The Role of Human-Centered Design in Healthcare Innovation: a Digital Health Equity Case Study.

Healthcare delivery has become more complicated, particularly with the addition of digital tools and advanced technologies that can further exacerbate existing disparities. New approaches to solve complex, multi-faceted problems are needed. Human-centered design (HCD), also known as design thinking, is an innovative set of methods to develop solutions to these types of issues using collaborative, team-based, and empathetic approaches focused on end user experiences. Originally advanced in technology sectors, HCD has garnered growing attention in quality improvement, healthcare redesign, and public health and medical education. During the COVID-19 pandemic, our healthcare organization recognized notable differences in utilization of virtual (video-based) services among specific patient populations. In response, we mobilized, and using HCD, we collectively brainstormed ideas, rapidly developed prototypes, and iteratively adapted solutions to work toward addressing this digital divide and clinic and systems-level struggles with improving and maintaining digital health access. HCD approaches create a cohesive team-based structure that permits the dismantling of organizational hierarchies and departmental silos. Here we share lessons learned on implementing HCD into clinical care settings and how HCD can result in the development of site-specific, patient-centered innovations to address access disparities and to improve digital health equity.

A design thinking-led approach to develop a responsive feeding intervention for Australian families vulnerable to food insecurity: Eat, Learn, Grow.

BACKGROUND: Design thinking is an iterative process that innovates solutions through a person-centric approach and is increasingly used across health contexts. The person-centric approach lends itself to working with groups with complex needs. One such group is families experiencing economic hardship, who are vulnerable to food insecurity and face challenges with child feeding. OBJECTIVE: This study describes the application of a design thinking framework, utilizing mixed methods, including co-design, to develop a responsive child-feeding intervention for Australian families-'Eat, Learn, Grow'. METHODS: Guided by the five stages of design thinking, which comprises empathizing, defining, ideating, prototyping, and testing. We engaged with parents/caregivers of a child aged 6 months to 3 years through co-design workshops (n = 13), direct observation of mealtimes (n = 10), a cross-sectional survey (n = 213) and semistructured interviews (n = 29). Findings across these methods were synthesized using affinity mapping to clarify the intervention parameters. Parent user testing (n = 12) was conducted online with intervention prototypes to determine acceptability and accessibility. A co-design workshop with child health experts (n = 9) was then undertaken to review and co-design content for the final intervention. RESULTS: Through the design thinking process, an innovative digital child-feeding intervention was created. This intervention utilized a mobile-first design and consisted of a series of short and interactive modules that used a learning technology tool. The design is based on the concept of microlearning and responds to participants' preferences for visual, brief and plain language information accessed via a mobile phone. User testing sessions with parents and the expert co-design workshop indicated that the intervention was highly acceptable. CONCLUSIONS: Design thinking encourages researchers to approach problems creatively and to design health interventions that align with participant needs. Applying mixed methods-including co-design- within this framework allows for a better understanding of user contexts, preferences and priorities, ensuring solutions are more acceptable and likely to be engaged.

Stakeholder needs assessment for developing ageing in place solutions - a qualitative study.

BACKGROUND: Ageing in place is a common desire among older adults and people in need of care. Accessible housing and ambient assisted living (AAL) technologies can help to live independently at home. However, they cannot replace the human support network of informal caregivers, healthcare professionals and social workers. The needs of these stakeholders should be considered and analysed in order to develop user-friendly and acceptable (digital) solutions for ageing in place while supporting human support networks in fulfilling their roles. This paper presents the first step for a comprehensive multi-level needs analysis within the framework of an user-centered design thinking approach. METHODS: Guideline-based interviews were conducted with healthcare professionals, social workers and an informal caregiver to collect data about the needs of older adults as well as people in need of care, and their human support networks. RESULTS: The call for more information that is easier to find is a common desire of the three groups. There is agreement on system-based communication and orientation problems, the existence of physical and psychological stress exacerbated by a lack of human resources, the desire for personalised care, the need to feel safe and supported in emergencies, and the need for advice and help with administrative tasks. Overall, the needs of one group are closely linked to those of the other. CONCLUSION: Stakeholder selection and diversity are decisive for findings about ageing in place. The overlaps between the stakeholders' needs offer chances and challenges at the same time for the development of user-friendly, acceptable (digital) solutions and products that support ageing in place.

Situational analysis of hypertension management at primary health care level in São Paulo, Brazil: population, healthcare professional and health system perspectives.

