Patient handling in health care involves lifting, transferring, repositioning, or mobilizing a patient’s body [1]. These actions—particularly the forward flexion and twisting that often accompany them—place substantial compressive and shear loads on the lumbar and cervical spine [2,3]. Even under ideal conditions, the weight of an adult often exceeds health care professionals’ lifting capacity [2]. Consequently, repeated exposure to high-load and awkward-posture tasks leads to acute sprains and strains of the low back, neck, and shoulders—the most common musculoskeletal injuries linked to patient-handling overexertion [4]. In 2020, the US Bureau of Labor Statistics reported approximately 10,510 workplace injuries in health care due to overexertion and bodily reactions [5]. At the Vancouver Island Health Authority (Island Health) in British Columbia, Canada, from April 1, 2021, to March 31, 2022, patient handling injuries accounted for 25% of all of Island Health’s WorkSafeBC (employer work incident insurance) claims, at a cost of approximately US $3.0 million and a total of 21,286 worker time-loss days. The majority of these claims involved musculoskeletal sprains and strains resulting from unsafe patient-handling maneuvers, confirming that manual handling remains one of the leading injury mechanisms among Island Health’s direct-care workforce.

Community health care workers provide personal care and daily-living support that routinely involves patient handling, often in clients’ homes where access to safety resources and handling tools is limited [6]. They face multiple unmet needs related to safe patient handling, including concerns about the lack of refresher training and a general “get it done” attitude among co-workers that may discourage safe practices [7,8]. This lack of accessible safety resources and support, combined with the challenging environments in which the community health care workers work, further increases their vulnerability to injury. Addressing these gaps is essential to prevent musculoskeletal injuries among community health care workers and to reduce medical costs and the broader burden on health care systems.

A growing body of research shows that interventions can promote safe patient handling and reduce musculoskeletal injuries among health care workers [9], including community health care workers [10]. A systematic review by Wåhlin et al [9] identified 4 categories of successful interventions: the provision and training of assistive equipment (eg, mechanical body lifts), peer coaching programs, physical exercise initiatives, and cultivating a workplace culture with strong management support. Interventions that provide continuous support, rather than one-time training, are more effective [11]. Successful programs not only reduce injuries but also yield cost savings, with studies reporting reduced claims and recurrences after implementation [11-13]. Additionally, emerging technologies, such as real-time audio biofeedback [14] and vibrotactile feedback on patient handling [15], show promise for further enhancing safety practices. However, the practicality and cost-effectiveness of these technologies in real-world health care settings remain uncertain, and their development has not consistently involved feedback from health care workers themselves. Given these proven benefits, despite the constraints of in-person interventions, there is a strong rationale for developing an accessible and effective safe patient handling program tailored to support community health care workers. A digital health intervention, such as a mobile health (mHealth) app, could deliver real-time training, resources, and tools—overcoming logistical barriers and providing continuous support in diverse and often isolated work environments [16,17].

Existing apps such as eUlift [18], Safe Patient Handling [19], and Pain Point [20] illustrate the potential of digital tools, but do not address the realities of community health care workers who provide care in clients’ homes, nor do they align with jurisdiction-specific musculoskeletal injury prevention policies; most also lack user-centered co-design with community health care workers and have not been evaluated in this population [10]. Despite extensive guidance and training programs, few tools are designed for community health care workers operating in clients’ homes, where equipment is limited, workflows are mobile, refresher training is irregular, and peer norms can discourage best practice [7,8]. This creates a practical need for a low-burden, user-centered microcoaching application that provides context-specific guidance and resources within health-system constraints. This study addresses this gap.

Evidence-based interventions have demonstrated their efficacy in promoting safe patient handling [9,13], yet logistical and resource barriers often limit their accessibility, particularly for community health care workers in isolated settings [6]. Island Health, Canada, has established the musculoskeletal injury prevention team to promote safe patient handling practices, but its capacity is constrained by the team’s small size, the large number of care workers, and the geographical spread of service areas. Despite successfully implementing guidelines, tools, and in-person training, these efforts are limited by costs and logistical challenges [21].

