1
|
Spaulding EM, Isakadze N, Molello N, Khoury SR, Gao Y, Young L, Antonsdottir IM, Azizi Z, Dorsch MP, Golbus JR, Ciminelli A, Brant LCC, Himmelfarb CR, Coresh J, Marvel FA, Longenecker CT, Commodore-Mensah Y, Gilotra NA, Sandhu A, Nallamothu B, Martin SS. Use of Human-Centered Design Methodology to Develop a Digital Toolkit to Optimize Heart Failure Guideline-Directed Medical Therapy. J Cardiovasc Nurs 2024; 39:245-254. [PMID: 37855732 PMCID: PMC11026295 DOI: 10.1097/jcn.0000000000001051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2023]
Abstract
BACKGROUND Guideline-directed medical therapies (GDMTs) improve quality of life and health outcomes for patients with heart failure (HF). However, GDMT utilization is suboptimal among patients with HF. OBJECTIVE The aims of this study were to engage key stakeholders in semistructured, virtual human-centered design sessions to identify challenges in GDMT optimization posthospitalization and inform the development of a digital toolkit aimed at optimizing HF GDMTs. METHODS For the human-centered design sessions, we recruited ( a ) clinicians who care for patients with HF across 3 hospital systems, ( b ) patients with HF with reduced ejection fraction (ejection fraction ≤ 40%) discharged from the hospital within 30 days of enrollment, and ( c ) caregivers. All participants were 18 years or older, English speaking, with Internet access. RESULTS A total of 10 clinicians (median age, 37 years [interquartile range, 35-41], 12 years [interquartile range, 10-14] of experience caring for patients with HF, 80% women, 50% White, 50% nurse practitioners) and three patients and one caregiver (median age 57 years [IQR: 53-60], 75% men, 50% Black, 75% married) were included. Five themes emerged from the clinician sessions on challenges to GDMT optimization (eg, barriers to patient buy-in). Six themes on challenges (eg, managing medications), 4 themes on motivators (eg, regaining independence), and 3 themes on facilitators (eg, social support) to HF management arose from the patient and caregiver sessions. CONCLUSIONS The clinician, patient, and caregiver insights identified through human-centered design will inform a digital toolkit aimed at optimizing HF GDMTs, including a patient-facing smartphone application and clinician dashboard. This digital toolkit will be evaluated in a multicenter, clinical trial.
Collapse
Affiliation(s)
- Erin M. Spaulding
- Johns Hopkins University School of Nursing, Baltimore, MD, US
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, US
- Digital Health Innovation Laboratory, Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, US
| | - Nino Isakadze
- Digital Health Innovation Laboratory, Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, US
- Johns Hopkins University School of Medicine, Baltimore, MD, US
| | - Nancy Molello
- Center for Health Equity, Johns Hopkins University, Baltimore, MD, US
| | - Shireen R. Khoury
- Digital Health Innovation Laboratory, Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, US
- Johns Hopkins University School of Medicine, Baltimore, MD, US
| | - Yumin Gao
- Digital Health Innovation Laboratory, Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, US
| | - Lisa Young
- Digital Health Innovation Laboratory, Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, US
- Johns Hopkins University School of Medicine, Baltimore, MD, US
| | | | - Zahra Azizi
- Division of Cardiology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, US
- Center for Digital Health, Stanford University, Stanford, CA, US
| | | | - Jessica R. Golbus
- Division of Cardiovascular Diseases, Department of Internal Medicine, University of Michigan, MI, US
- Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), University of Michigan, MI, US
- The Center for Clinical Management and Research, Ann Arbor VA Medical Center, MI, US
| | - Ana Ciminelli
- Faculdade de Medicina & Centro de Telessaúde do Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Luisa C. C. Brant
- Faculdade de Medicina & Centro de Telessaúde do Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Cheryl R. Himmelfarb
- Johns Hopkins University School of Nursing, Baltimore, MD, US
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, US
- Johns Hopkins University School of Medicine, Baltimore, MD, US
| | - Josef Coresh
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, US
| | - Francoise A. Marvel
- Digital Health Innovation Laboratory, Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, US
- Johns Hopkins University School of Medicine, Baltimore, MD, US
| | - Chris T. Longenecker
- Division of Cardiology and Department of Global Health, University of Washington, Seattle, WA, US
| | - Yvonne Commodore-Mensah
- Johns Hopkins University School of Nursing, Baltimore, MD, US
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, US
- Center for Health Equity, Johns Hopkins University, Baltimore, MD, US
| | | | - Alexander Sandhu
- Center for Health Equity, Johns Hopkins University, Baltimore, MD, US
- Division of Cardiology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, US
| | - Brahmajee Nallamothu
- Division of Cardiovascular Diseases, Department of Internal Medicine, University of Michigan, MI, US
- Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), University of Michigan, MI, US
- The Center for Clinical Management and Research, Ann Arbor VA Medical Center, MI, US
| | - Seth S. Martin
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, US
- Digital Health Innovation Laboratory, Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, US
- Johns Hopkins University School of Medicine, Baltimore, MD, US
- Center for Health Equity, Johns Hopkins University, Baltimore, MD, US
- Johns Hopkins University Whiting School of Engineering, Baltimore, MD, US
| |
Collapse
|
2
|
Naanyu V, Koros H, Goodrich S, Siika A, Toroitich-Ruto C, Bateganya M, Wools-Kaloustian K. Post-intervention perceptions on the antiretroviral therapy community group model in Trans Nzoia County, Kenya. Pan Afr Med J 2024; 47:113. [PMID: 38828427 PMCID: PMC11143075 DOI: 10.11604/pamj.2024.47.113.41843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 02/19/2024] [Indexed: 06/05/2024] Open
Abstract
Introduction the increasing number of people receiving antiretroviral therapy (ART) in sub-Saharan Africa has stressed already overburdened health systems. A care model utilizing community-based peer-groups (ART Co-ops) facilitated by community health workers (CHW) was implemented (2016-2018) to address these challenges. In 2018, a post-intervention study assessed perceptions of the intervention. Methods forty participants were engaged in focus group discussions consisting of ART Co-op clients, study staff, and health care providers from Kitale HIV clinic. Data were analyzed thematically for content on the intervention, challenges, and recommendations for improvement. Results all participants liked the intervention. However, some reported traveling long distances to attend ART Co-op meetings and experiencing stigma with ART Co-ops participation. The ART Co-op inclusion criteria were considered appropriate; however, additional outreach to deliberately include spouses living with HIV, the disabled, the poor, and HIV pregnant women was recommended. Participants liked CHW-directed quarterly group meetings which included ART distribution, adherence review, and illness identification. The inability of the CHW to provide full clinical care, inconvenient meeting venues, poor timekeeping, and non-attendance behaviors were noted as issues. Participants indicated that program continuation, regular CHW training, rotating meetings at group members´ homes, training ART Co-ops leaders to assume CHW tasks, use of pill diaries to check adherence, nutritional support, and economically empowering members through income generation projects would be beneficial. Conclusion the intervention was viewed positively by both clinic staff and clients. They identified specific challenges and generated actionable key considerations to improve access and acceptability of the community-based model of care.
Collapse
Affiliation(s)
- Violet Naanyu
- Department of Sociology Psychology and Anthropology, School of Arts and Social Sciences, Moi University, Eldoret, Kenya
- AMPATH Qualitative Research Core, Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Hillary Koros
- AMPATH Qualitative Research Core, Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Suzanne Goodrich
- Division of Infectious Diseases, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Abraham Siika
- Department of Medicine, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Cathy Toroitich-Ruto
- Division of Global HIV and TB (DGHT), Centers for Global Health (CGH), US Centers for Disease Control and Prevention (CDC), Nairobi, Kenya
| | | | - Kara Wools-Kaloustian
- Division of Infectious Diseases, Indiana University School of Medicine, Indianapolis, IN, USA
| |
Collapse
|
3
|
Medina-Marino A, Sibanda N, Putt M, Joseph Davey D, Smith P, Thirumurthy H, Bekker LG, Buttenheim A. Improving HIV testing, linkage, and retention in care among South African men through U=U messaging: A study protocol for two sequential hybrid type 1 effectiveness- implementation randomized controlled trials. RESEARCH SQUARE 2023:rs.3.rs-3349696. [PMID: 37886512 PMCID: PMC10602079 DOI: 10.21203/rs.3.rs-3349696/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
BACKGROUND Increasing HIV testing and treatment coverage among people living with HIV (PLHIV) is essential for achieving global AIDS epidemic control. However, compared to women, cis-gender heterosexual men living with HIV are significantly less likely to know their HIV status, initiate anti-retroviral therapy (ART) and achieve viral suppression. This is particularly true in South Africa, where men are also at increased risk of mortality resulting from AIDS-related illnesses. While there is growing knowledge of Treatment as Prevention or the concept Undetectable=Untransmittable (U=U) among PLHIV in Western and high-income countries, the reach and penetration of the U=U message in sub-Saharan Africa remains limited, and few studies have evaluated the impact of accessible and relatable U=U messages on ART initiation and adherence. To address these gaps, rigorous evaluations of interventions that incorporate U=U messages are needed, especially among men in high prevalence settings. METHODS Building on our U=U messages that we previously developed for men using behavioral economics insights and a human-centered design, we will conduct two sequential hybrid type 1 effectiveness-implementation trials to evaluate the impact of U=U messages on men's uptake of community-based HIV testing and ART initiation (Trial 1), and retention in care and achievement of viral suppression (Trial 2). A cluster randomized trial will be implemented for Trial 1, with HIV testing service site-days randomized to U=U or standard-of-care (SoC) messages inviting men to test for HIV. An individual-level randomized control trial will be implemented for Trial 2, with men initiating ART at six government clinics randomized to receive U=U counselling or SoC treatment adherence messaging. We will incorporate a multi-method evaluation to inform future implementation of U=U messaging interventions. The study will be conducted in the Buffalo City Metro Health District of the Eastern Cape Province and in the Cape Town Metro Health District in the Western Cape Province in South Africa. DISCUSSION These trials are the first to rigorously evaluate the impact of U=U messaging on HIV testing uptake, ART initiation and achievement of viral suppression among African men. If effective, these messaging interventions can shape global HIV testing, treatment and adherence counselling guidelines and practices.
Collapse
|
4
|
Daniels J, Peters RPH, Portle S, Mashabela N, Struthers H, Radebe O, Nel D, Medina-Marino A, Bongo C, Stephenson R. Developing the Speaking Out and Allying Relationships Intervention on Videoconference for HIV-Positive GBMSM in Eastern Cape, South Africa. Am J Mens Health 2023; 17:15579883231197355. [PMID: 37675590 PMCID: PMC10486223 DOI: 10.1177/15579883231197355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 08/01/2023] [Accepted: 08/09/2023] [Indexed: 09/08/2023] Open
Abstract
In South Africa, HIV prevalence for gay, bisexual, and men who have sex with men (GBMSM) is as high as 49.5%, yet only 25.7% are taking treatment, resulting in transmission risk between partners and the need for dyadic interventions for men in relationships. Through our preliminary research, we identified the evidence-based intervention Healthy Relationships (HR)-an HIV risk assessment and status disclosure intervention for those in relationships-to be tailored into videoconference format for partnered HIV-positive GBMSM in South Africa. The HR adaptation, called SOAR (Speaking Out & Allying Relationships), applied a human-centered design approach. In-depth interviews were conducted with HIV-positive GBMSM (N = 15) to refine intervention preferences with results used to establish a beta SOAR. A trained interventionist conducted SOAR functionality (n = 6) and usability (n = 7) tests with separate invited groups composed of the original participants interviewed. Field logs, focus group discussions, and a study-specific preference survey were administered. Thematic analysis and descriptive statistics were completed with a convergent analytical approach used to understand usability. Overall experience of GBMSM in SOAR was good (69%) or excellent (31%). More than half of the participants (61%) rated using videoconferencing for SOAR as good, with 38% rating it as fair. All participants stated that SOAR was understandable and satisfactory with willingness to recommend it to other GBMSM. This adaptation approach was effective, and the resultant SOAR intervention has the potential to improve individual coping and HIV communication skills with partners to engage with biomedical prevention and in turn support GBMSM couples.
