Design and implementation of a pediatric failure to thrive registry system in Iran

Abstract

BACKGROUND:

Failure to thrive (FTT) refers to inadequate growth caused by an inability to acquire or use enough calories for growth. It refers to a failure to develop over time, which can lead to more serious problems in adulthood if left untreated. FTT is a significant global health concern, particularly in developing countries like Iran. Effective FTT management necessitates timely, inclusive, and precise data on children’s FTT status. A pediatric FTT registry system is a useful tool for gathering and managing data on children with FTT. This study proposes a pediatric FTT registry system for Iran.

MATERIALS AND METHODS:

A developmental-applied study was conducted in three phases during 2024. The first phase involved defining the features of a pediatric FTT registry system through interviews with experts. The second phase entailed expert validation using the Delphi method. In the third phase, the software was designed based on a conceptual model using the Hypertext Preprocessor programming language and the Laravel framework. PostgreSQL was employed as the database management system. Moreover, Nielsen’s Ten Usability Heuristics was used to evaluate the software’s usability from the users’ perspectives.

RESULTS:

Experts validated the features of the pediatric FTT registry system, resulting in a framework that included eight headings, 24 sub-headings, and 117 data elements. The usability assessment of the software revealed that the highest number of issues concerned the “error prevention” indicator, whereas the “aesthetic and minimalist design” indicator presented the fewest problems and was assumed flawless.

CONCLUSION:

A pediatric FFT registry system contributes significantly to service planning, management, disease surveillance, and research. Accordingly, future research is recommended to investigate the feasibility of implementing the pediatric FFT registry system in Iran.

Introduction

Failure to thrive (FFT) is defined as inadequate growth or the inability to maintain normal growth, usually during early childhood.[1] Failure to gain height and weight during infancy is a sign of slowed growth. Malnutrition is thought to be the direct or indirect cause of approximately 60% of deaths among children under the age of five.[2] Mothers of short stature, particularly adolescents, are more likely to give birth to infants with low birth weight, which may increase their risk of FTT during childhood.[3,4]

FTT represents a decrease or cessation of physical growth indicated by height and weight measurements below the 3^rd or 5^th percentile or by a downward shift in growth across two major growth percentiles. This condition is associated with abnormal growth and development.[5]

Many studies have used impaired weight gain as an indicator of FTT. Neglecting FTT can lead to serious complications in children, such as an increased risk of certain chronic diseases and mortality, reduced learning, and impairments in cognitive, emotional, and physical abilities.[6]

There is a consensus that severe and prolonged malnutrition, prevalent in developing countries, can negatively impact a child’s cognitive development later in life. Children with FTT at the age of eight have been found to attain lower cognitive scores and poorer overall academic performance compared to prematurely born peers without FTT. According to a research study, early interventions (up to the age of eight) to address FTT can lead to little difference in adulthood—in terms of IQ and reading skills—between those who suffered from FTT in childhood and those who had appropriate growth. However, a history of FTT has been associated with stunting, poor math performance, and suboptimal work habits.[1]

Third-world countries exhibit a higher FTT prevalence compared to the global average. In the majority of these countries, the physical growth of infants and children often lags behind international norms.[7] A 2022 study in Iran reported a 19% prevalence of underweight and a 20% prevalence of stunting among children aged 6–14.[8]

The Iranian Ministry of Health and Medical Education has recommended implementing control programs based on scientific evidence to prevent a waste of financial and human resources and to ensure access to high-quality, reliable, accurate, and timely data. One such initiative is developing disease registries. Systematic data collection facilitates the evaluation of specific outcomes, health-related characteristics, and outcomes using epidemiological criteria.[9]

Registry systems serve as critical support information systems that help organize patient data, streamline service delivery, and track patient health outcomes. A registry system collects digitized patient data sets and charts patient attributes over time, whereby patients with specific conditions can be identified.[10]

Bull et al. developed an FTT registry system in a clinic where information such as patient name, age, medical record number, mother tongue, the dates of the last three visits regardless of visit type, follow-up interval recommended by the primary care provider, and FTT care coordination notes were recorded.[11]

Considering the current circumstances, there is a need to establish a pediatric FTT registry system to enhance and improve the management of therapeutic and healthcare services in this area. This study sought to establish a pediatric FTT registry system in Iran to inform the development of preventive strategies, enhance care quality, contribute to management, and facilitate early interventions, ultimately aiming to reduce more serious health consequences in adulthood among children with FTT. Furthermore, an electronic system for recording and storing data facilitates long-term access to valuable research data for researchers.