This study aimed to (1) provide detailed insights into the unmet needs of Island Health community health care workers with respect to safe patient handling resources and access to information, (2) translate those needs into a user-centered prototype of the Safe Patient Handling Musculoskeletal Injury-Prevention (SPH MSIP) smartphone app through an iterative co-design process, and (3) establish the acceptability and feasibility of the SPH MSIP app to support community health care workers’ safe patient handling practices using a mixed methods design. To our knowledge, this is the first app to offer on-demand safe patient handling tools specifically for community health care workers in their work environments. The study also lays the groundwork for testing the hypothesis that on-demand digital coaching, through videos and support tools, can reduce the frequency and severity of musculoskeletal injuries, as well as related WorkSafeBC claims and costs.

We adopted a pragmatist orientation to prioritize answers that are actionable for decision-making in this health-system context [22]. Accordingly, we used a mixed methods single-group feasibility design with prespecified progression criteria to judge whether a larger trial is warranted, and we paired brief quantitative signals with qualitative explanations to understand why those signals emerged [23,24].

In addition to pragmatism, this research adopted a Patient-Oriented Research approach [24]. Patient-oriented research spans information-sharing, consultation/collaboration, shared decision-making/full partnership, and patient-led models [24,25]. Since it increases relevance and acceptability, it enhances uptake and dissemination [24,26]. Aligned with this approach, we engaged musculoskeletal injury prevention coaches, app developers, health system decision-makers, and community health care workers with lived experience of musculoskeletal (patient-handling) injuries. This multidisciplinary team optimized the design and feasibility of the SPH MSIP app and supported co-design, implementation, and adoption.

The research methods were further guided by the IDEAS framework [27], a user-centered design process for developing and evaluating digital interventions. IDEAS is an acronym for its 4 overarching stages: Integrate, Design, Assess, and Share, encompassing 10 phases: empathize, specify, ground, ideate, prototype, gather, build, pilot, evaluate, and share [27]. This study specifically addressed the first 3 overarching stages of the IDEAS framework, encompassing several of the framework’s phases: Integrate (ie, empathize, specify, and ground), Design (ie, ideate, prototype, gather, and build), and Assess (ie, pilot). It also emphasizes the integration of behavioral theory. The Technology Acceptance Model (TAM; [28-30] was selected to inform the development of research questions and guide data interpretation. The TAM [28] posits that perceived usefulness (belief that a technology enhances performance) and perceived ease of use (belief that it is effortless to use) influence attitudes, behavioral intentions, and adoption [29,30]. These constructs provide a practical framework for designing and evaluating user-centered tools [31], and are particularly relevant for assessing the SPH MSIP app. Widely applied in mHealth and app development [32,33], TAM has proven effective in identifying key factors that drive technology acceptance and sustained use in health care settings.

Consistent with our pragmatist and Patient-Oriented Research approach, and using IDEAS to structure activities, we organized 3 phases: phase 1 needs-finding with end users, phase 2 iterative co-design of the SPH MSIP prototype, and phase 3 a single-group mixed methods feasibility study with predefined progression criteria. Specifically, phase 1 merged theoretical insights with end user input to identify unmet safe-patient-handling needs among Island Health community health care workers (objective 1). Phase 2 used iterative co-design with the patient-oriented research team and the app developer to transform those needs into a functional SPH MSIP prototype (objective 2). Phase 3 assessed the prototype’s feasibility and acceptability (objective 3) in a single-group mixed methods study [34], combining postintervention questionnaires with qualitative interviews and survey items to contextualize the numbers. While quantitative methods were the primary focus, qualitative data enriched the understanding of participants’ experiences. To evaluate feasibility, the study established predefined success criteria, including an enrollment rate of ≥50% and a retention rate of ≥75%. Acceptability was measured using a participant satisfaction threshold of a mean score ≥4 points on a 7-point Likert scale.