Collapse
Affiliation(s)
- Joseph Daniels
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ, USA
| | - Remco P. H. Peters
- Foundation for Professional Development, East London, South Africa
- Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa
| | - Sarah Portle
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ, USA
| | | | | | | | - Dawie Nel
- Engage Men’s Health, East London, South Africa
| | - Andrew Medina-Marino
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Cikizwa Bongo
- Foundation for Professional Development, East London, South Africa
| | - Rob Stephenson
- School of Nursing, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
5
|
Kaduru CC, Mbagwu GC, Aadum DK, Eshikhena G, Idim GA, Ibe UF, Sabenus T, Jenson FG, Egbe E, Aworabhi-Oki N, Masa H, Bekesu M, Oyeyemi AS. Using community theater to improve demand for vaccination services in the Niger Delta Region of Nigeria. BMC Proc 2023; 17:6. [PMID: 37400839 PMCID: PMC10316554 DOI: 10.1186/s12919-023-00263-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2023] [Indexed: 07/05/2023] Open
Abstract
INTRODUCTION Despite abundant evidence showing immunization as a lifesaving public health measure, a large proportion of Nigerian children are still not or fully vaccinated. Lack of awareness and distrust of the immunization process by caregivers are some of the reasons for poor immunization coverage which need to be addressed. This study aimed at improving vaccination demand, acceptance and uptake in Bayelsa and Rivers State, both in the Niger Delta Region (NDR) of Nigeria through a human-centered process of trust building, education and social support. METHODS A quasi-experimental intervention christened Community Theater for Immunization (CT4I) was deployed in 18 selected communities between November 2019 and May 2021 in the two states. In the intervention localities, relevant stakeholders including the leadership of the health system, community leaders, health workers and community members were engaged and actively involved in the design and performance of the theaters. The content for the theater showcased real stories, using a human-centered design (HCD) of ideation, co-creation, rapid prototyping, feedback collection and iteration. Pre- and post-intervention data on the demand and utilization of vaccination services were collected using a mixed method. RESULTS In the two states, 56 immunization managers and 59 traditional and religious leaders were engaged. Four broad themes implicating user and provider factors emerged from the 18 focus group discussions as responsible for low immunization uptake in the communities. Of the 217 caregivers trained on routine immunization and theater performances, 72% demonstrated a knowledge increase at the post-test. A total of 29 performances attended by 2,258 women were staged with 84.2% of the attendees feeling satisfied. At the performances, 270 children received vaccine shots (23% were zero-dose). There was a 38% increase in the proportion of fully immunized children in the communities and 9% decline in the proportion of zero-dose children from baseline. CONCLUSION Both demand- and supply-side factors were identified as responsible for poor vaccination in the intervention communities. Our intervention demonstrates that caregivers will demand immunization services if they are engaged through community theater using a human-centered design (HCD). We recommend a scaling up of HCD to address the challenge of vaccine hesitancy.
Collapse
Affiliation(s)
| | | | - Dumale Koko Aadum
- Corona Management Systems: 2B Samuel A. Ogedengbe Crescent Jabi, Abuja FCT, Nigeria
| | - Ganiyat Eshikhena
- Corona Management Systems: 2B Samuel A. Ogedengbe Crescent Jabi, Abuja FCT, Nigeria
| | - Godwin Anusa Idim
- Corona Management Systems: 2B Samuel A. Ogedengbe Crescent Jabi, Abuja FCT, Nigeria
| | - Uche Francis Ibe
- Corona Management Systems: 2B Samuel A. Ogedengbe Crescent Jabi, Abuja FCT, Nigeria
| | - Timiebiere Sabenus
- Corona Management Systems: 2B Samuel A. Ogedengbe Crescent Jabi, Abuja FCT, Nigeria
| | - Fofah Gawain Jenson
- Corona Management Systems: 2B Samuel A. Ogedengbe Crescent Jabi, Abuja FCT, Nigeria
| | - Edmund Egbe
- , WHO - World Health Organization: WHO office, State Secretariat Complex, Third Floor, Yenagoa, Bayelsa State, Nigeria
| | - Neni Aworabhi-Oki
- Bayelsa State Primary Healthcare Board: State Secretariat Complex Third Floor, Yenagoa, Bayelsa State, Nigeria
| | - Happiness Masa
- Bayelsa State Primary Healthcare Board: State Secretariat Complex Third Floor, Yenagoa, Bayelsa State, Nigeria
| | - Martins Bekesu
- Bayelsa State Primary Healthcare Board: State Secretariat Complex Third Floor, Yenagoa, Bayelsa State, Nigeria
| | - Abisoye Sunday Oyeyemi
- Department of Community Medicine, Niger Delta, University, Wilberforce Island, Bayelsa State, Nigeria
| |
Collapse
|
6
|
Musiimenta A, Tumuhimbise W, Atukunda E, Mugaba A, Linnemayr S, Haberer J. Digital Adherence Technologies and Mobile Money Incentives for Management of Tuberculosis Medication Among People Living With Tuberculosis: Mixed Methods Formative Study. JMIR Form Res 2023; 7:e45301. [PMID: 37043263 PMCID: PMC10134020 DOI: 10.2196/45301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 02/22/2023] [Accepted: 03/07/2023] [Indexed: 03/09/2023] Open
Abstract
BACKGROUND Although there is an increasing use of digital adherence technologies (DATs), such as real-time monitors and SMS reminders in tuberculosis medication adherence, suboptimal patient engagement with various DATs has been reported. Additionally, financial constraints can limit DAT's utility. The perceived usefulness and the design mechanisms of DATs linked to mobile money financial incentives for tuberculosis medication management remain unclear. OBJECTIVE The aim of this study is to describe the perceived usefulness and design mechanisms for a DAT intervention called My Mobile Wallet, which is composed of real-time adherence monitors, SMS reminders, and mobile money incentives to support tuberculosis medication adherence in a low-income setting. METHODS This study used mixed methods approaches among persons with tuberculosis recruited from the Tuberculosis Clinic in the Mbarara Regional Referral Hospital. We purposively sampled 21 persons with tuberculosis aged 18 years and older, who owned cell phones and were able to use SMS text messaging interventions. We also enrolled 9 participants who used DATs in our previous study. We used focus group discussions with the 30 participants to solicit perceptions about the initial version of the My Mobile Wallet intervention, and then iteratively refined subsequent versions of the intervention following a user-centered design approach until the beta version of the intervention that suited their needs was developed. Surveys eliciting information about participants' cell phone use and perceptions of the intervention were also administered. Content analysis was used to inductively analyze qualitative data to derive categories describing the perceived usefulness of the intervention, concerns, and design mechanisms. Stata (version 13; StataCorp) was used to analyze survey data. RESULTS Participants expressed the perceived usefulness of the My Mobile Wallet intervention in terms of being reminded to take medication, supported with transport to the clinic, and money to meet other tuberculosis medication-related costs, all of which were perceived to imply care, which could create a sense of connectedness to health care workers. This could consequently cause participants to develop a self-perceived need to prove their commitment to adherence to health care workers who care for them, thereby motivating medication adherence. For fear of unintended tuberculosis status disclosure, 20 (67%) participants suggested using SMS language that is confidential-not easily related to tuberculosis. To reduce the possibilities of using the money for other competing demands, 25 (83%) participants preferred sending the money 1-2 days before the appointment to limit the time lag between receiving the money and visiting the clinic. CONCLUSIONS DATs complemented with mobile money financial incentives could potentially provide acceptable approaches to remind, support, and motivate patients to adhere to taking their tuberculosis medication. TRIAL REGISTRATION ClinicalTrials.gov NCT05656287; https://clinicaltrials.gov/ct2/show/NCT05656287.
Collapse
Affiliation(s)
- Angella Musiimenta
- Faculty of Computing and Informatics, Mbarara University of Science and Technology, Mbarara, Uganda
- Angels Compassion Research and Development Initiative, Mbarara, Uganda
| | - Wilson Tumuhimbise
- Faculty of Computing and Informatics, Mbarara University of Science and Technology, Mbarara, Uganda
- Angels Compassion Research and Development Initiative, Mbarara, Uganda
| | - Esther Atukunda
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Aaron Mugaba
- Faculty of Computing and Informatics, Mbarara University of Science and Technology, Mbarara, Uganda
- Angels Compassion Research and Development Initiative, Mbarara, Uganda
| | - Sebastian Linnemayr
- Department of Economics, Sociology, and Statistics, Rand Corporation, Santa Monica, CA, United States
| | - Jessica Haberer
- Medicine Department, Harvard Medical School, Boston, MA, United States
- Center for Global Health, Massachusetts General Hospital, Boston, MA, United States
| |
Collapse
|
7
|
Isakadze N, Molello N, MacFarlane Z, Gao Y, Spaulding EM, Commodore Mensah Y, Marvel FA, Khoury S, Marine JE, Michos ED, Spragg D, Berger RD, Calkins H, Cooper LA, Martin SS. The Virtual Inclusive Digital Health Intervention Design to Promote Health Equity (iDesign) Framework for Atrial Fibrillation: Co-design and Development Study. JMIR Hum Factors 2022; 9:e38048. [DOI: 10.2196/38048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 06/28/2022] [Accepted: 08/02/2022] [Indexed: 11/05/2022] Open
Abstract
Background
Smartphone ownership and mobile app use are steadily increasing in individuals of diverse racial and ethnic backgrounds living in the United States. Growing adoption of technology creates a perfect opportunity for digital health interventions to increase access to health care. To successfully implement digital health interventions and engage users, intervention development should be guided by user input, which is best achieved by the process of co-design. Digital health interventions co-designed with the active engagement of users have the potential to increase the uptake of guideline recommendations, which can reduce morbidity and mortality and advance health equity.
Objective
We aimed to co-design a digital health intervention for patients with atrial fibrillation, the most common cardiac arrhythmia, with patient, caregiver, and clinician feedback and to describe our approach to human-centered design for building digital health interventions.
Methods
We conducted virtual meetings with patients with atrial fibrillation (n=8), their caregivers, and clinicians (n=8). We used the following 7 steps in our co-design process: step 1, a virtual meeting focused on defining challenges and empathizing with problems that are faced in daily life by individuals with atrial fibrillation and clinicians; step 2, a virtual meeting focused on ideation and brainstorming the top challenges identified during the first meeting; step 3, individualized onboarding of patients with an existing minimally viable version of the atrial fibrillation app; step 4, virtual prototyping of the top 3 ideas generated during ideation; step 5, further ranking by the study investigators and engineers of the ideas that were generated during ideation but were not chosen as top-3 solutions to be prototyped in step 4; step 6, ongoing engineering work to incorporate top-priority features in the app; and step 7, obtaining further feedback from patients and testing the atrial fibrillation digital health intervention in a pilot clinical study.
Results
The top challenges identified by patients and caregivers included addressing risk factor modification, medication adherence, and guidance during atrial fibrillation episodes. Challenges identified by clinicians were complementary and included patient education, addressing modifiable atrial fibrillation risk factors, and remote atrial fibrillation episode management. Patients brainstormed more than 30 ideas to address the top challenges, and the clinicians generated more than 20 ideas. Ranking of the ideas informed several novel or modified features aligned with the Theory of Health Behavior Change, features that were geared toward risk factor modification; patient education; rhythm, symptom, and trigger correlation for remote atrial fibrillation management; and social support.
Conclusions
We co-designed an atrial fibrillation digital health intervention in partnership with patients, caregivers, and clinicians by virtually engaging in collaborative creation through the design process. We summarize our experience and describe a flexible approach to human-centered design for digital health intervention development that can guide innovative clinical investigators.
Collapse
|
8
|
Hak F, Guimarães T, Santos M. Towards effective clinical decision support systems: A systematic review. PLoS One 2022; 17:e0272846. [PMID: 35969526 PMCID: PMC9377614 DOI: 10.1371/journal.pone.0272846] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 07/27/2022] [Indexed: 11/21/2022] Open
Abstract
Background Clinical Decision Support Systems (CDSS) are used to assist the decision-making process in the healthcare field. Developing an effective CDSS is an arduous task that can take advantage from prior assessment of the most promising theories, techniques and methods used at the present time. Objective To identify the features of Clinical Decision Support Systems and provide an analysis of their effectiveness. Thus, two research questions were formulated: RQ1—What are the most common trend characteristics in a CDSS? RQ2—What is the maturity level of the CDSS based on the decision-making theory proposed by Simon? Methods AIS e-library, Decision Support Systems journal, Nature, PlosOne and PubMed were selected as information sources to conduct this systematic literature review. Studies from 2000 to 2020 were chosen covering search terms in CDSS, selected according to defined eligibility criteria. The data were extracted and managed in a worksheet, based on the defined criteria. PRISMA statements were used to report the systematic review. Results The outcomes showed that rule-based module was the most used approach regarding knowledge management and representation. The most common technological feature adopted by the CDSS were the recommendations and suggestions. 19,23% of studies adopt the type of system as a web-based application, and 51,92% are standalone CDSS. Temporal evolution was also possible to visualize. This study contributed to the development of a Maturity Staging Model, where it was possible to verify that most CDSS do not exceed level 2 of maturity. Conclusion The trend characteristics addressed in the revised CDSS were identified, compared to the four predefined groups. A maturity stage model was developed based on Simon’s decision-making theory, allowing to assess the level of maturity of the most common features of the CDSS. With the application of the model, it was noticed that the phases of choice and implementation are underrepresented. This constitutes the main gap in the development of an effective CDSS.