The novelty of the present study is its pioneering effort to establish and implement a pediatric FTT registry system for the first time in Iran—a developing nation with a high burden of FTT-related diseases like stunting and underweight among children. In contrast to other currently available FTT registry systems based mainly on minor clinical information, in this study, an all-encompassing and context-sensitive framework is intended to be constructed through the adoption of a multi-stage developmental-applied approach, such as expert interviews and the Delphi method for feature validation. Utilizing modern technologies such as Hypertext Preprocessor (PHP) programming language, Laravel framework, and PostgreSQL database, the system has been developed to provide secure, scalable data management. The application of Nielsen’s Ten Usability Heuristics in advancing user-centered design makes the registry even more unique, filling a critical gap for systematic health-data collection technology for FTT in Iran.

Secondly, the innovativeness of the study also resides in the ability to revolutionize evidence-based policy-making and the provision of health care in a country where FTT constitutes a public health concern. By developing a registry system that gathers accessible, valid, and up-to-date data, the research aims to improve early diagnosis, prevention, and treatment of FTT, crucial considering its long-term implications, like cognitive delay and risk of chronic disease. In being designed to enable not just clinical management but also disease surveillance, service planning, and research, the system offers a model that can be modified for other low- and middle-income countries. By establishing Iran’s distinctive health-care requirements and laying the groundwork for future implementation, this research marks a valuable milestone in the field of health informatics for closing an urgent nutritional health gap.

Materials and Methods

Study design and setting

Developmental and applied in nature, this research was conducted in three phases. The first phase involved identifying qualitatively the features of the pediatric FTT registry system through interviews. In the second phase, the features of the registry system were validated quantitatively using the Delphi method. Lastly, the third phase entailed designing and evaluating a prototype of the pediatric FTT registry system in Iran.

Study participants and sampling

Purposive sampling was employed to recruit participants for interviews. Inclusion criteria were faculty membership at Tehran University of Medical Sciences (TUMS), Iran University of Medical Sciences (IUMS), or Shahid Beheshti University of Medical Sciences (SBUMS); a specialty degree in pediatrics or nutrition; and a minimum of three years of professional experience. Eleven individuals met these criteria.

In the validation phase of the registry system’s features, 28 general practitioners from healthcare centers, pediatricians, and nutritionists were selected purposively based on the following criteria:

• Holding a specialized doctorate in pediatrics or nutrition and being a faculty member of TUMS, IUMS, or SBUMS for pediatricians and nutritionists

• Having a minimum working experience of three years and holding a master’s degree or higher in nutrition for the Nutrition Improvement Office staff

• Holding a degree in general medicine and at least three years of work experience.

Sampling in the prototype evaluation phase was purposive and non-random, based on specific criteria. Participants were required to have at least three years of experience as faculty members at TUMS, IUMS, or SBUMS; hold a doctoral degree in pediatrics or nutrition; and have at least three years of work experience in the Nutritional Improvement Office. Additionally, participants needed to have sufficient experience in human–computer interaction. Ten individuals were selected based on these criteria.

Data collection tool and technique

An interview guide with open questions, developed based on a literature review, served as the data collection tool in the first phase. The guide comprised eight themes (objectives, structure, data sources, data sets, classification systems, data processing and reporting, distribution and access, and data quality) and 25 questions related to the themes. The content validity of the interview guide was verified through in-depth interviews with one nutritionist and one pediatrician.