Ethical approval was obtained from the University of Victoria Human Research Ethics Board and harmonized ethics approval by Research Ethics BC (REBC#: H23-00322). All participants were adults and provided written, electronic informed consent before any procedures; participation was voluntary, and participants could withdraw at any time or skip any question without penalty. All questionnaire and interview responses were collected in a secure web-based survey platform and Zoom (Zoom Communications), respectively, immediately exported, and stored on a password-protected server in the Behavioural Medicine Laboratory at the University of Victoria. A unique study ID (not names or e-mail addresses) was assigned at first contact; the reidentification key is kept in a separate, encrypted file accessible only to the principal investigator and project coordinator. Audio files were deleted after verbatim transcription. Deidentified analytic files will be retained for 5 years, after which they will be permanently erased from the secure server. The use of the SPH MSIP app during client care was not required; participants were directed to follow employer phone-use and privacy policies and to access content outside client interactions where possible. The app contains training content only and does not collect audio, images, GPS, or client-identifying information. The app was installed on employer-issued work phones.

In phase 2, a series of 4 meetings was conducted, during which the patient-oriented research team collaborated with Pathverse to coideate and codevelop the SPH MSIP app prototype. The team reviewed the selected safe patient handling tools in detail with the app developer, allowing for targeted discussions about integrating these tools into the app and addressing technical considerations. Feedback from this session guided initial design choices. Then, Pathverse incorporated patient-oriented research team feedback into the evolving prototype, presenting updated versions for further review and input. Using TAM [28,30] as a guiding framework, these successive cycles emphasized the enhancement of perceived usefulness and ease of use, while iterative design revisions focused on ensuring the app’s compatibility with users’ work environments. The collaborative approach prioritized the alignment of app features with user needs, fostering positive attitudes toward adoption and usage intentions. By the final meeting, the prototype had been refined and finalized, fully integrating the patient-oriented research team’s insights and meeting the established goals for functionality and user experience. This collaborative approach ensured the app was optimized effectively, resulting in a practical, user-centered tool for safe patient handling support.

Based on phase 1 meetings, we identified key unmet needs among community health care workers related to safe patient handling and injury prevention, as well as specific feedback on safe patient handling tools that could enhance the SPH MSIP APP under development. Several major concerns and needs were expressed (Textbox 1 for details), including the high risk of injury due to client care tasks, frequent work in isolation at client homes, and a tendency to prioritize client needs over personal safety. Furthermore, gaps in safe patient handling knowledge and practices were noted, such as limited access to training on point-of-care risk assessment and challenges in obtaining refresher training on safe handling practices. Additionally, a “get it done” culture in the workplace, alongside inconsistent proficiency among leaders in safe handling techniques, emerged as a significant issue affecting community health care workers’ safety and effectiveness. Notably, participants also highlighted specific high-risk patient handling activities that require additional support and clear guidance, including boosting clients in bed, assisting clients with compression stockings, providing care in low or bariatric beds, and assisting clients with walking in confined spaces. Essential equipment used in these tasks, such as slings, transfer belts, and slider sheets, requires proper usage training, and community health care workers expressed a need for accessible, step-by-step instructions. In addition, it was made clear by participants that the app needed to address practical questions that community health care workers often face, such as “How do I best use my body in this situation?” and “What is the best practice for this specific patient care task?” Overall, community health care workers emphasized that the app should provide easily accessible, concise, and practical information that could be accessed without disrupting client interactions.

Building on the unmet needs identified in phase 1, phase 2 focused on designing a user-centered SPH MSIP APP tailored to community health care workers’ challenges in safe patient handling practices (Table 2). Collaborating with Pathverse, the app addressed critical gaps in safe patient handling knowledge, training accessibility, and the unique challenges of working in isolated client homes. The app provided clear, practical guidelines for high-risk tasks such as boosting clients in bed, assisting with compression stockings, and managing bariatric or low beds, as well as proper use of commonly used equipment like slings, transfer belts, and slider sheets. Tools such as point-of-care risk assessment and pre-standing safety check guides were also included to support safety and decision-making. The SPH MSIP APP improved training accessibility with mobile-friendly resources and concise, scenario-specific instructional videos. A tailored algorithm streamlined access to relevant materials, minimizing disruptions during client care. Although some tools and equipment (eg, Sara Stedy, Etac Turner) fell outside the project’s scope, most high-priority resources were successfully integrated, offering a reliable and practical resource to enhance community health care workers’ safe patient handling practices. Educational content (training videos, PDF, and equipment checklists) was adapted directly from Island Health’s Occupational Health and Safety safe-patient-handling resources. All materials were produced or reviewed by MSIP coaches, occupational health and safety specialists, and professionals to ensure they reflected standard device use and current workplace guidelines before being embedded in the app [41,42]. Screenshots of the SPH MSIP APP can be found in Figure 1.