Collapse
Affiliation(s)
- Francini Hak
- Algoritmi Research Center, University of Minho, Braga, Portugal
- * E-mail:
| | - Tiago Guimarães
- Algoritmi Research Center, University of Minho, Braga, Portugal
| | - Manuel Santos
- Algoritmi Research Center, University of Minho, Braga, Portugal
| |
Collapse
|
9
|
Mukherjee TI, Zerbe A, Falcao J, Carey S, Iaccarino A, Kolada B, Olmedo B, Shadwick C, Singhal H, Weinstein L, Vitale M, De Gusmao EDP, Abrams EJ. Human-Centered Design for Public Health Innovation: Codesigning a Multicomponent Intervention to Support Youth Across the HIV Care Continuum in Mozambique. GLOBAL HEALTH, SCIENCE AND PRACTICE 2022; 10:e2100664. [PMID: 35487546 PMCID: PMC9053144 DOI: 10.9745/ghsp-d-21-00664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 03/08/2022] [Indexed: 11/15/2022]
Abstract
Adolescents and young people represent a growing proportion of people living with HIV (AYAHIV), and there is an urgent need to design, implement, and test interventions that retain AYAHIV in care. Using a human-centered design (HCD) approach, we codesigned CombinADO, an intervention to promote HIV viral suppression and improve antiretroviral therapy (ART) adherence and retention in care among AYAHIV in Nampula, Mozambique. The HCD process involves formative design research with AYAHIV, health care providers, parents/caretakers, and experts in adolescent HIV; synthesis of findings to generate action-oriented insights; ideation and prototyping of intervention components; and a pilot study to assess feasibility, acceptability, and uptake of intervention components.CombinADO promotes ART adherence and retention in care by fostering peer connectedness and belonging, providing accessible medical knowledge, demystifying and destigmatizing HIV, and cultivating a sense of hope among AYAHIV. Successful prototypes included a media campaign to reduce HIV stigma and increase medical literacy; a toolkit to help providers communicate and address the unique needs of AYAHIV clients; peer-support groups to improve medical literacy, empower youth, and provide positive role models for people living with HIV; support groups for parents/caregivers; and discreet pill containers to promote adherence outside the home. In the next phase, the effectiveness of CombinaADO on retention in care, ART adherence, and viral suppression will be evaluated using a cluster-randomized control trial.We demonstrate the utility of using HCD to cocreate a multicomponent intervention to retain AYAHIV in care. We also discuss how the HCD methodology enriches participatory methods and community engagement. This is then illustrated by the youth-driven intervention development of CombinADO by fostering youth empowerment, addressing power imbalances between youth and adult stakeholders, and ensuring that language and content remain adolescent friendly.
Collapse
Affiliation(s)
- Trena I Mukherjee
- Department of Epidemiology, Columbia Mailman School of Public Health, New York, NY, USA.
| | - Allison Zerbe
- ICAP at Columbia University Mailman School of Public Health, New York, NY, USA
| | | | | | | | | | | | | | | | | | | | | | - Elaine J Abrams
- Department of Epidemiology, Columbia Mailman School of Public Health, New York, NY, USA
- ICAP at Columbia University Mailman School of Public Health, New York, NY, USA
- Department of Pediatrics, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| |
Collapse
|
10
|
Geng EH, Nash D, Phanuphak N, Green K, Solomon S, Grimsrud A, Sohn AH, Mayer KH, Bärnighausen T, Bekker LG. The question of the question: impactful implementation science to address the HIV epidemic. J Int AIDS Soc 2022; 25:e25898. [PMID: 35384312 PMCID: PMC8982316 DOI: 10.1002/jia2.25898] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 02/18/2022] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Questions about the implementation of evidence-based intervention to treat and prevent HIV have risen to the top of the field's scientific priorities. Despite the availability of highly efficacious treatment and prevention interventions, impact has fallen short of targets because these interventions are used with insufficient reach, consistency, sustainability and equity in diverse real-world settings. At present, substantial excitement for implementation science - defined as research methods and strategies to improve use of evidence-based interventions - has focused on developing and disseminating methods to conduct rigorous research. Yet, impactful answers depend on a sometimes less visible, but even more important, step: asking good questions about implementation. DISCUSSION In this commentary, we offer several considerations for researchers formulating implementation research questions based on several distinctive features of the field. First, as findings are used not only by other researchers but by implementers, scientific questions must incorporate a range of stakeholder and community perspectives to be most relevant. Second, real-world settings are contextually diverse, and the most relevant scientific questions must position answers to make sense within these contexts (whether geographical, organizational and sociological), rather than apart from them. Third, implementation is complex and dynamic; consequently, research questions must make use of emerging standards in describing implementation strategies and their effects whenever possible. Finally, the field of implementation science continues to evolve, so framing problems with a diverse disciplinary lens will enable researchers to pose insightful and impactful questions. CONCLUSIONS We are now at a juncture marked by both rich evidence-based interventions and a persistent global pandemic. To achieve continued scientific progress against the HIV epidemic, asking the right questions might be part of the answer itself.
Collapse
Affiliation(s)
- Elvin H Geng
- Center for Dissemination and Implementation, Institute of Public Health, Division of Infectious Diseases, Department of Medicine, School of Medicine at Washington University in St. Louis, St. Louis, Missouri, USA
| | - Denis Nash
- Institute for Implementation Science in Population Health, City University of New York, New York, USA.,Department of Epidemiology and Biostatistics, Graduate School of Public Health, City University of New York, New York, USA
| | | | | | - Sunil Solomon
- Division of Infectious Diseases, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | | | | | - Kenneth H Mayer
- The Fenway Institute and Harvard Medical School, Boston, Massachusetts, USA
| | - Till Bärnighausen
- Heidelberg Institute of Global Health, Faculty of Medicine and University Hospital, Heidelberg, Germany
| | - Linda-Gail Bekker
- Institute of Infectious Disease and Molecular Medicine, Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
11
|
Müller P, Velez Lapão L. Mixed methods systematic review and metasummary about barriers and facilitators for the implementation of cotrimoxazole and isoniazid-Preventive therapies for people living with HIV. PLoS One 2022; 17:e0251612. [PMID: 35231047 PMCID: PMC8887777 DOI: 10.1371/journal.pone.0251612] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 02/10/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Cotrimoxazole and isoniazid preventive therapy (CPT, IPT) have been shown to be efficacious therapies for the prevention of opportunistic infections and tuberculosis (TB) among people living with human immunodeficiency virus (HIV). Despite governments' efforts to translate World Health Organization recommendations into practice, implementation remains challenging. This review aimed to explore and compare CPT and IPT with respect to similarities and differences of barriers identified across high TB/HIV burden countries. A secondary objective was to identify facilitators for implementing both preventive therapies. METHODS We searched MEDLINE, Web of Science and SCOPUS databases for peer-reviewed literature published before September 2020. We extracted and synthesized our findings using Maxqda software. We applied framework synthesis in conjunction with metasummary to compare both therapies with respect to similarities and differences of barriers identified across seven health system components (in line with the modified WHO's Framework for action). Protocol registration: PROSPERO (CRD42019137778). FINDINGS We identified four hundred and eighty-two papers, of which we included forty for review. Although most barrier themes were identical for both preventive therapies, we identified seven intervention-specific themes. Like for CPT, barriers identified for IPT were most frequently classified as 'service delivery-related barriers' and 'patient & community-related barriers'. 'Health provider-related barriers' played an important role for implementing IPT. Most facilitators identified referred to health system strengthening activities. CONCLUSIONS For researchers with limited working experience in high TB/HIV burden countries, this review can provide valuable insights about barriers that may arise at different levels of the health system. For policymakers in high TB/HIV burden countries, this review offers strategies for improving the delivery of IPT (or any newer therapy regimen) for the prevention of TB. Based on our findings, we suggest initial and continuous stakeholder involvement, focusing on the efficient use and reinforcement of existing resources for health.
Collapse
Affiliation(s)
- Pia Müller
- Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical (IHMT), Universidade Nova de Lisboa (UNL), Lisboa, Portugal
| | - Luís Velez Lapão
- Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical (IHMT), Universidade Nova de Lisboa (UNL), Lisboa, Portugal
| |
Collapse
|
12
|
Göttgens I, Oertelt-Prigione S. The Application of Human-Centered Design Approaches in Health Research and Innovation: A Narrative Review of Current Practices. JMIR Mhealth Uhealth 2021; 9:e28102. [PMID: 34874893 PMCID: PMC8691403 DOI: 10.2196/28102] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 07/16/2021] [Accepted: 10/21/2021] [Indexed: 12/14/2022] Open
Abstract
Background Human-centered design (HCD) approaches to health care strive to support the development of innovative, effective, and person-centered solutions for health care. Although their use is increasing, there is no integral overview describing the details of HCD methods in health innovations. Objective This review aims to explore the current practices of HCD approaches for the development of health innovations, with the aim of providing an overview of the applied methods for participatory and HCD processes and highlighting their shortcomings for further research. Methods A narrative review of health research was conducted based on systematic electronic searches in the PubMed, CINAHL, Embase, Cochrane Library, Web of Science, PsycINFO, and Sociological Abstracts (2000-2020) databases using keywords related to human-centered design, design thinking (DT), and user-centered design (UCD). Abstracts and full-text articles were screened by 2 reviewers independently based on predefined inclusion criteria. Data extraction focused on the methodology used throughout the research process, the choice of methods in different phases of the innovation cycle, and the level of engagement of end users. Results This review summarizes the application of HCD practices across various areas of health innovation. All approaches prioritized the user’s needs and the participatory and iterative nature of the design process. The design processes comprised several design cycles during which multiple qualitative and quantitative methods were used in combination with specific design methods. HCD- and DT-based research primarily targeted understanding the research context and defining the problem, whereas UCD-based work focused mainly on the direct generation of solutions. Although UCD approaches involved end users primarily as testers and informants, HCD and DT approaches involved end users most often as design partners. Conclusions We have provided an overview of the currently applied methodologies and HCD guidelines to assist health care professionals and design researchers in their methodological choices. HCD-based techniques are challenging to evaluate using traditional biomedical research methods. Previously proposed reporting guidelines are a step forward but would require a level of detail that is incompatible with the current publishing landscape. Hence, further development is needed in this area. Special focus should be placed on the congruence between the chosen methods, design strategy, and achievable outcomes. Furthermore, power dimensions, agency, and intersectionality need to be considered in co-design sessions with multiple stakeholders, especially when including vulnerable groups.
Collapse
Affiliation(s)
- Irene Göttgens
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, Netherlands
| | - Sabine Oertelt-Prigione
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, Netherlands
| |
Collapse
|
13
|
Blynn E, Harris E, Wendland M, Chang C, Kasungami D, Ashok M, Ayenekulu M. Integrating Human-Centered Design to Advance Global Health: Lessons From 3 Programs. GLOBAL HEALTH, SCIENCE AND PRACTICE 2021; 9:S261-S273. [PMID: 34845049 PMCID: PMC8628497 DOI: 10.9745/ghsp-d-21-00279] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 08/11/2021] [Indexed: 01/03/2023]
Abstract
Lessons from 3 global health programs indicate that human-centered design (HCD) holds great potential for developing more tailored, impactful, and sustainable products and services to improve health and well-being. However, to take advantage of the full benefits of HCD, global health practitioners need to intentionally design and implement programs differently from typical health programs that do not incorporate design. Background: Human-centered design (HCD) is increasingly being used as a complementary approach to traditional global health methods due to its ability to bring new ideas to entrenched problems, integrate multiple stakeholder perspectives, and bring in a strong human lens among other advantages. To reap these benefits, public health and design practitioners in global health programs can learn from the early experiences of integrating HCD to advance these efforts. Objective: This article distills lessons gathered from 3 programs leveraging HCD to advance global health programming: (1) the “V” program which used an HCD approach to reframe the once-a-day HIV prevention pill from a potentially stigmatizing medicine into empowering self-care; (2) the Adolescents 360 program which integrated HCD to create a service for adolescent girls to access contraception in Ethiopia and to scale this offering nationwide; and (3) Reimagining TA which used HCD to help shift perceptions around traditional technical assistance models to one of co-creation, defining a new approach for non-financial support for health systems strengthening. Findings: To inform global health programs that are considering employing an HCD approach, lessons learned are distilled into 3 categories: (1) planning: considerations for problem definition and project scoping to allow for flexibility and selection of appropriate methods; (2) engaging: reflections on the means to productively engage different stakeholder groups to build alignment, understanding, and buy-in; (3) applying: adoption of new ways of working during implementation to best take advantage of the benefits of HCD while promoting long-term program sustainability and learning. Conclusion: These lessons represent an important step on the pathway to demonstrate the contributions of HCD to improving the effectiveness of health programs at a time when the global health community needs the most robust set of tools possible to meet the demands of our current pandemic context and beyond.
Collapse
Affiliation(s)
- Emily Blynn
- Independent consultant, Washington, DC, USA.
| | - Emily Harris
- U.S. Agency for International Development, Washington, DC, USA
| | | | | | | | - Monisha Ashok
- U.S. Agency for International Development, Washington, DC, USA
| | | |
Collapse
|
14
|
Brenner LD, Brudney R, Castaneda J, Liu A, Reyna ME, Leffel KR, Suskind D. Using Human-Centered Design in Personalized Anticipatory Guidance: Enriching Anticipatory Guidance on Early Cognitive and Language Development. Clin Pediatr (Phila) 2021; 60:528-542. [PMID: 34706580 DOI: 10.1177/00099228211051198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In this study, we aimed to create a novel tool to assist providers at 2 Chicago-area Federally Qualified Health Centers in giving guidance on early cognitive and language development during well-child visits. We utilized a human-centered design (HCD) process to address specific barriers to providing this guidance and create a tool shaped by the needs of providers and parents. Phase I involved collaborative prototype design; phase II involved implementation, feedback gathering, and responsive iterations of the tool; and phase III involved a collective review of the HCD process. The final version of the tool was a concise, colorful, and parent-accessible "Brain Building Guide" intended for interactive provider and parent use. It featured personalized information about parental knowledge and suggested areas for guidance. It was both satisfactory to stakeholders and efficacious in improving parental knowledge immediately post-visit and 1 month out. It should be further evaluated in a randomized controlled trial.
