Utilizing mobile health and community informants to collect real-time health care data in extremely low resource environments

Background

Mobile health provides promising opportunities to perform population surveillance in rural, impoverished, or unstable communities. The objective of this study was to test the efficacy and accuracy of data collected by community informants in extreme low-resource environments using electronic surveys and mobile phones.

Methods

We carried out a population-based, cross-sectional survey between October and November 2017 measuring access to health care and prenatal services for pregnant women in the Northern Region of Malawi. The survey was conducted by members of the community who received one day of training and volunteered to conduct a survey for each live birth that occurred within their predetermined catchment area. A study member audited less than 2% of survey responses, where community informant responses were compared to community member self-reports.

Results

A total of 915 survey responses were recorded by 21 community informants. These surveys recorded 621 live births and 4 cases of maternal mortality. This represents a maternal mortality rate of 0.64% (95% confidence interval (CI) = 0.2% to 1.6%), roughly equal to the United Nations Children’s Fund (UNICEF) estimate from 2015 of 634 per 100 000 live births, or 0.63%. This survey captured 120 births by adolescent mothers aged 15-19 out of 673 responses about maternal age. This represents 17.8% (95% CI = 15.1% to 20.9%) of all births, slightly higher than the UNICEF estimate of 143 per 1000 live births (14.3%). Finally, 51.7% of women were recorded as attending 4 antenatal care visits (95% CI = 47.8% to 55.7%), consistent with the 2015-2016 Demographic and Health Survey (DHS) value of 51%.

Conclusions

The use of cellular phones and electronic surveys by community informants allowed for the real-time capture of data in an area where access is limited by seasonally impassable roads and unreliable cell reception. The data recorded by the surveys is comparable to accepted statistics in several measures. Community reporting of health care data can provide an efficient method of monitoring extremely rural or hard to reach communities.

Opportunities for Regulatory Changes to Promote Pediatric Device Innovation in the United States: Joint Recommendations From Pediatric Innovator Roundtables

Objective: The purpose of this report is to provide insight from pediatric stakeholders with a shared desire to facilitate a revision of the current United States regulatory pathways for the development of pediatric healthcare devices. Methods: On August 5, 2020, a group of innovators, engineers, professors and clinicians met to discuss challenges and opportunities for the development of new medical devices for pediatric health and the importance of creating a regulatory environment that encourages and accelerates the research and development of such devices. On January 6, 2021, this group joined regulatory experts at a follow-up meeting. Results: One of the primary issues identified was the need to present decision-makers with opportunities that change the return-on-investment balance between adult and pediatric devices to promote investment in pediatric devices. Discussion/Conclusion: Several proposed strategies were discussed, and these strategies can be divided into two broad categories: 1. Removal of real and perceived barriers to pediatric device innovation; 2. Increasing incentives for pediatric device innovation.

Abstract IA15: Mobile virtual human health care guides for young adult childhood cancer survivors