In the validation phase, a questionnaire was used as the data collection instrument to validate the identified features using the Delphi method. Once the interviews were completed, the features of the pediatric FTT registry software were categorized, and a framework was designed using the MAXQDA software based on the interviewees’ responses. The questionnaire used in the first round of the Delphi method included components centered around the core axes, i.e. objectives, structure, data sources, data sets, classification system, data processing and reporting, information distribution and access, and data quality. Respondents were asked to rate the importance of each component on a five-point Likert scale ranging from “very high importance” to “very low importance.” The questionnaire’s content validity was verified through a review by five experts in nutrition and pediatrics.

The data collection tool used in the problem identification phase was Nielsen’s Ten Usability Heuristics,[12] which was translated and validated in terms of face and content validity in earlier studies.[13] The reliability of this checklist was reassessed in the current study using Cronbach’s alpha (α = 0.89). This checklist comprises ten principles, including visibility of system status, match between system and the real world, user control and freedom, consistency and standards, helping users recognize, diagnose, and recover from errors, error prevention, recognition over recall, flexibility and efficiency, aesthetic and minimalist design, and help and documentation. The problems identified by each independent evaluator were discussed in a joint meeting. After the common issues were identified, the final list of problems was presented to each of the evaluators, and the severity of each problem was determined. The results were input into the Excel software to calculate the mean severity score.

Ethical consideration

This research was carried out under strict ethical standards to safeguard the health of participants and the credibility of the research process. The protocol for research was examined and approved by the Iran University of Medical Sciences Institutional Review Board, with ethical approval code IR.IUMS.REC.1401.463. Each stage of the research, from the expert interviews to software development, was structured to meet national and international ethical guidelines, as identified in the Declaration of Helsinki.

Informed consent was gathered from all interviewees and validators involved in the interviewing and validation procedures, and they were duly made aware of the purpose, procedures, and possible consequences of the study. The subjects were assured their right to withdraw at any time without penalty. Privacy was ensured through anonymizing all the data collected and storing them in compliance with the data protection law. There was no personal or sensitive information revealed in creating or testing the pediatric FTT registry system. Furthermore, the research team made sure that the design of the system gave user privacy and data security top priority, including ways to avoid unauthorized access or data leaks.

Statistical analysis method

Data were analyzed based on descriptive statistical indices to assess the validity of the final features of the pediatric FTT registry system until a consensus was reached. After the questionnaires from the first round of the Delphi study were collected, the median, mean, interquartile range, and agreement percentage were computed for each component. The acceptance threshold for features as final elements in the FTT registry system was an agreement of 75% or higher regarding “very high importance = 5” and “high importance = 4” options. Items with an agreement level of <50% were excluded. Moreover, in cases where agreement was between 50% and 75%, the items were re-surveyed in the subsequent round of the Delphi study. The Delphi technique was employed until a consensus was reached regarding the features and research axes.

Once a conceptual model for the Iranian pediatric FTT registry software was designed, a web-based prototype was developed using the PHP programming language with the Laravel framework and PostgreSQL as the database management system. PHP, Laravel, and PostgreSQL are a combination that provides a stable, scalable, and secure web-based application appropriate for the Iranian pediatric FTT registry requirements.

Results

Eleven experts were interviewed to identify the system’s features. Their demographic profiles are summarized in Table 1.

Table 1.

Frequency distribution of interviewees’ demographic characteristics

Demographic Characteristics		Specialty																						Number
		Pediatrician						Nutritionist						General Practitioner
		P1		P2		P3		P4		P5		P6		P7		P8		P9		P10		P11
Age
20–29										*		*										*		3
30–39		*		*				*						*										4
40–49						*										*				*				3
50–59																		*						1
Gender
Male								*								*						*		3
Female		*		*		*				*		*		*				*		*				8
Experience (year)
3–5										*				*								*		3
6–10				*		*		*				*								*				5
11–20		*														*		*						3
Education
Master’s								*		*		*												3
General practitioner														*		*		*		*		*		5
Specialty		*		*		*																		3

The first phase, based on expert interviews to define features of an FTT registry system, identified 117 data elements across eight categories: objectives (4 subcategories), structure (4), classification system (1), data processing and reporting (2), distribution and access (1), data quality (1), management data (4), and clinical data (10).