Collapse
Affiliation(s)
| | - Risa Brudney
- University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Jason Castaneda
- University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Asher Liu
- TMW Center for Early Learning + Public Health, Chicago, IL, USA
| | - Megan E Reyna
- TMW Center for Early Learning + Public Health, Chicago, IL, USA
| | | | - Dana Suskind
- TMW Center for Early Learning + Public Health, Chicago, IL, USA
| |
Collapse
|
15
|
Smith P, Buttenheim A, Schmucker L, Bekker LG, Thirumurthy H, Davey DLJ. Undetectable = Untransmittable (U = U) Messaging Increases Uptake of HIV Testing Among Men: Results from a Pilot Cluster Randomized Trial. AIDS Behav 2021; 25:3128-3136. [PMID: 34057659 PMCID: PMC8165342 DOI: 10.1007/s10461-021-03284-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2021] [Indexed: 01/20/2023]
Abstract
HIV testing coverage in sub-Saharan Africa is lower among men than women. We investigated the impact of a peer-delivered U = U (undetectable equals untransmittable) message on men’s HIV testing uptake through a cluster randomised trial with individual mobile clinic days as unit of randomisation. On standard of care (SOC) days, peer promoters informed men about the availability of HIV testing at the mobile clinic. On intervention days, peer promoters delivered U = U messages. We used logistic regression adjusting for mobile clinic location, clustering by study day, to determine the percentage of invited men who tested for HIV at the mobile clinic. Peer promoters delivered 1048 invitations over 12 days. In the SOC group, 68 (13%) of 544 men invited tested for HIV (3, 4.4% HIV-positive). In the U = U group, 112 (22%) of 504 men invited tested for HIV (7, 6.3% HIV-positive). Men in the U = U group had greater odds of testing for HIV (adjusted odds ratio = 1.89, 95% CI 1.21–2.95; p = 0.01). Tailored, peer-delivered messages that explain the benefits of HIV treatment in reducing HIV transmission can increase men’s HIV testing uptake.
Collapse
Affiliation(s)
- Philip Smith
- The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Science, University of Cape Town, Cape Town, South Africa.
| | - Alison Buttenheim
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Laura Schmucker
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Linda-Gail Bekker
- The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Science, University of Cape Town, Cape Town, South Africa
| | - Harsha Thirumurthy
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Dvora L Joseph Davey
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, USA
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
16
|
Pillsbury MKM, Mwangi E, Andesia J, Njuguna B, Bloomfield GS, Chepchumba A, Kamano J, Mercer T, Miheso J, Pastakia SD, Pathak S, Thakkar A, Naanyu V, Akwanalo C, Vedanthan R. Human-centered implementation research: a new approach to develop and evaluate implementation strategies for strengthening referral networks for hypertension in western Kenya. BMC Health Serv Res 2021; 21:910. [PMID: 34479556 PMCID: PMC8414706 DOI: 10.1186/s12913-021-06930-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 08/23/2021] [Indexed: 11/17/2022] Open
Abstract
Background Human-centered design (HCD) is an increasingly recognized approach for engaging stakeholders and developing contextually appropriate health interventions. As a component of the ongoing STRENGTHS study (Strengthening Referral Networks for Management of Hypertension Across the Health System), we report on the process and outcomes of utilizing HCD to develop the implementation strategy prior to a cluster-randomized controlled trial. Methods We organized a design team of 15 local stakeholders to participate in an HCD process to develop implementation strategies. We tested prototypes for acceptability, appropriateness, and feasibility through focus group discussions (FGDs) with various community stakeholder groups and a pilot study among patients with hypertension. FGD transcripts underwent content analysis, and pilot study data were analyzed for referral completion and reported barriers to referral. Based on this community feedback, the design team iteratively updated the implementation strategy. During each round of updates, the design team reflected on their experience through FGDs and a Likert-scale survey. Results The design team developed an implementation strategy consisting of a combined peer navigator and a health information technology (HIT) package. Overall, community participants felt that the strategy was acceptable, appropriate, and feasible. During the pilot study, 93% of referrals were completed. FGD participants felt that the implementation strategy facilitated referral completion through active peer engagement; enhanced communication between clinicians, patients, and health administrators; and integrated referral data into clinical records. Challenges included referral barriers that were not directly addressed by the strategy (e.g. transportation costs) and implementation of the HIT package across multiple health record systems. The design team reflected that all members contributed significantly to the design process, but emphasized the need for more transparency in how input from study investigators was incorporated into design team discussions. Conclusions The adaptive process of co-creation, prototyping, community feedback, and iterative redesign aligned our implementation strategy with community stakeholder priorities. We propose a new framework of human-centered implementation research that promotes collaboration between community stakeholders, study investigators, and the design team to develop, implement, and evaluate HCD products for implementation research. Our experience provides a feasible and replicable approach for implementation research in other settings. Trial registration Clinicaltrials.gov, NCT02501746, registration date: July 17, 2015, Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06930-2.
Collapse
Affiliation(s)
- Mc Kinsey M Pillsbury
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Eunice Mwangi
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Josephine Andesia
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | | | | | - Agneta Chepchumba
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Jemima Kamano
- Moi Teaching and Referral Hospital, Eldoret, Kenya.,College of Health Sciences, School of Medicine, Moi University, Eldoret, Kenya
| | - Tim Mercer
- Department of Population Health, The University of Texas at Austin Dell Medical School, Austin, TX, USA
| | - Juliet Miheso
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Sonak D Pastakia
- Center for Health Equity and Innovation, Purdue University, West Lafayette, IN, USA
| | | | | | - Violet Naanyu
- College of Health Sciences, School of Medicine, Moi University, Eldoret, Kenya
| | | | - Rajesh Vedanthan
- Department of Population Health, NYU Grossman School of Medicine, 180 Madison Avenue, 8th floor, New York, NY, 10016, USA.
| |
Collapse
|
17
|
Byonanebye DM, Mackline H, Sekaggya-Wiltshire C, Kiragga AN, Lamorde M, Oseku E, King R, Parkes-Ratanshi R. Impact of a mobile phone-based interactive voice response software on tuberculosis treatment outcomes in Uganda (CFL-TB): a protocol for a randomized controlled trial. Trials 2021; 22:391. [PMID: 34120649 PMCID: PMC8201814 DOI: 10.1186/s13063-021-05352-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 06/02/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Throughout the last decade, tuberculosis (TB) treatment success has not surpassed 90%, the global target. The impact of mobile health interventions (MHIs) on TB treatment outcomes is unknown, especially in low- and middle-income countries (LMICs). MHIs, including interactive voice response technology (IVRT), may enhance adherence and retention in the care of patients with tuberculosis and improve TB treatment outcomes. This study seeks to determine the impact of IVRT-based MHI on TB treatment success (treatment completion and cure rates) in patients with TB receiving care at five public health facilities in Uganda. METHODS We used a theory-based and human-centered design (HCD) to adapt an already piloted software to design "Call for life-TB" (CFL-TB), an MHI that utilizes IVRT to deliver adherence and appointment reminders and allows remote symptom reporting. This open-label, multicenter, randomized controlled trial (RCT), with nested qualitative and economic evaluation studies, will determine the impact of CFL-TB on TB treatment success in patients with drug-susceptible TB in Uganda. Participants (n = 274) at the five study sites will be randomized (1:1 ratio) to either control (standard of care) or intervention (adherence and appointment reminders, and health tips) arms. Multivariable regression models will be used to compare treatment success, adherence to treatment and clinic appointments, and treatment completion at 6 months post-enrolment. Additionally, we will determine the cost-effectiveness, acceptability, and perceptions of stakeholders. The study received national ethical approval and was conducted in accordance with the international ethical guidelines. DISCUSSION This randomized controlled trial aims to evaluate interactive voice response technology in the context of resource-limited settings with a high burden of TB and high illiteracy rates. The software to be evaluated was developed using HCD and the intervention was based on the IMB model. The software is tailored to the local context and is interoperable with the MHI ecosystem. The HCD approach ensures higher usability of the MHI by integrating human factors in the prototype development. This research will contribute towards the understanding of the implementation and impact of the MHI on TB treatment outcomes and the health system, especially in LMICs. TRIAL REGISTRATION ClinicalTrials.gov NCT04709159 . Registered on January 14, 2021.
Collapse
Affiliation(s)
- Dathan Mirembe Byonanebye
- Makerere University School of Public Health, P.O. Box 7072, Kampala, Uganda. .,Infectious Diseases Institute, Makerere University, P.O. Box 22418, Kampala, Uganda.
| | - Hope Mackline
- Infectious Diseases Institute, Makerere University, P.O. Box 22418, Kampala, Uganda
| | | | - Agnes N Kiragga
- Infectious Diseases Institute, Makerere University, P.O. Box 22418, Kampala, Uganda
| | - Mohammed Lamorde
- Infectious Diseases Institute, Makerere University, P.O. Box 22418, Kampala, Uganda
| | - Elizabeth Oseku
- Infectious Diseases Institute, Makerere University, P.O. Box 22418, Kampala, Uganda
| | - Rachel King
- Infectious Diseases Institute, Makerere University, P.O. Box 22418, Kampala, Uganda
| | | |
Collapse
|
18
|
Bartlett R, Boyle JA, Simons Smith J, Khan N, Robinson T, Ramaswamy R. Evaluating human-centred design for public health: a case study on developing a healthcare app with refugee communities. RESEARCH INVOLVEMENT AND ENGAGEMENT 2021; 7:32. [PMID: 34053451 PMCID: PMC8166144 DOI: 10.1186/s40900-021-00273-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 04/15/2021] [Indexed: 05/07/2023]
Abstract
BACKGROUND Australian women from migrant and refugee communities experience reduced access to sexual and reproductive healthcare. Human-centred design can be a more ethical and effective approach to developing health solutions with underserved populations that are more likely to experience significant disadvantage or social marginalisation. This study aimed to evaluate how well Shifra, a small Australian-based not-for-profit, applied human-centred design when developing a web-based application that delivers local, evidence-based and culturally relevant health information to its non-English speaking users. METHODS This study undertook a document review, survey, and semi-structured interviews to evaluate how well Shifra was able to achieve its objectives using a human-centred design approach. RESULTS A co-design process successfully led to the development of a web-based health app for refugee and migrant women. This evaluation also yielded several important recommendations for improving Shifra's human-centred design approach moving forward. CONCLUSIONS Improving refugees' access to sexual and reproductive health is complex and requires innovative and thoughtful problem solving. This evaluation of Shifra's human-centred design approach provides a helpful and rigorous guide in reporting that may encourage other organisations undertaking human-centred design work to evaluate their own implementation.
Collapse
Affiliation(s)
- Rebeccah Bartlett
- Monash Centre for Health Research and Implementation – MCHRI, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Jacqueline A. Boyle
- Monash Centre for Health Research and Implementation – MCHRI, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Jessica Simons Smith
- Public Health Leadership Program, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Nadia Khan
- Monash Centre for Health Research and Implementation – MCHRI, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Tracy Robinson
- School of Nursing, Midwifery & Indigenous Health, Faculty of Science, Charles Sturt University, Bathurst, Australia
| | - Rohit Ramaswamy
- Public Health Leadership Program, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, USA
| |
Collapse
|
19
|
Assessing the application of human-centered design to translational research. J Clin Transl Sci 2021; 5:e130. [PMID: 34367675 PMCID: PMC8327548 DOI: 10.1017/cts.2021.794] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 05/06/2021] [Accepted: 05/15/2021] [Indexed: 11/28/2022] Open
Abstract
Introduction: Human-centered design (HCD) training offers the potential to improve both team processes and products. However, the use of HCD to improve the quality of team science is a relatively recent application, and its benefits and challenges have not been rigorously evaluated. We conducted a qualitative study with health sciences researchers trained in HCD methods. We aimed to determine how researchers applied HCD methods and perceived the benefits and barriers to using HCD on research teams. Methods: We conducted 1-hour, semi-structured interviews with trainees from three training cohorts. Interviews focused on perceptions of the training, subsequent uses of HCD, barriers and facilitators, and perceptions of the utility of HCD to science teams. Data analysis was conducted using Braun and Clarke’s process for thematic analysis. Results: We interviewed nine faculty and nine staff trained in HCD methods and identified four themes encompassing HCD use, benefits, challenges, and tensions between HCD approaches and academic culture. Conclusions: Trainees found HCD relevant to research teams for stakeholder engagement, research design, project planning, meeting facilitation, and team management. They also described benefits of HCD in five distinct areas: creativity, egalitarianism, structure, efficiency, and visibility. Our data suggest that HCD has the potential to help researchers work more inclusively and collaboratively on interdisciplinary teams and generate more innovative and impactful science. The application of HCD methods is not without challenges; however, we believe these challenges can be overcome with institutional investment.