Since the mid-1990s, a significant scientific literature has evolved regarding the mental/physical health outcomes from the use of what we now refer to as Clinical Virtual Reality (VR). While the preponderance of clinical work with VR has focused on building immersive virtual worlds for treating anxiety disorders with exposure therapy, providing distracting immersive experiences for acute pain management, and supporting physical rehabilitation with game-based interactive content, there are other emerging areas that have extended the impact of VR in healthcare. One such area involves the recent technological advances that have led to the evolution of intelligent virtual human (VH) agents. VH representations can now be designed to perceive and act in a 3D virtual world, engage in face-to-face spoken dialogues with real users, and in some cases, can exhibit human-like emotional reactions. We have reported positive outcomes from studies using VHs in the role of virtual patients for training novice clinicians, as job interview/social skill trainers for persons on the autism spectrum, and as online health care support agents with university students and military veterans. The computational capacity now exists to deliver similar VH interactions by way of mobile device technology. This capability can support the “anywhere/anytime” availability of VH characters as agents for engaging users with clinical care information and could provide opportunities for improving access to care and emotional support for childhood cancer survivors (CCS). With a survivorship rate of over 83%, CCS are living longer, with estimates indicating that there will be over 500,000 CCS in the United States by 2020. However, CCS are at high risk for late effects of treatment, including recurring or secondary cancers, unhealthy lifestyle, disengagement from care, and the lack of the social support that has been shown to be vital for health and well-being. The majority of CCS will have at least one chronic condition by age 40. Moreover, existing initiatives to serve the needs of CCS have had limited success as these populations can be hard to reach and difficult to engage. We conducted two preliminary studies to inform development and evaluate the usefulness of a mobile app that included VH interaction and guidance to help CCS navigate survivorship and maintain health. In Study 1, two rounds of focus group interviews were conducted with 15 CCS aged 13-30 years. In Study 2, a pilot VH-driven app was developed using the information collected in Study 1. The app was downloaded, tested, and evaluated for one week by 60 CCS between the ages of 13-29 years. The results indicated that dynamic, accessible, engaging and survivor-focused VH approaches could address the needs of young, “digitally native” CCS. We will present a brief introduction to the clinical use of VHs within the VR context (Rizzo), followed by a discussion of a new mobile-enabled VH project designed to promote access to health care information and emotional support in young adult CCS (Spruijt-Metz).

Citation Format: Skip Rizzo, Donna Spruijt-Metz, Arno Hartholt, Bill Swartout, Kayla de la Haye, Joel Milam, David Freyer, Kimberly Miller, Anamara Ritt-Olson, Stacy Schepens-Niemiec, Shinyi Wu, Maryalice Jordan-Marsh, Amie Hwang, Anya Samek, Dennis Wixon, George Tolomiczenko, Kenneth Hayashida, Marientina Gotsis, Stefan Schneider, Swaroop Samek, Yaniv Bar-Cohen. Mobile virtual human health care guides for young adult childhood cancer survivors [abstract]. In: Proceedings of the AACR Special Conference on Modernizing Population Sciences in the Digital Age; 2019 Feb 19-22; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(9 Suppl):Abstract nr IA15.

Linking Engineering and Medical Training: A USC program seeks to introduce medical and engineering students to medical device development

Medical students are attracted by the prospect of a meaningful addition to their clinical work. Engineering students are excited by a unique opportunity to learn directly alongside their medical student peers. For both, as well as the scientific community at large, the boutique program at the University of Southern California (USC) linking engineering and medical training at the graduate level is instructive of a new way of approaching engineering education that can potentially provide benefits to both students and society. Students who have grown up in an era of ?mass customization? in the retail and service industries can enjoy that same degree of flexibility also in the realm of education. At the same time, society gains engineers who have developed an increased empathy and awareness of the clinical contexts in which their innovations will be implemented.

Understanding the patients' perspective of emotional support to significantly improve overall patient satisfaction

This article presents the results of a research study that laid out important considerations for organizations to improve their patient satisfaction scores. It addresses a dimension of patient satisfaction that appears to garner little attention in healthcare contexts: emotional support. Though the literature strongly suggests that emotional support is correlated to overall patient satisfaction, few organizations have systematically attempted to understand the elements of outstanding emotional support. Research at a community teaching hospital in Ontario has shed light on the essential components of emotional support. In this article, a typology of emotional support is offered. With a better understanding of the components of emotional support, organizations may be able to undertake actions that could potentially improve patient satisfaction scores and, in turn, the overall quality of patient care.

IBD 2009: emerging research frontiers on the path to a cure

The Crohn's and Colitis Foundation of Canada (CCFC) hosted a research symposium in April 2009. The current article presents short synopses of the presentations given at that symposium. Invitees included CCFC-funded clinician-scientists and researchers, research administrators and international leaders in inflammatory bowel disease research. Research challenges were outlined while acknowledging advances made in several domains relevant to informing the search for cures. Following the scientific presentations, discussions endorsed current activities of the CCFC and supported the creation of a new pediatric inflammatory bowel disease initiative.

Universal health insurance and health care access for homeless persons

OBJECTIVES

We examined the extent of unmet needs and barriers to accessing health care among homeless people within a universal health insurance system.