Validation of the failure to thrive registry system features

Twenty-eight experts participated in the validation stage. The demographic characteristics of the experts at this stage are presented in Table 2.

Table 2.

Frequency distribution of demographic variables of experts participating in the first round of the delphi study

Variable		n (%)
Age group
30–34		8 (28.6)
35–39		10 (35.7)
40–44		5 (17.9)
45–49		2 (7.1)
>50		3 (10.7)
Gender
Male		16 (57.1)
Female		12 (42.9)
Field of study
General practitioner		8 (28.6)
Pediatrics		10 (35.7)
Nutrition		10 (35.7)
Academic degree
Master’s		9 (32.1)
General practitioner		8 (28.6)
Specialist		11 (39.3)
Experience (year)
<5		7 (25)
5–10		11 (39.3)
11–15		2 (7.1)
16–20		5 (17.9)
21–25		1 (3.6)
26–29		2 (7.1)

The Delphi method results for the FTT registry system validation failed to confirm certain data elements, namely “assessment of healthcare services provided for children with FTT,” “estimation of service needs and enhancement of care quality,” and “increasing public awareness to prevent and control pediatric FTT,” under the system’s “objectives” feature. Likewise, the data elements “service provider users (providing access for all data producers)” under the system’s “data distribution and access” feature, as well as the data elements “zip code” and “birth order” under the system’s “management data,” and the data element “paraclinical procedures,” under the system’s “clinical data” did not meet the validation threshold (score within the 50–75 range) and were thus forwarded to the second round of the Delphi study. Moreover, experts proposed the inclusion of the Z-score as a diagnostic patient data element under the clinical data category.

The second round of the Delphi study involved all 28 experts from the first round. The items included for this round comprised eight elements from the first round that had achieved a 50%–75% agreement level as well as three additional elements suggested by the experts. The findings from the second round are detailed in Table 3.

Table 3.

Results of Delphi’s second round concerning the failure to thrive registry system’s features

Row		Title		Data Element		Mean		Median		Mode		Interquartile range (Q1, Q3)		Agreement Percentage		Consensus
1		Objectives		Assessment of healthcare services provided for children with FTT		3.2		3		3		(3 and 3)		17.8		-
				Estimation of service needs and enhancement of care quality		2.5		3		3		(2 and 3)		17.8		-
				Increasing public awareness to prevent and control pediatric FTT		3.9		4		4		(4 and 4)		7.1		-
2		Distribution and access		Service provider users (providing access for all data producers)		3.8		4		4		(4 and 4)		92.8		√
3		Management data		Zip code		2.07		2		2		(2 and 2)		0		-
				birth order		2.07		2		2		(2 and 2)		0		-
4		Clinical data		Medical imaging (type of medical imaging, anatomical location, date of imaging, result)		4.6		5		5		(5 and 5)		85.7		√
				Pathology		4.6		5		5		(5 and 5)		85.7		√
				weight-to-height Z-score		4.7		5		5		(5 and 5)		92.8		√
				height-for-age Z-score		4.7		5		5		(5 and 5)		92.8		√
				Weight-for-age Z-score		4.7		5		5		(5 and 5)		92.8		√

FTT=Failure to thrive

Once the pediatric FTT registry system’s features were identified and validated, a conceptual model and a web-based software prototype were developed using PHP programming language and the Laravel framework. PostgreSQL was used as the database management system. For instance, class [Figure 1], registration [Figure 2], and data entry [Figure 3] diagrams were designed. A web application was subsequently created, allowing users to access the registry system through a web browser by entering the address roshd.mahdikarami.ir. Upon login [Figure 4], users were directed to the data entry page of the pediatric FTT registry system [Figure 5].

