Community Health Recommendations Driven by mHealth Population Surveillance Data Amongst Burmese Displaced People in Eastern India: A Pilot Usability Assessment of a Mobile Health Application for Data Collection.

With recent increases in armed conflict and forced migration, refugee health has become a growing priority amongst those who work in global health. Refugees and forced migrants, also known as displaced persons, face barriers to accessing health services and are often at an increased risk for adverse health outcomes, such as sexual violence, infectious diseases, poor maternal outcomes, and mental health concerns. Mobile health (mHealth) applications have been shown to increase access and improve health outcomes among refugee populations. Our study aims to evaluate the feasibility of using a novel mHealth application to conduct population health surveillance data collection amongst a population of Myanmar citizens who have been forced to relocate to eastern India. The data collected in a low-resource setting through the mHealth application will be used to identify priority areas for intervention which will assist in the development of a tailored intervention plan that best suits our population.

Designing Support to help Health Communication Professionals Convey Numbers Clearly to the Public - A Needs Assessment and Formative Usability Evaluation.

Communicating health-related probabilities to patients and the public presents challenges, although multiple studies have demonstrated that we can promote comprehension and appropriate application of numbers by matching presentation formats (e.g., percentage, bar charts, icon arrays) to communication goal (e.g., improving recall, decreasing worry, taking action). We used this literature to create goal-driven, evidence-based guidance to support health communicators in conveying probabilities. We then conducted semi-structured interviews with 39 health communicators to understand: communicators' goals for expressing probabilities, formats they choose to convey probabilities, and perceptions of prototypes of our "communicating numbers clearly" guidance. We found that communicators struggled to articulate granular goals for their communication, impeding their ability to select appropriate guidance. Future work should consider how best to support health communicators in selecting granular, differentiable goals to support broadly comprehensible information design.

Developing Population Health Surveillance Using mHealth in Low-Resource Settings: Qualitative Assessment and Pilot Evaluation.

BACKGROUND: Population surveillance data are essential for understanding population needs and evaluating health programs. Governmental and nongovernmental organizations in western Myanmar did not previous have means for conducting robust, electronic population health surveillance. OBJECTIVE: This study involved developing mobile health (mHealth)-based population health surveillance in a rural, low-resource setting with minimal cellular infrastructure in western Myanmar. This was an early formative study in which our goal was to establish the initial feasibility of conducting mHealth population health surveillance, optimizing procedures, and building capacity for future work. METHODS: We used an iterative design process to develop mHealth-based population health surveillance focused on general demographics (eg, total census, age category, sex, births, and deaths). Interviews were conducted with international consultants (nurse midwives) and local clinicians (nurses and physicians) in Myanmar. Our analytic approach was informed by the Systems Engineering Initiative for Patient Safety work systems model to capture the multilevel user needs for developing health interventions, which was used to create a prototype data collection tool. The prototype was then pilot-tested in 33 villages to establish an initial proof of concept. RESULTS: We conducted 7 interviews with 5 participants who provided feedback regarding the domains of the work system, including environmental, organizational, sociocultural, technological, informational, and task- and people-based considerations, for adapting an mHealth tool. Environmental considerations included managing limited electricity and internet service. Organizational needs involved developing agreements to work within existing government infrastructure as well as leveraging the communal nature of societies to describe the importance of surveillance data collection and gain buy-in. Linguistic diversity and lack of experience with technology were both cited as people- and technology-based aspects to inform prototype design. The use of mobile tools was also viewed as a means to improve the quality of the data collected and as a feasible option for working in settings with limited internet access. Following the prototype design based on the findings of initial interviews, the mHealth tool was piloted in 33 villages, allowing our team to collect census data from 11,945 people for an initial proof of concept. We also detected areas of potentially missing data, which will need to be further investigated and mitigated in future studies. CONCLUSIONS: Previous studies have not focused heavily on the early stages of developing population health surveillance capacity in low- and middle-income countries. Findings related to key design considerations using a work systems lens may be informative to others developing technology-based solutions in extremely low-resource settings. Future work will involve collecting additional health-related data and further evaluating the quality of the data collected. Our team established an initial proof of concept for using an mHealth tool to collect census-related information in a low-resource, extremely rural, and low-literacy environment.

Social Determinants of Health and Patient Safety: An Analysis of Patient Safety Event Reports Related to Limited English-Proficient Patients.

