Quality and Quantity 35% users rated the app to have highly accurate description (Fig. 14), 75% of the users feel that the app has clearly specified measurable and highly achievable goals (Fig. 15), 30% of the users have rated the app as highly relevant (Fig. 16), 45%) of the users find it to be comprehensive (Fig. 17), 37% users rate it as perfectly logical/clear (Fig. 18), 96% users who agree to know the Fig. 6 Percentage distribution of respondents on the Criteria of "Target Group" under the section "Engagement".(Source: Graphical representation of the data collected) Fig. 7 Percentage distribution of respondents on the Criteria of "Performance" under the section "Functionality".(Source: Graphical representation of the data collected) source (Fig. 19) and 22% users feel the outcome to have been tested in more than 3 RCTs (Fig. 20).
e. Subjective Quality: It rates app on four dimensions, Recommendation, Frequency of App Usage, Payment for the app and Overall rating of the app.
99% users who would recommend this app to people who might benefit from it (Fig. 21), 11% users would use this app for more than 50 times in a year, 41% 10-50 times (Fig. 22), 12% users would like to pay for this app, 46% may pay (Fig. 23) and 33% of the respondents gave it a 5-star rating (Fig. 24).

Reliability of App
Item-Reliability of the Mobile Rating App in evaluating the content of the App: This is the consistency or reliability of the items of mobile rating App in Fig. 8 Percentage distribution of respondents on the Criteria of "Ease of Use" under the section "Functionality".(Source: Graphical representation of the data collected) Fig. 9 Percentage distribution of respondents on the Criteria of "Navigation" under the section "Functionality".(Source: Graphical representation of the data collected) evaluating the content of the GAIT App (Figs. 25,26,27,28) along the following sub-dimensions: Engagement, Functionality, and Aesthetics, Information, and App subjective quality.The reliability of the app was then calculated statistically using the cronbach's alpha.
It was calculated using SPSS version 26 and for each section of the Mobile App Rating Scale.The overall reliability of the was calculated and found to be 0.944 proving it to be excellent on reliability.

Discussion
Academic institutions need to be redesigned for the twenty-first century to accommodate changes in the rapidly evolving nature of the modern educational landscape.These changes include the sharply rising competition, the rising demand for higher education, the changing nature and type of information, the rapid advancements in information and communication technologies, and the sophistication and speed of change of these technologies (ICTs).Changes brought about by the diverse learning styles, goals, and demographics of the upcoming generation of students are also significant.
Interest in using mobile technology for training and education is growing as it becomes more accessible.Even though there is a lot of anticipation about using mobile learning, it is still quite new.This is particularly true in developing nations.Mobile learning along with related educational software programs due to their ease of use, portability and powerful computing power [18,19] offer robust creative solutions, and opportunities to address a number of the contemporary challenges experienced by learners in the current environment [20].Also, with the availability of a number of less expensive mobile devices, such as smart phones, tablets and iPads, the use of these simple-to-use Fig. 10 Percentage distribution on the Criteria of "Gestural Design" under the section "Functionality".(Source: Graphical representation of the data Fig. 11 Percentage of respondents on the Criteria of under section "Aesthetics".(Source: Graphical representation of the data collected) mobile software applications, commonly referred to as APPs, have rapidly gained in popularity.This necessitates that learning materials be created that are mobile compatible, and which can be delivered using a range of technologies.Both educators, as well as learners are increasingly finding that the use of such technology is making teaching and learning easier and more fun for the millennial student [20][21][22].But, teachers will be required to receive training on how to design, incorporate, and deliver mobile learning.
However, there is a paucity of content specific Apps in education, particularly in the field of Physiotherapy, necessitating the creation and development of subject specific applications for teaching and learning.The use of the app for mobile devices in medical education is more recent.The first app described in the literature for this purpose was developed and validated by the University of Colorado.The Radiology Resident iPad Toolbox was validated as an educational, economic and mobile instrument, which increases the efficiency of study [23].In relation to the study of the electrocardiogram, the first app for mobile devices for this purpose was described by Tofield [24], although without a description of the validation of this tool for teaching.The app developed on GAIT is one of its kind which is mainly for teaching and learning and is prepared in accordance with the curricular requirements.
The purpose of this research was twofold: (1) to develop a valid mobile App that covered the study of gait, an important learning module for physiotherapists; and (2) evaluate the app by potential users.Overall, it was observed that physiotherapy students/interns, postgraduate physiotherapy students, practicing physiotherapists and faculty expressed a high level of satisfaction with the Gait mobile app, with a majority of the users giving it a four star rating or more.Furthermore, users were more than willing to use the mobile app on Gait in class on a regular basis and expressed their willingness to purchase it.They found the App engaging as it contained good interactive interfaces with features that could be customized keeping in mind the user's requirements.Learners could adjust the font and image size for better visualization, found the content logical, appropriate, and the uninterrupted movement between the 20 Percentage distribution of respondents on the Criteria of "Evidence Based" under the section "Information".(Source: Graphical representation of the data collected) Fig. 21 Percentage distribution of respondents on the Criteria of "Recommendation" under the section "Subjective Quality".(Source: Graphical representation of the data collected) relevant screens made it easy to use and enriched their experience.More than two thirds of the users found that the application contained quality content on Gait, which was necessary, comprehensive, and concise for students at an undergraduate level.Users also appreciated the use and integration of appropriate, content specific videos to facilitate and enrich textual content.
These findings, similar to Robinson et al. [25], indicate that students of the millennial generation and beyond appreciate well designed mobile Apps are very comfortable receiving information and learning using smart phones and tablets.In addition, it is observed that they become very confident in its optimum utilization very rapidly with little or no training.
Furthermore, good visual appeal and high-quality resolution makes the App more acceptable and appealing.