Figure 1.

Class diagram of the pediatric failure to thrive registry system

Figure 2.

Diagram used for registration in the pediatric failure to thrive registry system

Figure 3.

Diagram used for data entry in the pediatric failure to thrive registry system

Figure 4.

Login page of the failure to thrive software

Figure 5.

Home screen of the failure to thrive software

Nielsen’s Ten Usability Heuristics were employed to evaluate the usability of the pediatric FTT registry software. Participant demographics are detailed in Table 4, and the evaluation results are summarized in Supplementry Table 1.

Table 4.

Frequency distribution of demographic variables of participants in the usability evaluation of the software for registering children’s developmental disorders

Demographic information				Frequency		Percentage
Gender		Female		6		60
		Male		4		40
Age		25-35		3		30
		36-45		5		50
		46-50		1		10
		51-60		1		10
Educational level		Bachelor’s degree		4		40
		Master’s degree		2		20
		Pediatrician		2		20
		Nutritionist		2		20
Work experience		3-5		4		40
		6-10		3		30
		11-15		3		30

Supplementry Table 1.

Frequency distribution of participants’ responses in the user usability evaluation of the system

Row		Criteria		Number of problems		Percentage of problems		Average severity of the problem		Severity of the problem
1		Visibility of the system status		2		14.3		0.43		Very little
2		Consistency between the system and the real world		1		7.1		0.50		Very little
3		User control and freedom		1		7.1		0.49		Very little
4		Adherence to standards and consistency		1		7.1		0.62		Very little
5		Helping users identify, diagnose, and correct errors		2		14.3		1.52		Little
6		Error prevention		3		21.4		1.75		Little
7		Recognition rather than recall		1		7.1		1.33		Little
8		Flexibility		1		7.1		0.65		Very little
9		Simple design and aesthetic aspects		0		0		-		-
10		Guidance and documentation		2		14.3		0.85		Very little

The usability evaluation of the pediatric FTT registry system based on Nielsen’s ten heuristics revealed minor problems. The “visibility of system status” heuristic exhibited two very minor problems: the selected icon was not sufficiently distinguishable from unselected icons, and there was no feedback indicating when a user could proceed to the next step after completing a task. The “match between system and the real world” heuristic showed one very minor problem: the system did not automatically add leading and trailing spaces to align decimal numbers. The “user control and freedom” heuristic had one very minor problem: users were unable to modify the default screen and file settings. The “consistency and standards” heuristic revealed one very minor problem: the alignment of integers and decimals was inconsistent. The “help users recognize, diagnose, and recover from errors” heuristic had two minor problems: the system did not use sound to indicate errors, and did not provide error severity levels in error messages. The “error prevention” heuristic had three minor problems: the system did not use a dot or underline to indicate field length, was not sensitive to typos, and did not warn users of potential errors. The “recognition over recall” heuristic had one very minor problem: the most important option was not placed at the beginning of each text. The “flexibility and efficiency” heuristic had one very minor problem: the system did not use the find previous and find next shortcuts for database searches. The “aesthetic and minimalist design” heuristic had no problems. Finally, the “help and documentation” heuristic had two very minor problems: the system did not provide additional information when options were unclear, and users could not adjust the level of details provided.

Discussion

This research sought to determine the features, design, and design of a pediatric FTT registry system. The required data elements for a pediatric FTT registry system were identified by reviewing relevant literature and interviewing experts. These elements were categorized into eight main headings (objectives, structure, classification system, data quality, data processing and reporting, data distribution and access, management data, and clinical data) and comprised 24 subheadings and 117 data elements.