Collapse
|
20
|
Andersson SR, Hassanen S, Momanyi AM, Onyango DK, Gatwechi DK, Lutukai MN, Aura KO, Mungai AM, Chandani YK. Using Human-Centered Design to Adapt Supply Chains and Digital Solutions for Community Health Volunteers in Nomadic Communities of Northern Kenya. GLOBAL HEALTH, SCIENCE AND PRACTICE 2021; 9:S151-S167. [PMID: 33727327 PMCID: PMC7971376 DOI: 10.9745/ghsp-d-20-00378] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 11/12/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND Unreliable and nonexistent supply chain procedures and processes are one of the primary barriers to achieving functional community health units in nomadic communities in the arid/semiarid counties of Kenya. METHODS We used a human-centered design (HCD) approach to engage communities and community health volunteers (CHVs) in redesigning a proven data-centric supply chain approach that included a digital solution, called cStock, for this challenging context. We conducted the HCD process in 4 phases: (1) understanding intent, (2) research and insights, (3) ideation and prototyping, and (4) supply chain design and requirements building. Data collection used qualitative methods and involved a range of stakeholders including CHVs, supervisors, and local beneficiaries. CHVs and their supervisors also participated in cStock usability testing. Drawing on insights and personas generated from the research, stakeholders ideated and codesigned supply chain tools. RESULTS The research identified critical insights for informing the redesign of cStock for nomadic communities. These insights were categorized into supply chain, information systems, human resources, behaviors, service delivery infrastructure, and connectivity. Four supply chain data solutions were designed, prototyped, tested, and iterated: a stock recording paper-based form, a user-friendly cStock application, a supervisor cStock application, and an unstructured supplementary service data reporting system using feature phones. CONCLUSIONS Using the HCD process incorporated the perspective of CHVs and their communities and provided key insights to inform the design of the supply chain and adapt cStock. The process helped make cStock to be inclusive and have the potential to have a meaningful impact on strengthening the supply chain for seminomadic and nomadic communities in northern Kenya. A strong supply chain for these CHVs will increase access to essential and reproductive health commodities and contribute to improving the overall health and well-being of these communities, especially women and children.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Karen O Aura
- Ministry of Health Republic of Kenya, Nairobi, Kenya
| | - Alex M Mungai
- Ministry of Health Republic of Kenya, Nairobi, Kenya
| | | |
Collapse
|
21
|
Bell J, Sharma S, Malone S, Levy M, Reast J, Ciecieląg J, Gogolina S, Ansons T, Fourie S, Braz R, Little K, Hasen N. Targeting interventions for HIV testing and treatment uptake: An attitudinal and behavioural segmentation of men aged 20-34 in KwaZulu-Natal and Mpumalanga, South Africa. PLoS One 2021; 16:e0247483. [PMID: 33690691 PMCID: PMC7946194 DOI: 10.1371/journal.pone.0247483] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 02/08/2021] [Indexed: 11/19/2022] Open
Abstract
Despite recent improvements, men still have worse HIV outcomes than women in South Africa. This study describes how young men form distinct behavioural and attitudinal subgroups, and is intended to inform the design of targeted interventions to encourage HIV testing and initiation on antiretroviral therapy. Data were collected using a cross-sectional survey with questions on men’s attitudes, beliefs and behaviours around HIV/AIDS. A total of 2,019 men were randomly sampled from eight district municipalities in KwaZulu-Natal and Mpumalanga provinces between October 2018 and January 2019. Men were eligible to participate if they were aged 20–34, Black African, had an education level below university graduation, were aware of HIV and were willing to disclose whether they had tested for HIV. Each participant responded to a questionnaire asking about their demographic characteristics, reported sexual behaviour, engagement with HIV testing and treatment services, alcohol consumption, HIV knowledge, attitudes to gender equity and reported level of depressive symptoms. Data were analysed using canonical correlation, hierarchical clustering and factor analysis techniques to produce five groups of men. The results were synthesised using Human Centred Design principles to suggests areas for potential intervention for each segment. The results showed that men vary based on their attitudes to gender and masculinity, use of alcohol, testing and treatment behaviour, HIV-related fears and preferences for testing modalities. Segment 1 (21%) avoids the topic of HIV, perhaps fearful of the impact on his life. Segment 2 (23%) is well connected to his community and has social concerns about HIV. Segment 3 (15%) struggles with more distal determinants of HIV acquisition such as unemployment and poor mental health. Segment 4 (25%) has concerns about the lifestyle changes that would be required if he were HIV positive. Segment 5 (16%) has a strong traditional mindset and is fearful of the ramifications of HIV in his community. The results will be used to design targeted interventions to increase HIV testing and treatment rates among young men in South Africa. Further research is required to understand the impact of interventions designed in this way.
Collapse
Affiliation(s)
- James Bell
- Ipsos Healthcare, London, United Kingdom
- * E-mail:
| | | | - Shawn Malone
- Population Services International, Johannesburg, South Africa
| | | | | | | | | | - Tamara Ansons
- Global Science Organisation, Ipsos, London, United Kingdom
| | | | | | - Kristen Little
- Population Services International, Washington, DC, United States of America
| | - Nina Hasen
- Population Services International, Washington, DC, United States of America
| |
Collapse
|
22
|
Oliveira M, Zancul E, Fleury AL. Design thinking as an approach for innovation in healthcare: systematic review and research avenues. ACTA ACUST UNITED AC 2020. [DOI: 10.1136/bmjinnov-2020-000428] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Design thinking has been increasingly adopted as an approach to support innovation in healthcare. Recent publications report design thinking application to various innovation projects, across medical specialties, including paediatrics, psychiatry, radiology, gastroenterology, oncology, orthopaedics and surgery, as well as to innovation in hospital operations and healthcare management. Current literature in the area typically focuses on single case descriptions. With the recent increase in the number of cases, there is an opportunity to assess multiple cases to identify patterns and avenues for further research. This study provides a systematic review of published design thinking projects in healthcare. The aim of the study is to provide an overview of how design thinking has been applied in the healthcare sector. Data collection was based on Institute of Scientific Information (ISI) Web of Science, PubMed and Scopus databases. The systematic review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A total of 32 original pieces of research was selected for analysis, being classified and assessed. The paper presents current status of research and practice from various perspectives, including the design thinking progression phase—inspiration, ideation, implementation—and the prevalence of design thinking tools. Avenues for further research include the need to increase focus on the inspiration phase, the opportunity for platforms for leveraging the integration of individuals in innovation projects, and the opportunity to enhance the role of lead users in healthcare innovation.
Collapse
|
23
|
Durski KN, Singaravelu S, Naidoo D, Djingarey MH, Fall IS, Yahaya AA, Aylward B, Osterholm M, Formenty P. Design thinking during a health emergency: building a national data collection and reporting system. BMC Public Health 2020; 20:1896. [PMID: 33298019 PMCID: PMC7725425 DOI: 10.1186/s12889-020-10006-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 12/03/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Design thinking allows challenging problems to be redefined in order to identify alternative user-center strategies and solutions. To address the many challenges associated with collecting and reporting data during the 2014 Ebola outbreak in Guinea, Liberia and Sierra Leone, we used a design thinking approach to build the Global Ebola Laboratory Data collection and reporting system. MAIN TEXT We used the five-stage Design Thinking model proposed by Hasso-Plattner Institute of Design at Stanford in Guinea, Liberia and Sierra Leone. This approach offers a flexible model which focuses on empathizing, defining, ideating, prototyping, and testing. A strong focus of the methodology includes end-users' feedback from the beginning to the end of the process. This is an iterative methodology that continues to adapt according to the needs of the system. The stages do not need to be sequential and can be run in parallel, out of order, and repeated as necessary. Design thinking was used to develop a data collection and reporting system, which contains all laboratory data from the three countries during one of the most complicated multi-country outbreaks to date. The data collection and reporting system was used to orient the response interventions at the district, national, and international levels within the three countries including generating situation reports, monitoring the epidemiological and operational situations, providing forecasts of the epidemic, and supporting Ebola-related research and the Ebola National Survivors programs within each country. CONCLUSIONS Our study demonstrates the numerous benefits that arise when using a design thinking methodology during an outbreak to solve acute challenges within the national health information system and the authors recommend it's use during future complex outbreaks.
Collapse
Affiliation(s)
- Kara N Durski
- World Health Organization Avenue Appia 20, 1202, Genève, Switzerland. .,University of Minnesota School of Public Health, 420 Delaware St SE, Minneapolis, MN, 55455, USA.
| | | | - Dhamari Naidoo
- World Health Organization Avenue Appia 20, 1202, Genève, Switzerland
| | - Mamoudou Harouna Djingarey
- World Health Organization, Regional Office for Africa, Cité du Djoué, P.O.Box 06, Brazzaville, Republic of Congo
| | - Ibrahima Soce Fall
- World Health Organization, Regional Office for Africa, Cité du Djoué, P.O.Box 06, Brazzaville, Republic of Congo
| | - Ali Ahmed Yahaya
- World Health Organization, Regional Office for Africa, Cité du Djoué, P.O.Box 06, Brazzaville, Republic of Congo
| | - Bruce Aylward
- World Health Organization Avenue Appia 20, 1202, Genève, Switzerland
| | - Michael Osterholm
- University of Minnesota School of Public Health, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Pierre Formenty
- World Health Organization Avenue Appia 20, 1202, Genève, Switzerland
| |
Collapse
|
24
|
Patel D, Berger CA, Kityamuwesi A, Ggita J, Kunihira Tinka L, Turimumahoro P, Feler J, Chehab L, Chen AZ, Gupta N, Turyahabwe S, Katamba A, Cattamanchi A, Sammann A. Iterative Adaptation of a Tuberculosis Digital Medication Adherence Technology to Meet User Needs: Qualitative Study of Patients and Health Care Providers Using Human-Centered Design Methods. JMIR Form Res 2020; 4:e19270. [PMID: 33289494 PMCID: PMC7755538 DOI: 10.2196/19270] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 06/29/2020] [Accepted: 09/24/2020] [Indexed: 12/25/2022] Open
Abstract
Background Digital adherence technologies have been widely promoted as a means to improve tuberculosis medication adherence. However, uptake of these technologies has been suboptimal by both patients and health workers. Not surprisingly, studies have not demonstrated significant improvement in treatment outcomes. Objective This study aimed to optimize a well-known digital adherence technology, 99DOTS, for end user needs in Uganda. We describe the findings of the ideation phase of the human-centered design methodology to adapt 99DOTS according to a set of design principles identified in the previous inspiration phase. Methods 99DOTS is a low-cost digital adherence technology wherein tuberculosis medication blister packs are encased within an envelope that reveals toll-free numbers that patients can call to report dosing. We identified 2 key areas for design and testing: (1) the envelope, including the form factor, content, and depiction of the order of pill taking; and (2) the patient call-in experience. We conducted 5 brainstorming sessions with all relevant stakeholders to generate a suite of potential prototype concepts. Senior investigators identified concepts to further develop based on feasibility and consistency with the predetermined design principles. Prototypes were revised with feedback from the entire team. The envelope and call-in experience prototypes were tested and iteratively revised through focus groups with health workers (n=52) and interviews with patients (n=7). We collected and analyzed qualitative feedback to inform each subsequent iteration. Results The 5 brainstorming sessions produced 127 unique ideas that we clustered into 6 themes: rewards, customization, education, logistics, wording and imagery, and treatment countdown. We developed 16 envelope prototypes, 12 icons, and 28 audio messages for prototype testing. In the final design, we altered the pill packaging envelope by adding a front flap to conceal the pills and reduce potential stigma associated with tuberculosis. The flap was adorned with either a blank calendar or map of Uganda. The inside cover contained a personalized message from a local health worker including contact information, pictorial pill-taking instructions, and a choice of stickers to tailor education to the patient and phase of treatment. Pill-taking order was indicated with colors, chevron arrows, and small mobile phone icons. Last, the call-in experience when patients report dosing was changed to a rotating series of audio messages centered on the themes of prevention, encouragement, and reassurance that tuberculosis is curable. Conclusions We demonstrated the use of human-centered design as a promising tool to drive the adaptation of digital adherence technologies to better address the needs and motivations of end users. The next phase of research, known as the implementation phase in the human-centered design methodology, will investigate whether the adapted 99DOTS platform results in higher levels of engagement from patients and health workers, and ultimately improves tuberculosis treatment outcomes.