METHODS

We randomly selected a representative sample of 1169 homeless individuals at shelters and meal programs in Toronto, Ontario. We determined the prevalence of self-reported unmet needs for health care in the past 12 months and used regression analyses to identify factors associated with unmet needs.

RESULTS

Unmet health care needs were reported by 17% of participants. Compared with Toronto's general population, unmet needs were significantly more common among homeless individuals, particularly among homeless women with dependent children. Factors independently associated with a greater likelihood of unmet needs were younger age, having been a victim of physical assault in the past 12 months, and lower mental and physical health scores on the 12-Item Short Form Health Survey.

CONCLUSIONS

Within a system of universal health insurance, homeless people still encounter barriers to obtaining health care. Strategies to reduce nonfinancial barriers faced by homeless women with children, younger adults, and recent victims of physical assault should be explored.

Drug problems among homeless individuals in Toronto, Canada: prevalence, drugs of choice, and relation to health status

BACKGROUND

Drug use is believed to be an important factor contributing to the poor health and increased mortality risk that has been widely observed among homeless individuals. The objective of this study was to determine the prevalence and characteristics of drug use among a representative sample of homeless individuals and to examine the association between drug problems and physical and mental health status.

METHODS

Recruitment of 603 single men, 304 single women, and 284 adults with dependent children occurred at homeless shelters and meal programs in Toronto, Canada. Information was collected on demographic characteristics and patterns of drug use. The Addiction Severity Index was used to assess whether participants suffered from drug problems. Associations of drug problems with physical and mental health status (measured by the SF-12 scale) were examined using regression analyses.

RESULTS

Forty percent of the study sample had drug problems in the last 30 days. These individuals were more likely to be single men and less educated than those without drug problems. They were also more likely to have become homeless at a younger age (mean 24.8 vs. 30.9 years) and for a longer duration (mean 4.8 vs. 2.9 years). Marijuana and cocaine were the most frequently used drugs in the past two years (40% and 27%, respectively). Drug problems within the last 30 days were associated with significantly poorer mental health status (-4.9 points, 95% CI -6.5 to -3.2) but not with poorer physical health status (-0.03 points, 95% CI -1.3 to 1.3)).

CONCLUSIONS

Drug use is common among homeless individuals in Toronto. Current drug problems are associated with poorer mental health status but not with poorer physical health status.

The health of homeless immigrants

BACKGROUND

This study examined the association between immigrant status and current health in a representative sample of 1189 homeless people in Toronto, Canada.

METHODS

Multivariate regression analyses were performed to examine the relationship between immigrant status and current health status (assessed using the SF-12) among homeless recent immigrants (< or = 10 years since immigration), non-recent immigrants (>10 years since immigration) and Canadian-born individuals recruited at shelters and meal programmes (response rate 73%).

RESULTS

After adjusting for demographic characteristics and lifetime duration of homelessness, recent immigrants were significantly less likely to have chronic conditions (RR 0.7, 95% CI 0.5 to 0.9), mental health problems (OR 0.4, 95% CI 0.2 to 0.7), alcohol problems (OR 0.2, 95% CI 0.1 to 0.5) and drug problems (OR 0.2, 95% CI 0.1 to 0.4) than non-recent immigrants and Canadian-born individuals. Recent immigrants were also more likely to have better mental health status (+3.4 points, SE +/-1.6) and physical health status (+2.2 points, SE +/-1.3) on scales with a mean of 50 and a SD of 10 in the general population.

CONCLUSION

Homeless recent immigrants are a distinct group who are generally healthier and may have very different service needs from other homeless people.

The effect of traumatic brain injury on the health of homeless people

BACKGROUND

We sought to determine the lifetime prevalence of traumatic brain injury and its association with current health conditions in a representative sample of homeless people in Toronto, Ontario.