In Imami’s study, which aimed at collecting a dataset on undernutrition in children under five years, a total of 56 data elements emerged under eight headings, including demographic and managerial data, clinical examinations, child growth, nutritional status, diagnostic data, medical history, and laboratory tests. The findings of this study are consistent with those of the present research.[14]

Sadeghi conducted a study to identify the essential components of a malnutrition registry system. The study identified 11 primary themes, including objectives, domestic stakeholder centers, and supporting organizations, international stakeholder centers and supporting organizations, national center or entity responsible for the registry, system quality and confidentiality functions, data sources and exchange, data collection methods, reporting, support, management data elements, and clinical data elements (consisting of 14 subthemes and 282 data elements).[15]

In their study on a pediatric healthcare dataset for Iran, Darabi extracted and validated essential data elements from child healthcare registration forms in three leading countries in pediatric care, namely, Australia, Canada, and the United States. The study introduced demographics, weight status, head circumference, growth charts, age classification, nutritional status classification, and medication supplement status as data elements, which agree with the current research.[16]

Generally speaking, a comparison of the findings of this study with other research shows that many of the data elements present in the Iranian pediatric FTT dataset, such as weight, height, body mass index, necessary follow-up tests, gender, father’s occupation, admission date, discharge date, attending physician’s name, clinical history, and medication supplements, overlap with pediatric malnutrition datasets.[14,15] As such, it is suggested that the electronic health records of children with FTT be linked and integrated with pediatric malnutrition data.

The software’s usability evaluation in this study revealed that the highest number of problems pertained to the “error prevention” indicator, while the “aesthetic and minimalist design” criterion was found to be the least problematic. These results agree with Sadeghi’s findings, where end-users rated the overall system usability as good. Moreover, the “overall user interaction” component received the highest score, while the “terminology and system information” component received the lowest score from users in Sadeghi’s study,[15] which corresponds with our study findings.

This study demonstrated that the pediatric FTT registry system could contribute significantly to the early detection, monitoring, and research of FTT. Other studies have also shown that information systems and database management systems can effectively reduce errors, enable early detection of FTT and nutritional disorders, and support future research in pediatric FTT.[15,17,18,19,20,21]

This study expands on Sadeghi’s work[15] by narrowing its focus to pediatric FTT, a specific subset of malnutrition, and developing a tailored registry system for the Iranian context, whereas Sadeghi’s study addressed a broader malnutrition registry encompassing 282 data elements across 11 themes, including stakeholder coordination and support structures. While Sadeghi’s framework included extensive organizational components, such as domestic and international stakeholder centers, this study prioritizes a streamlined set of 117 data elements, emphasizing clinical and management data directly relevant to FTT, such as Z-scores for weight-for-age and height-for-age, which were validated through expert consensus using the Delphi method. In contrast to Sadeghi’s broader approach, which did not emphasize usability testing, the current study integrates Nielsen’s Ten Usability Heuristics to evaluate the system’s user interface, identifying critical issues like error prevention that could affect clinical adoption. Both researches, nonetheless, concur on the importance of reporting and data quality, although this research’s context-specificity and usability orientation present a more tailored solution for FTT management, potentially making it more appropriate in resource-scarce clinical settings.

In contrast to Darabi’s study,[16] which focused on extracting a general pediatric healthcare dataset from international models (Australia, Canada, and the United States), this study specifically addresses FTT within Iran’s unique healthcare landscape, incorporating locally relevant data elements like fathers’ occupations and regional health metrics. Darabi’s dataset, while comprehensive for general pediatric care, included fewer data elements (e.g., head circumference, growth charts) and did not emphasize the development of a functional registry system with a software prototype. The current study advances Darabi’s work by not only validating a comparable set of data elements but also implementing them in a web-based system using PHP, Laravel, and PostgreSQL, designed for scalability and integration into Iran’s health infrastructure. Furthermore, Darabi’s study did not assess usability, whereas this study’s evaluation revealed critical insights, such as the need for improved error prevention, which could influence the system’s practical utility. By building a context-specific, usable registry system, this study offers a practical tool for FTT management that extends beyond the theoretical dataset compilation of Darabi’s work, addressing a gap in operationalizing pediatric health data in a developing country setting.