Collapse
Affiliation(s)
- Devika Patel
- Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Christopher Allen Berger
- Division of Pulmonary and Critical Care Medicine and Center for Tuberculosis, University of California, San Francisco, San Francisco, CA, United States
| | - Alex Kityamuwesi
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Joseph Ggita
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | | | | | - Joshua Feler
- School of Medicine, Yale University, New Haven, CA, United States
| | - Lara Chehab
- Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Amy Z Chen
- Everwell Health Solutions, Bangalore, India
| | | | | | - Achilles Katamba
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda.,Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Adithya Cattamanchi
- Division of Pulmonary and Critical Care Medicine and Center for Tuberculosis, University of California, San Francisco, San Francisco, CA, United States.,Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Amanda Sammann
- Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| |
Collapse
|
25
|
Amoakoh HB, Klipstein-Grobusch K, Agyepong IA, Amoakoh-Coleman M, Kayode GA, Reitsma JB, Grobbee DE, Ansah EK. Can an mhealth clinical decision-making support system improve adherence to neonatal healthcare protocols in a low-resource setting? BMC Pediatr 2020; 20:534. [PMID: 33243172 PMCID: PMC7694934 DOI: 10.1186/s12887-020-02378-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Accepted: 10/07/2020] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND This study assessed health workers' adherence to neonatal health protocols before and during the implementation of a mobile health (mHealth) clinical decision-making support system (mCDMSS) that sought to bridge access to neonatal health protocol gap in a low-resource setting. METHODS We performed a cross-sectional document review within two purposively selected clusters (one poorly-resourced and one well-resourced), from each arm of a cluster-randomized trial at two different time points: before and during the trial. The total trial consisted of 16 clusters randomized into 8 intervention and 8 control clusters to assess the impact of an mCDMSS on neonatal mortality in Ghana. We evaluated health workers' adherence (expressed as percentages) to birth asphyxia, neonatal jaundice and cord sepsis protocols by reviewing medical records of neonatal in-patients using a checklist. Differences in adherence to neonatal health protocols within and between the study arms were assessed using Wilcoxon rank-sum and permutation tests for each morbidity type. In addition, we tracked concurrent neonatal health improvement activities in the clusters during the 18-month intervention period. RESULTS In the intervention arm, mean adherence was 35.2% (SD = 5.8%) and 43.6% (SD = 27.5%) for asphyxia; 25.0% (SD = 14.8%) and 39.3% (SD = 27.7%) for jaundice; 52.0% (SD = 11.0%) and 75.0% (SD = 21.2%) for cord sepsis protocols in the pre-intervention and intervention periods respectively. In the control arm, mean adherence was 52.9% (SD = 16.4%) and 74.5% (SD = 14.7%) for asphyxia; 45.1% (SD = 12.8%) and 64.6% (SD = 8.2%) for jaundice; 53.8% (SD = 16.0%) and 60.8% (SD = 11.7%) for cord sepsis protocols in the pre-intervention and intervention periods respectively. We observed nonsignificant improvement in protocol adherence in the intervention clusters but significant improvement in protocol adherence in the control clusters. There were 2 concurrent neonatal health improvement activities in the intervention clusters and over 12 in the control clusters during the intervention period. CONCLUSION Whether mHealth interventions can improve adherence to neonatal health protocols in low-resource settings cannot be ascertained by this study. Neonatal health improvement activities are however likely to improve protocol adherence. Future mHealth evaluations of protocol adherence must account for other concurrent interventions in study contexts.
Collapse
Affiliation(s)
- Hannah Brown Amoakoh
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Centre, Utrecht University, Utrecht, The Netherlands
- School of Public Health, University of Ghana, P.O. Box LG13, Legon Accra, Ghana
| | - Kerstin Klipstein-Grobusch
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Centre, Utrecht University, Utrecht, The Netherlands
- Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Irene Akua Agyepong
- Research and Development Division, Ghana Health Service, Dodowa Accra, Ghana
| | | | - Gbenga A. Kayode
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Centre, Utrecht University, Utrecht, The Netherlands
- International Research Centre of Excellence, Institute of Human Virology, Abuja, Nigeria
| | - J. B. Reitsma
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Centre, Utrecht University, Utrecht, The Netherlands
| | - Diederick E. Grobbee
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Centre, Utrecht University, Utrecht, The Netherlands
| | | |
Collapse
|
26
|
Leonard E, de Kock I, Bam W. Barriers and facilitators to implementing evidence-based health innovations in low- and middle-income countries: A systematic literature review. EVALUATION AND PROGRAM PLANNING 2020; 82:101832. [PMID: 32585317 DOI: 10.1016/j.evalprogplan.2020.101832] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 03/23/2020] [Accepted: 06/04/2020] [Indexed: 05/25/2023]
Abstract
The unsuccessful implementation of health innovations occurs frequently, leading to missed opportunities where improvements could have been made on various aspects of a health system. The purpose of this study is to identify, assess and synthesise the facilitators and barriers to sustainably implementing evidence-based health innovations in a low- and middle-income country (LMIC) context. To identify the LMIC specific facilitators and barriers, a systematic literature review was conducted. 79 studies were analysed, and the implementation barriers and facilitators identified in each study were extracted. The extracted barriers and facilitators were categorised and synthesized into one of seven concepts: context, innovation, relations and networks, institutions, knowledge, actors or resources. There were no substantial variations between the frequency that each concept was identified as a facilitator or barrier to implementation. However, resources, which includes time, human, financial and physical resources, was the most frequently mentioned concept; emphasising the need to focus on the resource situation in LMICs. This study contributes to the growing literature that aims to inform health system planners and evaluators in LMICs on effectively and sustainably implementing evidence-based health innovations.
Collapse
Affiliation(s)
- Elizabeth Leonard
- Department of Industrial Engineering, Stellenbosch University, Stellenbosch, Western Cape, South Africa.
| | - Imke de Kock
- Department of Industrial Engineering, Stellenbosch University, Stellenbosch, Western Cape, South Africa
| | - Wouter Bam
- Department of Industrial Engineering, Stellenbosch University, Stellenbosch, Western Cape, South Africa
| |
Collapse
|
27
|
Babione JN, Ocampo W, Haubrich S, Yang C, Zuk T, Kaufman J, Carpendale S, Ghali W, Altabbaa G. Human-centred design processes for clinical decision support: A pulmonary embolism case study. Int J Med Inform 2020; 142:104196. [DOI: 10.1016/j.ijmedinf.2020.104196] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 05/19/2020] [Accepted: 05/22/2020] [Indexed: 12/30/2022]
|
28
|
Arrivillaga M, Bermúdez PC, García-Cifuentes JP, Botero J. Innovative prototypes for cervical cancer prevention in low-income primary care settings: A human-centered design approach. PLoS One 2020; 15:e0238099. [PMID: 32833974 PMCID: PMC7446804 DOI: 10.1371/journal.pone.0238099] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 08/10/2020] [Indexed: 12/24/2022] Open
Abstract
This article presents the design process of innovative prototypes for cervical cancer prevention in primary care centers located in low-income settings in Cali, Colombia, using the Human-Centered Design (HCD). The project was developed in collaboration with a public healthcare network comprised of 38 urban and rural centers with women between the ages of 25 and 65 years, healthcare providers of the cancer program, healthcare administrators and the general manager of said network. Our HCD process involved five stages: research, need synthesis, ideation and co-design process, prototyping and in-context usability testing. In practice, some of the stages are overlapped and iterated throughout the design process. We conducted observations, open-ended interviews and conversations, multi-stakeholder workshops, focus groups, systematic text condensation analyses and tests in real contexts. As a result, we designed four prototypes: (1) 'Encanto': An educational manicure service, (2) 'No le des la espalda a la citología': A media-based strategy, (3) An educational wireless queuing device in the waiting room, and (4) Citobot: A cervical cancer early detection device, system, and method. The tests carried out with each prototype showed their value, limitations and possibilities in terms of subsequent development and validation through public health research or clinical research. We recognize that a longer-term evaluation is required in order to determine whether the prototypes will be used regularly, integrated into cervical cancer screening services and effectively improve access to cytology as a screening test. We conclude that HCD is a useful for design-based prevention in the field of cervical cancer. The integration of this approach with public health research would allow the generation of evidence during to the formulation of policies and programs as well as optimize existing interventions and, ultimately, facilitate the scalability and financing of what actually works.
Collapse
Affiliation(s)
- Marcela Arrivillaga
- Department of Public Health and Epidemiology, Pontificia Universidad Javeriana, Cali, Colombia
| | - Paula C. Bermúdez
- Department of Public Health and Epidemiology, Pontificia Universidad Javeriana, Cali, Colombia
| | | | - Jorge Botero
- Centro de Consultoría y Educación Continua, Pontificia Universidad Javeriana, Cali, Colombia
| |
Collapse
|
29
|
Kiyasseh D, Zhu T, Clifton D. The Promise of Clinical Decision Support Systems Targetting Low-Resource Settings. IEEE Rev Biomed Eng 2020; 15:354-371. [PMID: 32813662 DOI: 10.1109/rbme.2020.3017868] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Low-resource clinical settings are plagued by low physician-to-patient ratios and a shortage of high-quality medical expertise and infrastructure. Together, these phenomena lead to over-burdened healthcare systems that under-serve the needs of the community. Alleviating this burden can be undertaken by the introduction of clinical decision support systems (CDSSs); systems that support stakeholders (ranging from physicians to patients) within the clinical setting in their day-to-day activities. Such systems, which have proven to be effective in the developed world, remain to be under-explored in low-resource settings. This review attempts to summarize the research focused on clinical decision support systems that either target stakeholders within low-resource clinical settings or diseases commonly found in such environments. When categorizing our findings according to disease applications, we find that CDSSs are predominantly focused on dealing with bacterial infections and maternal care, do not leverage deep learning, and have not been evaluated prospectively. Together, these highlight the need for increased research in this domain in order to impact a diverse set of medical conditions and ultimately improve patient outcomes.
Collapse
|
30
|
Digitizing Infectious Disease Clinical Guidelines for Improved Clinician Satisfaction. Comput Inform Nurs 2020; 38:303-311. [PMID: 32079814 DOI: 10.1097/cin.0000000000000612] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The purpose of this project was to implement an improved rapid-deployment clinical decision support strategy for the detection and treatment of emerging and reemerging infectious diseases within an electronic health record informed by end-user satisfaction. After a review of the evidence and comprehensive workflow assessments, interdisciplinary focus groups were assembled to determine current infectious disease needs within the electronic health record and what guidance should be provided to clinicians to assist in making the best decisions for both patient care and population health. Education and reeducation issues were handled throughout the implementation process. Using the Plan-Do-Study-Act quality improvement framework for rapid cycle deployment, the design was implemented and monitored. To evaluate efficacy and clinician satisfaction of the implementation, presurvey and postsurvey measurements were employed. The Clinical Information System Implementation Evaluation Scale was used, along with demographic and qualitative textual questions, to evaluate clinician satisfaction. Findings indicate the implementation was successful (P < .05).
Collapse
|
31
|
Human-Centered Design Lessons for Implementation Science: Improving the Implementation of a Patient-Centered Care Intervention. J Acquir Immune Defic Syndr 2020; 82 Suppl 3:S230-S243. [PMID: 31764259 PMCID: PMC6880397 DOI: 10.1097/qai.0000000000002216] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Supplemental Digital Content is Available in the Text. Evidence-based HIV interventions often fail to reach anticipated impact due to insufficient utilization in real-world health systems. Human-centered design (HCD) represents a novel approach in tailoring innovations to fit end-users, narrowing the gap between efficacious interventions and impact at scale.
Collapse
|
32
|
Smith C, van Velthoven MH, Truong ND, Nam NH, Anh VP, AL-Ahdal TMA, Hassan OG, Kouz B, Huy NT, Brewster M, Pakenham-Walsh N. How primary healthcare workers obtain information during consultations to aid safe prescribing in low-income and lower middle-income countries: a systematic review. BMJ Glob Health 2020; 5:e002094. [PMID: 32337085 PMCID: PMC7170426 DOI: 10.1136/bmjgh-2019-002094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 02/18/2020] [Accepted: 02/28/2020] [Indexed: 11/04/2022] Open
Abstract
Background We systematically reviewed the evidence on how primary healthcare workers obtain information during consultations to support decision-making for prescribing in low and lower middle-income countries. Methods We searched electronic databases, consulted the Healthcare Information For All network, hand searched reference lists, ran citation searches of included studies and emailed authors of identified papers. Two reviewers extracted data and appraised quality with relevant tools. Results Of 60 497 records found, 23 studies met our inclusion criteria. Fourteen studies were observational and nine were interventional. Frequently mentioned sources of information were books, leaflets, guidelines, aids and the internet. These sources were sometimes out of date and health workers reported being confused which to use. Internet access varied and even when it was available, use was limited by technical issues. Of the five electronic tools that were assessed, four had positive outcomes. Tools assisted prescribers with medicine selection and dosage calculations, which increased prescribing accuracy. The quality of reporting varied but was overall low. Discussion Studies indicated a lack of up-to-date and relevant medicine information in low and lower middle-income settings. Internet-based sources appeared to be useful when it is possible to download content for offline use and to update when there is internet access. Electronic tools showed promise, but their accuracy needs to be validated and they should focus on giving actionable advice to guide prescribers. PROSPERO registration number CRD42018091088.