METHODS

We surveyed 601 men and 303 women at homeless shelters and meal programs in 2004-2005 (response rate 76%). We defined traumatic brain injury as any self-reported head injury that left the person dazed, confused, disoriented or unconscious. Injuries resulting in unconsciousness lasting 30 minutes or longer were defined as moderate or severe. We assessed mental health, alcohol and drug problems in the past 30 days using the Addiction Severity Index. Physical and mental health status was assessed using the SF-12 health survey. We examined associations between traumatic brain injury and health conditions.

RESULTS

The lifetime prevalence among homeless participants was 53% for any traumatic brain injury and 12% for moderate or severe traumatic brain injury. For 70% of respondents, their first traumatic brain injury occurred before the onset of homelessness. After adjustment for demographic characteristics and lifetime duration of homelessness, a history of moderate or severe traumatic brain injury was associated with significantly increased likelihood of seizures (odds ratio [OR] 3.2, 95% confidence interval [CI] 1.8 to 5.6), mental health problems (OR 2.5, 95% CI 1.5 to 4.1), drug problems (OR 1.6, 95% CI 1.1 to 2.5), poorer physical health status (-8.3 points, 95% CI -11.1 to -5.5) and poorer mental health status (-6.0 points, 95% CI -8.3 to -3.7).

INTERPRETATION

Prior traumatic brain injury is very common among homeless people and is associated with poorer health.

Physicians' knowledge of alcohol, tobacco and folic acid in pregnancy

OBJECTIVE

To assess: (1) physicians' knowledge and clinical confidence regarding problematic substance use in pregnancy compared to folic acid, and (2) physicians' desire for education in this area and their preferred learning modalitiestools.

DESIGN

Self-administered survey.

SETTING

Family Medicine Forum 2004 in Toronto, Canada.

PARTICIPANTS

Physicians attending Family Medicine Forum 2004 in Toronto who provide antenatal care.

MAIN OUTCOME MEASURES

Knowledge of folic acid, smoking and alcohol in pregnancy. Clinical confidence and interest in resources regarding problematic substance use in pregnancy.

RESULTS

Sixty-six surveys completed. Physicians answered 92.3% of folic acid questions correctly, compared to 82.0% for nicotine and 57.1% for alcohol. Scores were higher on questions about effects of nicotine and alcohol use in pregnancy than on questions about treatment options. A perceived inability to influence clinical outcomes and a lack of professional resources regarding substance use in pregnancy were also identified. Physicians were interested in learning more about problematic substance use in pregnancy, particularly from continuing medical education events, websites and pocket cards.

CONCLUSION

Participants' level of knowledge regarding substance use in pregnancy was significantly lower than their knowledge of folic acid, as was their clinical confidence. This lack of knowledge was not attributable to disinterest and clearly more educational resources are needed to address this topic.

Endoscopy teaching in Canada: A survey of obstetrics and gynecology program directors and graduating residents

OBJECTIVE

To examine the current state of basic and advanced gynecologic endoscopy teaching in Canadian Obstetrics and Gynecology (Ob/Gyn) residency programs.

METHODS

On Institutional Research Board approval, 2 pretested anonymous questionnaires were developed: one distributed to all Canadian Ob/Gyn program directors and a second to graduating residents (Canadian Task Force classification III). Two mailings were sent to maximize response, and some department chairs received personal telephone calls by the senior author to encourage participation. Residents on maternity leave were excluded from the study.

RESULTS

Fifteen of 16 (94%) program directors, and 47 of 62 (76%) residents participated. Directors expect all residents to be knowledgeable and competent performing basic endoscopic procedures on graduation. However, considerable variation exists among programs that teach advanced endoscopy. Some of the more important factors limiting integration of advanced endoscopic teaching include paucity of trained faculty, lack of attending interest, scarcity of operating time, and financial constraints. Most graduating residents consider undertaking additional gynecologic endoscopy fellowships.

CONCLUSION

Most Ob/Gyn program directors and graduating residents consider endoscopic surgery essential to contemporary practice. There is consensus to improve resident teaching in gynecologic endoscopy and commitment to better prepare future practitioners to ensure patient safety. Paucity of trained faculty and fiscal constraints appear to be important limiting factors.