Limitations
Mobile App developed could only be used by android users.

Future scope
Future studies are necessary to evaluate the learning and the retention of the knowledge with this app.
Creation and evaluation of more such curriculumbased tools in education, covering both practical and theoretical aspects of a subject.

Conclusion
The present study has developed and validated an android based mobile application, GAIT which is based on BPT curriculum.This may prove useful in delivering the content online and may set a bench mark for today's generation learning.
Especially for work-based learners or the learning scenarios like in recent covid situation, mobile learning (m Learning) has a lot of potential.These advantages include the ability to participate in professional growth during "stolen moments" whenever and wherever and anywhere; combining access to research material, assessment and evaluation, and continuing education; and providing 24-h "just in time" support for basic needs -all through the learners' acquainted ease of their own with decreased load of attendance.

Inclusion criteria 1 .
Teaching faculty with a minimum of five (5) years of experience.2. MPT Physiotherapy students.3. Final year BPT students and Interns.4. Should have access to an android smart phone.

Fig. 1
Fig. 1 Percentage distribution of the Panel of 203 experts who rated the Gait app.(Source: Graphical representation of the data collected)

Fig. 4 Fig. 5
Fig.4 Percentage distribution of respondents on the Criteria of "Customization" under the section "Engagement".(Source: Graphical representation of the data collected)

Fig. 12 Fig. 13
Fig.12 Percentage distribution of on the Criteria of "Graphics" under the section (Source: Graphical representation of the data

Fig. 14 Fig. 15 Fig. 16 Fig. 17
Fig.14 Percentage distribution of respondents on the Criteria of "Accuracy" under the section "Information".(Source: Graphical representation of the data collected)

Fig. 18 Fig. 19
Fig.18 Percentage distribution of respondents on the Criteria of "Visual Information" the section "Information".(Source: Graphical representation the data collected)

Fig. 22 Fig. 23 Fig. 25
Fig.22 Percentage distribution of respondents on the Criteria of "Usage" under the section "Subjective Quality".(Source: Graphical representation of the data collected)

Fig. 26
Fig. 26 Interface of the GAIT app