Collapse
Affiliation(s)
- Chris Smith
- School of Tropical Medicine and Global Health (TMGH), Nagasaki University, Nagasaki, Japan
- Department of Clinical Research, London School of Hygiene and Tropical Medicine Faculty of Infectious and Tropical Diseases, London, UK
| | - Michelle Helena van Velthoven
- School of Tropical Medicine and Global Health (TMGH), Nagasaki University, Nagasaki, Japan
- Department of Paediatrics, Oxford University, Oxford, Oxfordshire, UK
| | - Nguyen Duc Truong
- Nagasaki University, Nagasaki, Japan
- Obstetrics and Gynecologic Department, FV Hospital, Ho Chi Minh City, Vietnam
| | - Nguyen Hai Nam
- Nagasaki University, Nagasaki, Japan
- Department of General Surgery, Ho Chi Minh City University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam
| | - Vũ Phan Anh
- Nagasaki University, Nagasaki, Japan
- Department of Neonatology, Children's Hospital 2, Ho Chi Minh City, Vietnam
| | - Tareq Mohammed Ali AL-Ahdal
- Nagasaki University, Nagasaki, Japan
- Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Osama Gamal Hassan
- Nagasaki University, Nagasaki, Japan
- Faculty of Medicine, South Valley University, Qena, Egypt
| | - Basel Kouz
- Nagasaki University, Nagasaki, Japan
- Faculty of Medicine, Damascus University, Damascus, Damascus Governorate, Syria
| | | | - Malcolm Brewster
- Healthcare Information For All (HIFA) network, Global Healthcare Information Network, Charlbury, UK
| | - Neil Pakenham-Walsh
- Healthcare Information For All (HIFA) network, Global Healthcare Information Network, Charlbury, UK
| |
Collapse
|
33
|
Aifah A, Okeke NL, Rentrope CR, Schexnayder J, Bloomfield GS, Bosworth H, Grover K, Hileman CO, Muiruri C, Oakes M, Webel AR, Longenecker CT, Vedanthan R. Use of a human-centered design approach to adapt a nurse-led cardiovascular disease prevention intervention in HIV clinics. Prog Cardiovasc Dis 2020; 63:92-100. [PMID: 32092444 PMCID: PMC7237285 DOI: 10.1016/j.pcad.2020.02.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 02/18/2020] [Indexed: 02/06/2023]
Abstract
Stakeholder-informed strategies addressing cardiovascular disease (CVD) burden among people living with HIV (PWH) are needed within healthcare settings. This study provides an assessment of how human-centered design (HCD) guided the adaptation of a nurse-led intervention to reduce CVD risk among PWH. Using a HCD approach, research staff guided two multidisciplinary "design teams" in Ohio and North Carolina, with each having five HCD meetings. We conducted acceptability and feasibility testing. Six core recommendations were produced by two design teams of key stakeholders and further developed after the acceptability and feasibility testing to produce a final list of 14 actionable areas of adaptation. Acceptability and feasibility testing revealed areas for adaptation, e.g. patient preferences for communication and the benefit of additional staff to support patient follow-up. In conclusion, along with acceptability and feasibility testing, HCD led to the production of 14 key recommendations to enhance the effectiveness and scalability of an integrated HIV/CVD intervention.
Collapse
Affiliation(s)
- Angela Aifah
- New York University Grossman School of Medicine, United States of America.
| | | | - Cynthia R Rentrope
- Frances Payne Bolton School of Nursing, Case Western Reserve University, United States of America
| | - Julie Schexnayder
- Frances Payne Bolton School of Nursing, Case Western Reserve University, United States of America
| | | | - Hayden Bosworth
- Duke University School of Medicine, United States of America; Durham VA Medical Center, United States of America
| | - Kiran Grover
- Duke University School of Medicine, United States of America
| | - Corrilynn O Hileman
- Case Western Reserve University School of Medicine, United States of America; MetroHealth Medical Center, United States of America
| | - Charles Muiruri
- Duke University School of Medicine, United States of America
| | - Megan Oakes
- Duke University School of Medicine, United States of America; Durham VA Medical Center, United States of America
| | - Allison R Webel
- Frances Payne Bolton School of Nursing, Case Western Reserve University, United States of America
| | - Chris T Longenecker
- Case Western Reserve University School of Medicine, United States of America; University Hospitals Harrington Heart & Vascular Institute, United States of America
| | - Rajesh Vedanthan
- New York University Grossman School of Medicine, United States of America
| |
Collapse
|
34
|
van der Westhuizen D, Conrad N, Douglas TS, Mutsvangwa T. Engaging Communities on Health Innovation: Experiences in Implementing Design Thinking. INTERNATIONAL QUARTERLY OF COMMUNITY HEALTH EDUCATION 2020; 41:101-114. [DOI: 10.1177/0272684x19900880] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Design thinking is an approach gaining momentum as a strategy for promoting empathy-driven, human-centered innovation. To evaluate the implementation of design thinking for engaging with communities about health and well-being, we undertook a qualitative analysis of an engagement between students and relevant community stakeholders during a project to develop a health intervention aimed at increasing medication compliance in an elderly community in South Africa. Major findings from this research indicated that design thinking offers opportunities for enriching community–university engagements. However, given constraints on time and procedure that are associated with the academy, the fast, dynamic style of design thinking is not optimally suited for developing the level of trust and rapport that is required for engagements in communities where social-cultural differences operate as barriers. Researchers who wish to utilize design thinking will need to devise and tailor additions to tool kits to meet the specific needs of engagements related to personal health and well-being.
Collapse
Affiliation(s)
- Donné van der Westhuizen
- Division of Biomedical Engineering, Department of Human Biology, University of Cape Town, South Africa
| | - Nailah Conrad
- Division of Biomedical Engineering, Department of Human Biology, University of Cape Town, South Africa
| | - Tania S. Douglas
- Division of Biomedical Engineering, Department of Human Biology, University of Cape Town, South Africa
| | - Tinashe Mutsvangwa
- Division of Biomedical Engineering, Department of Human Biology, University of Cape Town, South Africa
| |
Collapse
|
35
|
Re-thinking Linkage to Care in the Era of Universal Test and Treat: Insights from Implementation and Behavioral Science for Achieving the Second 90. AIDS Behav 2019; 23:120-128. [PMID: 31161462 PMCID: PMC6773672 DOI: 10.1007/s10461-019-02541-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
To successfully link to care, persons living with HIV must negotiate a complex series of processes from HIV diagnosis through initial engagement with HIV care systems and providers. Despite the complexity involved, linkage to care is often oversimplified and portrayed as a single referral step. In this article, we offer a new conceptual framework for linkage to care, tailored to the current universal test and treat era that presents linkage to care as its own nuanced pathway within the larger HIV care cascade. Conceptualizing linkage to care in this way may help better identify and specify processes posing a barrier to linkage, and allow for the development of targeted implementation and behavioral science-based approaches to address them. Such approaches are likely to be most relevant to programmatic and clinical settings with limited resources and high HIV burden.
Collapse
|
36
|
Mannell J, Willan S, Shahmanesh M, Seeley J, Sherr L, Gibbs A. Why interventions to prevent intimate partner violence and HIV have failed young women in southern Africa. J Int AIDS Soc 2019; 22:e25380. [PMID: 31441229 PMCID: PMC6706780 DOI: 10.1002/jia2.25380] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 07/31/2019] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Adolescent girls and young women aged 15 to 24 years have some of the highest HIV incidence rates globally, with girls two to four times more likely to be living with HIV than their male peers. High levels of intimate partner violence (IPV) experienced by this age group is a significant risk factor for HIV acquisition. While behavioural interventions to prevent IPV and HIV in southern Africa have seen some success in reducing self-reported experiences of IPV, these interventions have largely failed to achieve similar outcomes for young women. DISCUSSION We identify three main reasons for the failure of IPV/HIV interventions for many young women in southern Africa. First, interventions are usually developed without the meaningful involvement of both young women and young men. Youth input into research design is largely focused on user testing or consultation of targeted groups, involving relatively low levels of participation. Second, interventions are focused on addressing individual risk factors rather than broader social and structural contexts of being a young woman. "Risk factor" interventions, rather than supporting women's agency, can pose a major barrier for supporting changes in behaviour among young women because they often fail to dislodge well-entrenched gender and age-related inequalities. Third, current intervention models have not adequately accounted for changes in gender norms and relationships across southern Africa. Individuals are getting married later in life (or not at all), new technologies are transforming romantic interactions and opening new opportunities for violence, and discussions about women's rights are both challenging gender inequalities and reinforcing them. CONCLUSIONS In order to move beyond the status quo of current approaches, and to support real innovation, IPV/HIV prevention interventions need to be co-developed with youth as part of a meaningful participatory process of research, intervention design, youth involvement in development and implementation. This process of co-development needs to be radical and break with the current focus on adapting existing interventions to meet the needs of young people, which are not well understood and often do not directly reflect their priorities. Broader social contexts and compound lenses are needed to avoid narrow approaches and to accommodate evolving norms.
Collapse
Affiliation(s)
| | - Samantha Willan
- Gender and Health Research UnitSouth African Medical Research CouncilPretoriaSouth Africa
| | - Maryam Shahmanesh
- Institute for Global HealthUniversity College LondonLondonUK
- Africa Health Research InstituteKwaZulu‐NatalSouth Africa
| | - Janet Seeley
- Institute for Global HealthUniversity College LondonLondonUK
- Department of Global Health and DevelopmentLondon School of Hygiene and Tropical MedicineLondonUK
| | - Lorraine Sherr
- Institute for Global HealthUniversity College LondonLondonUK
| | - Andrew Gibbs
- Gender and Health Research UnitSouth African Medical Research CouncilPretoriaSouth Africa
- Centre for Rural HealthSchool of Nursing and Public HealthUniversity of KwaZulu‐NatalDurbanSouth Africa
| |
Collapse
|
37
|
O'Donovan J, Verkerk M, Winters N, Chadha S, Bhutta MF. The role of community health workers in addressing the global burden of ear disease and hearing loss: a systematic scoping review of the literature. BMJ Glob Health 2019; 4:e001141. [PMID: 30899572 PMCID: PMC6407559 DOI: 10.1136/bmjgh-2018-001141] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 01/18/2019] [Accepted: 01/25/2019] [Indexed: 12/21/2022] Open
Abstract
Introduction Community health workers (CHWs) have the potential to improve access to ear and hearing services for people across low-income or middle-income countries, remote, underserved, or resource-poor areas of the world. We performed a systematic scoping review to identify evidence on how CHWs are currently deployed in the prevention, screening, diagnosis, treatment and management of ear disease and hearing loss; methods to train and support CHWs in this context; and cost-effectiveness of CHWs. Methods We performed a systematic search of the literature from September 1978 to 18 March 2018 from 11 major databases and the grey literature. Results We identified 38 original studies that met the inclusion criteria, taking place across South Asia (n=13), Oceania (n=7), North America (n=7), South America (n=6) and Africa (n=5). 23 studies showed CHWs can increase community participation in screening. They can conduct screening using whispered voice tests, noisemakers for neonatal screening, automated audiological tests and otoscopy. Eight studies focused specifically on the evaluation of programmes to train CHWs, and three provided a general programme description. Three studies documented a role of CHWs in the treatment of ear disease or hearing loss, such as performing ear washouts, instillation of topical antibiotics or fitting of hearing aids. Only one study provided an indepth cost-utility analysis regarding the use of CHWs to conduct hearing screening, and no studies commented on the role of CHWs in the prevention of hearing loss. Conclusion CHWs have been employed in diverse ways to address the global burden of ear disease and hearing loss. Future research needs to explore the role of CHWs in preventative strategies, identify optimum methods to train and support CHWs, and explore their cost-effectiveness.
Collapse
Affiliation(s)
- James O'Donovan
- Department of Education, University of Oxford, Oxford, UK.,Division of Research and Health Equity, Omni Med, Mukono, Uganda
| | - Misha Verkerk
- Department of Otolaryngology, King's College Hospital NHS Foundation Trust, London, UK
| | - Niall Winters
- Department of Education, University of Oxford, Oxford, UK
| | - Shelly Chadha
- WHO Programme for Prevention of Deafness and Hearing Loss, World Health Organization, Geneva, Switzerland
| | - Mahmood F Bhutta
- Department of ENT, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| |
Collapse
|
38
|
Syzdykova A, Malta A, Zolfo M, Diro E, Oliveira JL. Open-Source Electronic Health Record Systems for Low-Resource Settings: Systematic Review. JMIR Med Inform 2017; 5:e44. [PMID: 29133283 PMCID: PMC5703976 DOI: 10.2196/medinform.8131] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Revised: 08/14/2017] [Accepted: 09/13/2017] [Indexed: 12/02/2022] Open
Abstract
Background Despite the great impact of information and communication technologies on clinical practice and on the quality of health services, this trend has been almost exclusive to developed countries, whereas countries with poor resources suffer from many economic and social issues that have hindered the real benefits of electronic health (eHealth) tools. As a component of eHealth systems, electronic health records (EHRs) play a fundamental role in patient management and effective medical care services. Thus, the adoption of EHRs in regions with a lack of infrastructure, untrained staff, and ill-equipped health care providers is an important task. However, the main barrier to adopting EHR software in low- and middle-income countries is the cost of its purchase and maintenance, which highlights the open-source approach as a good solution for these underserved areas. Objective The aim of this study was to conduct a systematic review of open-source EHR systems based on the requirements and limitations of low-resource settings. Methods First, we reviewed existing literature on the comparison of available open-source solutions. In close collaboration with the University of Gondar Hospital, Ethiopia, we identified common limitations in poor resource environments and also the main requirements that EHRs should support. Then, we extensively evaluated the current open-source EHR solutions, discussing their strengths and weaknesses, and their appropriateness to fulfill a predefined set of features relevant for low-resource settings. Results The evaluation methodology allowed assessment of several key aspects of available solutions that are as follows: (1) integrated applications, (2) configurable reports, (3) custom reports, (4) custom forms, (5) interoperability, (6) coding systems, (7) authentication methods, (8) patient portal, (9) access control model, (10) cryptographic features, (11) flexible data model, (12) offline support, (13) native client, (14) Web client,(15) other clients, (16) code-based language, (17) development activity, (18) modularity, (19) user interface, (20) community support, and (21) customization. The quality of each feature is discussed for each of the evaluated solutions and a final comparison is presented. Conclusions There is a clear demand for open-source, reliable, and flexible EHR systems in low-resource settings. In this study, we have evaluated and compared five open-source EHR systems following a multidimensional methodology that can provide informed recommendations to other implementers, developers, and health care professionals. We hope that the results of this comparison can guide decision making when needing to adopt, install, and maintain an open-source EHR solution in low-resource settings.