Interventions to improve the health of the homeless: a systematic review

BACKGROUND

Homelessness is a widespread problem in the United States. The primary goal of this systematic review is to provide guidance in the development and organization of programs to improve the health of homeless people.

METHODS

MEDLINE, CINAHL, HealthStar, PsycINFO, Sociological Abstracts, and Social Services Abstracts databases were searched from their inception through July 2004 using the following terms: homeless, homeless persons, and homelessness. References of key articles were also searched. 4564 abstracts were screened, and 258 articles underwent full review. Seventy-three studies conducted from 1988 to 2004 met inclusion criteria (use of an intervention, use of a comparison group, and the reporting of health-related outcomes). Two authors independently abstracted data from studies and assigned quality ratings using explicit criteria.

RESULTS

Forty-five studies were rated good or fair quality. For homeless people with mental illness, case management linked to other services was effective in improving psychiatric symptoms, and assertive case management was effective in decreasing psychiatric hospitalizations and increasing outpatient contacts. For homeless people with substance abuse problems, case management resulted in greater decreases in substance use than did usual care. For homeless people with latent tuberculosis, monetary incentives improved adherence rates. Although a number of studies comparing an intervention to usual care were positive, studies comparing two interventions frequently found no significant difference in outcomes.

CONCLUSIONS

Coordinated treatment programs for homeless adults with mental illness or substance abuse usually result in better health outcomes than usual care. Health care for homeless people should be provided through such programs whenever possible. Research is lacking on interventions for youths, families, and conditions other than mental illness or substance abuse.

The association between homelessness and suicidal ideation and behaviors: results of a cross-sectional survey

This study was carried out with three goals: (1) to determine the prevalence of suicidal ideation and suicide attempts among the homeless; (2) to determine what aspects of homelessness predict suicidality, and (3) to determine which aspects remain predictive after controlling for key covariates, such as mental illness. A sample of 330 homeless adults were interviewed. Sixty-one percent of the study sample reported suicidal ideation and 34% had attempted suicide. Fifty-six percent of the men and 78% of the women reported prior suicidal ideation, while 28 percent of the men and 57% of the women had attempted suicide. Childhood homelessness of at least 1 week without family members and periods of homelessness longer than 6 months were found to be associated with suicidal ideation. Psychiatric diagnoses were also associated with suicidality in this sample.

Characteristics of persons who are homeless for the first time

The Pathways Into Homelessness project in Toronto interviewed 300 unaccompanied adult users of homeless shelters to identify characteristics of individuals who are homeless for the first time. The sample reflected the total population of homeless shelter users in terms of age, sex, level of use, and type of shelter. Two fifths of the sample were homeless for the first time. There were more similarities than differences between those who were homeless for the first time and those who had been homeless previously. The prevalence of psychiatric and substance use disorders and the rate of previous hospitalization did not differ between first-time homeless persons and those who had been homeless before. The two groups were distinguished by some childhood experiences related to housing. Both groups had multiple indicators of serious problems, suggesting that the need for intervention is as pressing for persons who are homeless for the first time as it is for the larger population of homeless persons.

Assessing homeless mentally ill persons for permanent housing: screening for safety

Although placement in community housing is a frequent intervention with populations of seriously mentally ill homeless individuals, there has been little formal investigation of the criteria used by clinicians in screening individuals for such placement. In this paper, we describe screening a population of 303 homeless people with severe mental illness for placement in independent apartments. We assess subjects' level of risk along multiple dimensions and determine the contribution of each risk dimension to the final safety decision. In addition, we evaluate the validity of the risk measures with other measures of clinical condition. Two-thirds of the sample were judged as safe for independent living. Assaultiveness was the most frequent risk identified, followed by self-destructiveness, substance abuse, and medication non-compliance. The final safety decision was associated most strongly with assaultiveness, self-destructiveness, and medication non-compliance. We conclude that it is possible to assess risk with measures that are available from shelter and medical records, and call for more research on the role of medication non-compliance in safety decisions and for longitudinal research to validate risk assessments.