BACKGROUND: Racial and ethnic disparities in healthcare safety have persisted for decades, particularly for patients with language barriers. Previous studies have investigated the frequency and nature of safety events impacting patients with language barriers; others have proposed solutions to fix them. A gap analysis, however, of how we are currently addressing safety issues and why these efforts have not been effective is lacking. METHOD: This analysis uses reports from a patient safety event reporting system. Reports contain information regarding no-harm (near miss) events and events where harm may have reached the patient. Reports occurring with patients with a preferred language other than English were extracted and analyzed to determine whether the language barrier contributed to the safety event, the language barrier was mentioned in the resolution, and themes were mentioned for addressing language barriers. RESULTS: A subset of 1553 events pertaining to non-English-speaking patients were first categorized as "likely" (3%), "plausibly" (10%), or "unlikely" (87%) related to the patient's language barrier. Second, events related to the patient's language barrier were categorized as directly addressing (19%), indirectly addressing (3%), not mentioning (69%) the language barrier, or containing insufficient information to determine whether the language barrier was addressed (7%). Third, thematic analysis revealed that the most common methods for addressing language barriers included presenting issues to interpreter services and subsequent use of interpreter services. CONCLUSIONS: This study found that it is challenging to determine the direct role of certain social determinants of health (e.g., language barriers) in safety events. In many cases, the language barrier was not addressed in the event report. Furthermore, when the language barrier was addressed, solution themes typically involved weaker, less sustainable suggested actions.

The active role of interpreters in medical discourse - An observational study in emergency medicine.

OBJECTIVE: To study communicative tasks executed and related strategies used by patients, health professionals, and medical interpreters. METHODS: English proficient and limited English proficient emergency department patients were observed. The content of patient-hospital staff communication was documented via pen and paper. Key themes and differences across interpreter types were established through qualitative analysis. Themes and differences across interpreter type were vetted and updated through member checking interviews. RESULTS: 6 English proficient and 9 limited English proficient patients were observed. Key themes in communicative tasks included: establishing, maintaining, updating, and repairing understanding and rapport. All tasks were observed with English proficient and limited English proficient patients. The difference with limited English proficient patients was that medical interpreters played an active role in completing communicative tasks. Telephone-based interpreters faced challenges in facilitating communicative tasks based on thematic comparisons with in-person interpreters, including issues hearing and lost information due to the lack of visual cues. CONCLUSIONS: Professional interpreters play an important role in communication between language discordant patients and health professionals that goes beyond verbatim translation. PRACTICAL IMPLICATIONS: Training for interpreters and health professionals, and the design of tools for facilitating language discordant communication, should consider the role of interpreters beyond verbatim translation.

Lower objectively and subjectively assessed numeracy are both associated with poorer self-rated health.

OBJECTIVE: To compare an objective with a subjective numeracy assessment for association with self-reported health status, where numeracy refers to "the degree to which individuals have the capacity to access, process, interpret, communicate, and act on numerical, quantitative, graphical, biostatistical, and probabilistic health information needed to make effective health decisions" RESULTS: We completed a secondary analysis of two population-based surveys, the Empire State Poll (n = 763) and the Program for the International Assessment of Adult Competencies (PIAAC; n = 2609). The first survey assessed numeracy with a 3-item subjective instrument. The second assessed numeracy with more than 20 math problems. Both used the same measure for self-reported health status. Lower numeracy, whether subjectively or objectively assessed, was associated with worse self-reported health, even after controlling for education and other sociodemographic confounders. The odds ratios for the association were very similar (0.91 and 0.90 respectively). A lengthy objective numeracy assessment and a brief self-report assessment had similar associations with health status. A brief self-report measure of numeracy has similar properties to a lengthy objective assessment and is likely to be more feasible to use to screen patients in practice.

The Age Limit Does Not Exist: A Pilot Usability Assessment of a SMS-Messaging and Smartwatch-Based Intervention for Older Adults with Depression.

Current treatments for major depressive disorder are either less effective for older adults (i.e. pharmacotherapy) or are challenging to extend to community settings (i.e. psychotherapy). To improve and extend mental health treatment for older adults, our team has expanded a previously developed streamlined talk-therapy model to incorporate a technology package that includes patient-reported outcome questions (sent via SMS) and a smartwatch. The goal of this pilot study was to assess and improve the usability, usefulness, and acceptability of the technology package. We completed a pilot feasibility and usability assessment with 15 older adults. Participants demonstrated the feasibility of use of the intervention, successfully completing 99% of their assigned tasks during the pilot. Findings were used to address usability barriers in preparation for future clinical trials. Our results highlight the importance completing usability assessment and involving older adults in the intervention design process when incorporating technology into care.