Collapse
Affiliation(s)
- Assel Syzdykova
- University of Aveiro, Department of Electronics, Telecommunications and Informatics (DETI) / Institute of Electronics and Informatics Engineering of Aveiro (IEETA), Aveiro, Portugal.,BMD Software, Aveiro, Portugal
| | - André Malta
- University of Aveiro, Department of Electronics, Telecommunications and Informatics (DETI) / Institute of Electronics and Informatics Engineering of Aveiro (IEETA), Aveiro, Portugal
| | - Maria Zolfo
- Institute of Tropical Medicine, Antwerp, Belgium
| | | | - José Luis Oliveira
- University of Aveiro, Department of Electronics, Telecommunications and Informatics (DETI) / Institute of Electronics and Informatics Engineering of Aveiro (IEETA), Aveiro, Portugal
| |
Collapse
|
39
|
Bazzano AN, Martin J, Hicks E, Faughnan M, Murphy L. Human-centred design in global health: A scoping review of applications and contexts. PLoS One 2017; 12:e0186744. [PMID: 29091935 PMCID: PMC5665524 DOI: 10.1371/journal.pone.0186744] [Citation(s) in RCA: 187] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 10/08/2017] [Indexed: 12/01/2022] Open
Abstract
Health and wellbeing are determined by a number of complex, interrelated factors. The application of design thinking to questions around health may prove valuable and complement existing approaches. A number of public health projects utilizing human centered design (HCD), or design thinking, have recently emerged, but no synthesis of the literature around these exists. The results of a scoping review of current research on human centered design for health outcomes are presented. The review aimed to understand why and how HCD can be valuable in the contexts of health related research. Results identified pertinent literature as well as gaps in information on the use of HCD for public health research, design, implementation and evaluation. A variety of contexts were identified in which design has been used for health. Global health and design thinking have different underlying conceptual models and terminology, creating some inherent tensions, which could be overcome through clear communication and documentation in collaborative projects. The review concludes with lessons learned from the review on how future projects can better integrate design thinking with global health research.
Collapse
Affiliation(s)
- Alessandra N. Bazzano
- Taylor Canter for Social Innovation and Design Thinking, Tulane University, New Orleans, United States of America
- * E-mail:
| | - Jane Martin
- Creative Social Change, London, United Kingdom
| | - Elaine Hicks
- Tulane University School of Public Health and Tropical Medicine, New Orleans, United States of America
| | - Maille Faughnan
- Taylor Canter for Social Innovation and Design Thinking, Tulane University, New Orleans, United States of America
- Tulane University School of Public Health and Tropical Medicine, New Orleans, United States of America
| | - Laura Murphy
- Taylor Canter for Social Innovation and Design Thinking, Tulane University, New Orleans, United States of America
- Tulane University School of Public Health and Tropical Medicine, New Orleans, United States of America
| |
Collapse
|
40
|
Adepoju IOO, Albersen BJA, De Brouwere V, van Roosmalen J, Zweekhorst M. mHealth for Clinical Decision-Making in Sub-Saharan Africa: A Scoping Review. JMIR Mhealth Uhealth 2017; 5:e38. [PMID: 28336504 PMCID: PMC5383806 DOI: 10.2196/mhealth.7185] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Revised: 02/17/2017] [Accepted: 02/21/2017] [Indexed: 02/07/2023] Open
Abstract
Background In a bid to deliver quality health services in resource-poor settings, mobile health (mHealth) is increasingly being adopted. The role of mHealth in facilitating evidence-based clinical decision-making through data collection, decision algorithms, and evidence-based guidelines, for example, is established in resource-rich settings. However, the extent to which mobile clinical decision support systems (mCDSS) have been adopted specifically in resource-poor settings such as Africa and the lessons learned about their use in such settings are yet to be established. Objective The aim of this study was to synthesize evidence on the use of mHealth for point-of-care decision support and improved quality of care by health care workers in Africa. Methods A scoping review of 4 peer-reviewed and 1 grey literature databases was conducted. No date limits were applied, but only articles in English language were selected. Using pre-established criteria, 2 reviewers screened articles and extracted data. Articles were analyzed using Microsoft Excel and MAXQDA. Results We retained 22 articles representing 11 different studies in 7 sub-Saharan African countries. Interventions were mainly in the domain of maternal health and ranged from simple text messaging (short message service, SMS) to complex multicomponent interventions. Although health workers are generally supportive of mCDSS and perceive them as useful, concerns about increased workload and altered workflow hinder sustainability. Facilitators and barriers to use of mCDSS include technical and infrastructural support, ownership, health system challenges, and training. Conclusions The use of mCDSS in sub-Saharan Africa is an indication of progress in mHealth, although their effect on quality of service delivery is yet to be fully explored. Lessons learned are useful for informing future research, policy, and practice for technologically supported health care delivery, especially in resource-poor settings.
Collapse
Affiliation(s)
- Ibukun-Oluwa Omolade Adepoju
- Athena Institute for Research on Innovation and Communication in Health and Life Sciences, Vrije Universiteit Amsterdam, Amsterdam, Netherlands.,Institute of Tropical Medicine, Maternal and Reproductive Health Unit, Department of Public Health, Antwerp, Belgium
| | - Bregje Joanna Antonia Albersen
- Athena Institute for Research on Innovation and Communication in Health and Life Sciences, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Vincent De Brouwere
- Institute of Tropical Medicine, Maternal and Reproductive Health Unit, Department of Public Health, Antwerp, Belgium
| | - Jos van Roosmalen
- Athena Institute for Research on Innovation and Communication in Health and Life Sciences, Vrije Universiteit Amsterdam, Amsterdam, Netherlands.,Leiden University Medical Center, Department of Obstetrics, Leiden, Netherlands
| | - Marjolein Zweekhorst
- Athena Institute for Research on Innovation and Communication in Health and Life Sciences, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| |
Collapse
|
41
|
Quality Improvement Project to Improve Patient Satisfaction With Pain Management: Using Human-Centered Design. J Nurs Care Qual 2017; 31:105-12; quiz 113-4. [PMID: 26447343 DOI: 10.1097/ncq.0000000000000161] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
In this quality improvement project, our health system developed a comprehensive, patient-centered approach to improving inpatient pain management and assessed its impact on patient satisfaction across 21 medical centers. Using human-centered design principles, a bundle of 6 individual and team nursing practices was developed. Patient satisfaction with pain management, as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems pain composite score, increased from the 25th to just under the 75th national percentile.
Collapse
|
42
|
Ellsworth MA, Dziadzko M, O'Horo JC, Farrell AM, Zhang J, Herasevich V. An appraisal of published usability evaluations of electronic health records via systematic review. J Am Med Inform Assoc 2017; 24:218-226. [PMID: 27107451 PMCID: PMC7654077 DOI: 10.1093/jamia/ocw046] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2015] [Revised: 02/25/2016] [Accepted: 03/01/2016] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE In this systematic review, we aimed to evaluate methodological and reporting trends present in the current literature by investigating published usability studies of electronic health records (EHRs). METHODS A literature search was conducted for articles published through January 2015 using MEDLINE (Ovid), EMBASE, Scopus, and Web of Science, supplemented by citation and reference list reviews. Studies were included if they tested the usability of hospital and clinic EHR systems in the inpatient, outpatient, emergency department, or operating room setting. RESULTS A total of 4848 references were identified for title and abstract screening. Full text screening was performed for 197 articles, with 120 meeting the criteria for study inclusion. CONCLUSION A review of the literature demonstrates a paucity of quality published studies describing scientifically valid and reproducible usability evaluations at various stages of EHR system development. A lack of formal and standardized reporting of EHR usability evaluation results is a major contributor to this knowledge gap, and efforts to improve this deficiency will be one step of moving the field of usability engineering forward.
Collapse
Affiliation(s)
- Marc A Ellsworth
- Division of Neonatal Medicine, Mayo Clinic, Rochester, MN, USA
- Multidisciplinary Epidemiology and Translational Research in Critical Care, Emergency and Perioperative Medicine (METRIC-PM) Group, Mayo Clinic, Rochester, MN, USA
| | - Mikhail Dziadzko
- Multidisciplinary Epidemiology and Translational Research in Critical Care, Emergency and Perioperative Medicine (METRIC-PM) Group, Mayo Clinic, Rochester, MN, USA
- Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
| | - John C O'Horo
- Multidisciplinary Epidemiology and Translational Research in Critical Care, Emergency and Perioperative Medicine (METRIC-PM) Group, Mayo Clinic, Rochester, MN, USA
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN, USA
| | - Ann M Farrell
- Mayo Clinic Libraries, Mayo Clinic, Rochester, MN, USA
| | - Jiajie Zhang
- School of Health Information Sciences, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Vitaly Herasevich
- Multidisciplinary Epidemiology and Translational Research in Critical Care, Emergency and Perioperative Medicine (METRIC-PM) Group, Mayo Clinic, Rochester, MN, USA
- Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
43
|
Green EP, Catalani C, Diero L, Carter EJ, Gardner A, Ndwiga C, Keny A, Owiti P, Israelski D, Biondich P. Do clinical decision-support reminders for medical providers improve isoniazid preventative therapy prescription rates among HIV-positive adults? Study protocol for a randomized controlled trial. Trials 2015; 16:141. [PMID: 25885266 PMCID: PMC4404590 DOI: 10.1186/s13063-015-0558-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 01/08/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This document describes a research protocol for a study designed to estimate the impact of implementing a reminder system for medical providers on the use of isoniazid preventative therapy (IPT) for adults living with HIV in western Kenya. People living with HIV have a 5% to 10% annual risk of developing active tuberculosis (TB) once infected with TB bacilli, compared to a 5% lifetime risk in HIV-negative people with latent TB infection. Moreover, people living with HIV have a 20-fold higher risk of dying from TB. A growing body of literature suggests that IPT reduces overall TB incidence and is therefore of considerable benefit to patients and the larger community. However, in 2009, of the estimated 33 million people living with HIV, only 1.7 million (5%) were screened for TB, and about 85,000 (0.2%) were offered IPT. METHODS/DESIGN This study will examine the use of clinical decision-support reminders to improve rates of initiation of preventative treatment in a TB/HIV co-morbid population living in a TB endemic area. This will be a pragmatic, parallel-group, cluster-randomized superiority trial with a 1:1 allocation to treatment ratio. For the trial, 20 public medical facilities that use clinical summary sheets generated from an electronic medical records system will participate as clusters. All HIV-positive adult patients who complete an initial encounter at a study cluster and at least one return encounter during the study period will be included in the study cohort. The primary endpoint will be IPT prescription at 3 months post the initial encounter. We will conduct both individual-level and cluster-level analyses. Due to the nature of the intervention, the trial will not be blinded. This study will contribute to the growing evidence base for the use of electronic health interventions in low-resource settings to promote high-quality clinical care, health system optimization and positive patient outcomes. Trial registration ClinicalTrials.gov NCT01934309, registered 29 August 2013.
Collapse
Affiliation(s)
- Eric P Green
- Kijani Consulting, 1289 Fordham Blvd, Suite 165, Chapel Hill, 27514, NC, USA.
- Duke Global Health Institute, Durham, PO Box 9051927708, NC, USA.
| | - Caricia Catalani
- InSTEDD, 955 Benecia Ave, Sunnyvale, 94085, CA, USA.
- School of Public Health, University of California, Berkeley, University Hall, Berkeley, 94720-7360, CA, USA.
| | - Lameck Diero
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, PO Box 460630100, Kenya.
- Department of Medicine, School of Medicine, College of Health Sciences, Moi University, Eldoret, PO Box 4606 030100, Kenya.
| | - E Jane Carter
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, PO Box 460630100, Kenya.
- Division of Medicine, Alpert Medical School of Brown University, Box G-A, Providence, 02912, RI, USA.
| | - Adrian Gardner
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, PO Box 460630100, Kenya.
- Division of Medicine, Alpert Medical School of Brown University, Box G-A, Providence, 02912, RI, USA.
- Department of Medicine, School of Medicine, College of Health Sciences, Moi University, Eldoret, PO Box 4606 030100, Kenya.
- Department of Medicine, School of Medicine, Indiana University, 340 W 10th St 6200, Indianapolis, 46202, IN, USA.
| | - Charity Ndwiga
- Population Council, General Accident House, Ralph Bunche Road, Nairobi, Kenya.
| | - Aggrey Keny
- Regenstrief Institute, 1050 Wishard Blvd, Indianapolis, 46202, IN, USA.
| | - Philip Owiti
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, PO Box 460630100, Kenya.
| | - Dennis Israelski
- School of Medicine, Stanford University, 291 Campus Dr, Stanford, 94305, CA, USA.
| | - Paul Biondich
- Regenstrief Institute, 1050 Wishard Blvd, Indianapolis, 46202, IN, USA.
| |
Collapse
|