The theme of adoption examined the extent to which participants used the app, their intent to continue using it, and their preparedness and confidence.

This 3-phase formative study showed that a co-designed SPH MSIP smartphone app is both feasible and acceptable for community health care workers. We achieved high recruitment (28/32, 88%), excellent retention (26/28, 93%), and strong user satisfaction/usability (mean 5.96/7), while qualitative feedback highlighted the app’s practicality, clarity, and seamless fit within everyday workflows. This study represents one of the few comprehensive efforts to develop and evaluate an app tailored specifically to the needs of community health care workers.

A key strength of this study is its rigorous, end-to-end co-design process: a multidisciplinary, patient-oriented research team of coaches, frontline workers, developers, and decision-makers guided every phase, ensuring the app matches the realities of community care settings. This collaborative approach translated into exceptional engagement and retention, and every prespecified usability and satisfaction criterion was surpassed. Moreover, the study delivers one of the first comprehensive evaluations of a safe-patient-handling m-health tool purpose-built for community health care workers, addressing a critical gap in the digital-safety literature.

This study also had several limitations that need to be acknowledged and addressed in future research. First, the small, self-selected sample may have introduced selection bias, as those who volunteered may have been more technologically adept or motivated than the broader community health care workers population. To address this, future effectiveness studies should use more inclusive recruitment strategies, potentially incorporating random sampling methods to capture a more representative demographic, and include a control or comparison group (eg, randomized or quasi-experimental design) to enable stronger causal inference [65]. Second, the absence of blinded participatory meetings in phase 1 may have influenced the data collection process, as researchers’ relationships with participants could have biased responses. Future studies should consider using independent facilitators for initial data collection phases to minimize potential biases and ensure the reliability of findings [66]. Furthermore, this feasibility trial did not assess the efficacy of the SPH MSIP app in reducing musculoskeletal injuries. A fully powered, longer-term randomized controlled trial is the logical next step to evaluate whether the app can lower musculoskeletal injury rates, lost-time claims, and related disability while enhancing patient-care outcomes. Future research should also focus on addressing the systemic barriers identified in this study, such as the lack of accessible, safe patient handling training and workplace cultural challenges, to ensure broader applicability and scalability of the intervention. By building on these findings and incorporating lessons learned, we can move closer to developing scalable, sustainable solutions that enhance safety and well-being for community health care workers in diverse settings. Additionally, this feasibility study used brief, adapted TAM items rather than a fully validated instrument tailored to community health care workers. This is not ideal for cross-study comparability, but it was a reasonable, low-burden choice for an early pilot focused on decision signals. Qualitative coding was conducted in Microsoft Excel. While acceptable for small feasibility datasets, Excel lacks features that enhance transparency and credibility. Future studies should consider using validated acceptance measures appropriate to this population, evaluate measurement properties in the target sample, and adopt dedicated qualitative software (eg, NVivo [Lumivero]) with a documented audit trail, multi-coder procedures with agreement checks, and reflexive memoing. Finally, the challenges associated with deploying the app on community health care workers’ devices underscore the need for organizational support and streamlined IT processes. Collaborating with health authorities to address systemic barriers to technology adoption will be essential for scaling the intervention [67]. Future iterations of the app could also incorporate advanced features, such as personalized feedback, gamification elements, and real-time analytics, to enhance user engagement and effectiveness over time.

To conclude, this single-group feasibility study provides preliminary signals of feasibility and acceptability for the SPH MSIP APP to address unmet safe patient-handling needs among community health care workers. The app was well-received, with high levels of satisfaction and usability reported by participants, suggesting its potential as a practical tool for improving safe patient handling practices. While these findings are promising, they should be interpreted with caution, given the small, self-selected sample and the absence of a control or comparison group; TAM outcomes were used as low-burden, descriptive indicators rather than validated, mechanism-testing measures. Future effectiveness studies should recruit more broadly, use validated acceptance instruments and dedicated qualitative software, and use controlled or randomized designs with longer follow-up to evaluate effects on musculoskeletal injury rates, disability-related absences, and other implementation outcomes.