It is important to examine the usability issues realized in the pediatric FTT registry system assessment, especially those involving error prevention, and investigate their potential effects on real-life adoption. During the usability test, the “error prevention” indicator posed the most difficulties, with serious outcomes when the system is used clinically. Error prevention is perhaps the most important area of usability, particularly in medical systems where data integrity is paramount. Accidental input errors due to insufficient input validation, poorly designed confirmation dialogues for important actions, or a lack of telling the user when they are entering data could cause inappropriately entered data to be stored in the registry. For example, if a worker enters incorrect anthropometric data, for instance, weight or height, it may lead to misclassification of the growth status of the child and trigger unnecessary clinical action or delayed intervention. Furthermore, if the system is not able to save longitudinal patient records against accidental deletion or alteration, they can be vulnerable to undermining their integrity, which is critical in order to monitor the trend of FTT over time. These kinds of errors not only raise questions on the integrity of the data but also contaminate user trust in the system, which is critical to its effective adoption.

The presence of such usability flaws can prevent the real-world deployment of the pediatric FTT registry system by doctors. If the system is seen as being clunky or error-prone, then clinicians will resist adopting it as part of their working routine and will continue with traditional manual methods or alternative systems instead. The resistance will probably be even stronger in resource-constrained environments such as Iran, where time and personnel are scarce, and the learning curve for the new technology must be low. Moreover, if the system does not avoid errors, it might put more workload on users, who would be required to spend additional time in error correction or checking data accuracy. Greater workload might deter adoption because healthcare practitioners prioritize efficiency and reliability in facilities. Ultimately, if the registry system does not become commonly used due to issues of usability, its potential to improve FTT management by way of total data collection and analysis would suffer significantly, preventing it from having any impact on public health outcomes.

To avoid these issues, it is essential that the development team places its priorities in addressing the issues of usability cited above, particularly error prevention. Offering proper input validation routines, for instance, restricting data entry to reasonable ranges for weight and height measurements, would avoid most common data entry mistakes. Offering confirmation dialogues for major operations like deleting or modifying patient data would minimize accidental data loss opportunities. Giving proper, context-sensitive help or tooltips during data input would also help users use the system appropriately, avoiding errors. Besides these technical changes, additional usability testing with real end-users—pediatricians, nutritionists, and clinic health workers in Iranian clinics, for example—would be beneficial. Through the iterative testing loop, any other usability challenges would become apparent, and the system would be adapted to the specific needs and workflow of its target users. Ongoing updates and improvements based on feedback from the users would also be critical to long-term use of the system.

Limitations and recommendations

Usability testing of the pediatric FTT registry system was done with a small number of participants, and this could have limited the generalizability of results. Testing a larger and more diverse user group with a more extensive array of healthcare providers from more than one Iranian clinical site would yield more comprehensive information on usability problems and system functioning. Additionally, the duration of the test was quite acceptable, perhaps not showing the capability of the system to perform when utilized over a long duration of time or under heterogeneous clinical settings. Longer use in real-world settings can uncover more usability issues or establish the system’s reliability over time. Finally, the lack of a clear and coherent definition of FTT in the literature made it challenging to normalize data elements that affected the system’s applicability to different settings. To move forward past these limitations, subsequent research would be helped by more representative and larger user populations, a longer evaluation time frame, and efforts toward the development of an FTT standard definition to enhance the registry’s utility and consistency.

Conclusion

Given the importance of pediatric FTT for the nation’s future health and the significant economic consequences, a FTT registry system would be invaluable for managing this condition across the country. When integrated into the national health system, such a system could help collect timely, accurate, integrated, and comprehensive data from healthcare providers. This information could then be used to make macro-level management decisions, such as treatment interventions, resource allocation based on regional disease burden, and the development of preventive programs. Although the system shows great promise, its small usability testing population and brief evaluation period highlight the need for additional fine-tuning and testing to validate it in a variety of clinical scenarios.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

This study was part of a PhD. thesis supported by Iran University of Medical Sciences (No: 1401-3-37-24298).