Observational study to understand interpreter service use in emergency medicine: why the key may lie outside of the initial provider assessment.

OBJECTIVE: To characterise the use of interpreter services and other strategies used to communicate with limited English proficient (LEP) patients throughout their emergency department visit. METHODS: We performed a process tracing study observing LEP patients throughout their stay in the emergency department. A single observer completed 47 hours of observation of 103 communication episodes between staff and nine patients with LEP documenting the strategy used to communicate (eg, professional interpreter, family member, own language skills) and duration of conversations for each communicative encounter with hospital staff members. Data collection occurred in a single emergency department in the eastern USA between July 2017 and February 2018. RESULTS: The most common strategy (per communicative encounter) was for the emergency department staff to communicate with the patient in English (observed in 29.1% of encounters). Total time spent in communicating was highest using telephone-based interpreters (32.9% of total time spent communicating) and in-person interpreters (29.2% of total time spent communicating). Communicative mechanism also varied by care task/phase of care with the most use of interpreter services or Spanish proficient staff (as primary communicator) occurring during triage (100%) and the initial provider assessment (100%) and the lowest interpreter service use during ongoing evaluation and treatment tasks (24.3%). CONCLUSIONS: Emergency department staff use various mechanisms to communicate with LEP patients throughout their length of stay. Utilisation of interpreter services was poorest during evaluation and treatment tasks, indicating that this area should be a focus for improving communication with LEP patients.

Interventions to increase patient portal use in vulnerable populations: a systematic review.

BACKGROUND: More than 100 studies document disparities in patient portal use among vulnerable populations. Developing and testing strategies to reduce disparities in use is essential to ensure portals benefit all populations. OBJECTIVE: To systematically review the impact of interventions designed to: (1) increase portal use or predictors of use in vulnerable patient populations, or (2) reduce disparities in use. MATERIALS AND METHODS: A librarian searched Ovid MEDLINE, EMBASE, CINAHL, and Cochrane Reviews for studies published before September 1, 2018. Two reviewers independently selected English-language research articles that evaluated any interventions designed to impact an eligible outcome. One reviewer extracted data and categorized interventions, then another assessed accuracy. Two reviewers independently assessed risk of bias. RESULTS: Out of 18 included studies, 15 (83%) assessed an intervention's impact on portal use, 7 (39%) on predictors of use, and 1 (6%) on disparities in use. Most interventions studied focused on the individual (13 out of 26, 50%), as opposed to facilitating conditions, such as the tool, task, environment, or organization (SEIPS model). Twelve studies (67%) reported a statistically significant increase in portal use or predictors of use, or reduced disparities. Five studies (28%) had high or unclear risk of bias. CONCLUSION: Individually focused interventions have the most evidence for increasing portal use in vulnerable populations. Interventions affecting other system elements (tool, task, environment, organization) have not been sufficiently studied to draw conclusions. Given the well-established evidence for disparities in use and the limited research on effective interventions, research should move beyond identifying disparities to systematically addressing them at multiple levels.

Assessment of Innovative Emergency Department Information Displays in a Clinical Simulation Center.

The objective of this work was to assess the functional utility of new display concepts for an emergency department information system created using cognitive systems engineering methods, by comparing them to similar displays currently in use. The display concepts were compared to standard displays in a clinical simulation study during which nurse-physician teams performed simulated emergency department tasks. Questionnaires were used to assess the cognitive support provided by the displays, participants' level of situation awareness, and participants' workload during the simulated tasks. Participants rated the new displays significantly higher than the control displays in terms of cognitive support. There was no significant difference in workload scores between the display conditions. There was no main effect of display type on situation awareness, but there was a significant interaction; participants using the new displays showed improved situation awareness from the middle to the end of the session. This study demonstrates that cognitive systems engineering methods can be used to create innovative displays that better support emergency medicine tasks, without increasing workload, compared to more standard displays. These methods provide a means to develop emergency department information systems-and more broadly, health information technology-that better support the cognitive needs of healthcare providers.