BACKGROUND: Government-led, population-wide initiatives are crucial for advancing the management of hypertension - a leading cause of cardiovascular disease (CVD) morbidity and mortality. An urban population health initiative was conducted against this backdrop, focussing on hypertension in the primary health system in São Paulo, Brazil. Within the frame of the initiative and under the supervision and leadership of the municipal health authorities, a situational analysis was conducted on the needs in hypertension management, marking the first phase of a Design Thinking process. This article describes the situational analysis process and presents the identified elements to be strengthened considering hypertension diagnosis, treatment and control. METHODS: First, a mixed-methods approach was used, starting with a literature review of municipal hypertension data followed by meetings (N = 20) with the local public health administration to assess health system level components. To investigate activities on hypertension diagnosis, treatment and control, nine primary healthcare units were selected from two districts of São Paulo city- Itaquera and Penha- which received an online form addressed to managers, participated in conversation circles of staff and patients, and underwent shadowing of community health agents. RESULTS: Data gave rise to two main outputs: (i) a patient care journey map; and (ii) a matrix summarizing the identified needs at patient, healthcare professional and health system level for diagnosis, treatment and control of hypertension. Patient awareness and knowledge of hypertension was found to be insufficient and its management needs to be improved. For health professionals, disease awareness, technical training, more time dedicated to patients, and simplified guidelines and clinical decision-making tools for hypertension management were identified as principal needs. The situational analysis found that the healthcare systems efficiency might be improved by establishing defined treatment and care delivery goals with a focus on outcomes and implemented through action plans. CONCLUSIONS: This situational analysis identified several needs related to hypertension control in São Paulo that are in line with global challenges to improve the control of CVD risk factors. Findings were also confirmed locally in an expansion phase of this situational analysis to additional primary care facilities. As a consequence, solutions were designed, promptly taken up and implemented by the municipal health secretariat.

Cocreating eating disorder education solutions: A design thinking approach to dietetics curricula in Australia.

BACKGROUND: As the prevalence of eating disorders continues to increase, there is an urgent need to equip the emerging dietetics workforce to provide care to this growing population. The present study aimed to describe a five-step design thinking process that was applied to brainstorm ideas and develop and test solutions for consideration in the future. METHODS: A pragmatic, five-step design thinking approach was used during a 1-day, in-person design thinking retreat. Purposive sampling was used to identify key stakeholders, including subject matter, learning and teaching, as well as lived experience experts, dietetics students and recent graduates. Reflexive thematic analysis was used to analyse brainstormed and design solution ideas. RESULTS: Seventeen participants attended the design thinking retreat in April 2023. Four education prototypes were developed and tested by stakeholders including: (1) a change to accreditation requirements for dietetics curricula; (2) a multimodal learning package for penultimate year students; (3) embedding disordered eating and eating disorder content into existing curriculum and upskilling educators; and (4) codesigning an eating disorder module. CONCLUSIONS: The design thinking retreat engaged a variety of stakeholders in curriculum design resulting in an array of prototype approaches that aimed to embed eating disorder content into university curricula. Further research is needed to test the prototypes and understand what impact this has on dietetics students' feelings of preparedness to provide care to people seeking this support.

Design thinking in medical education to tackle real world healthcare problems: The MasterMinds Challenge.

EDUCATIONAL CHALLENGE: Medical education must equip future professionals with the necessary skills to navigate the complex healthcare landscape. Clinical knowledge is essential, and critical and creative thinking skills are vital to meet the challenges of the system. Design thinking offers a structured approach that integrates creativity and innovation, yet its application in medical education is absent. SOLUTION AND IMPLEMENTATION: The compulsory MasterMinds Challenge course at Leiden University Medical Center utilizes design thinking principles to address real world healthcare challenges. Final-year medical students participated in a two-day program. The course encompassed empathizing with stakeholders, problem definition, ideation, prototyping, and refining solutions. Presentation skills were emphasized, culminating in a symposium where teams showcase their outcomes. Implementation of the MasterMinds Challenge course was successful with 33 sessions delivered to 1217 medical students. Challenges covered various healthcare topics, yielding creative yet practical outcomes. Students appreciate the real world healthcare challenge, team-based approach, and the applicability of design thinking principles. Challenge owners expressed satisfaction with students' commitment, creativity, and empathizing abilities. LESSONS LEARNED AND NEXT STEPS: To further enhance the MasterMinds Challenge course, a more longitudinal format is being designed, enabling greater autonomy and emphasizing the refining and implementation phases. The course can be extended to medical postgraduate professionals and interdisciplinary collaborations, fostering innovative ideas beyond current practices. By developing problem-solving skills, the MasterMinds Challenge course contributes to a future-proof medical education program and prepares students to meet the evolving needs of healthcare.

Flipped online teaching of histology and embryology with design thinking: design, practice and reflection.

BACKGROUND: Flexible hybrid teaching has become the new normal of basic medical education in the postepidemic era. Identifying ways to improve the quality of curriculum teaching and achieve high-level talent training is a complex problem that urgently needs to be solved. Over the course of the past several semesters, the research team has integrated design thinking (DT) into undergraduate teaching to identify, redesign and solve complex problems in achieving curriculum teaching and professional talent training objectives. METHODS: This study is an observational research. A total of 156 undergraduate stomatology students from Jining Medical University in 2021 were selected to participate in two rounds of online flipped teaching using the design thinking EDIPT (empathy, definition, idea, prototype, and test) method. This approach was applied specifically to the chapters on the respiratory system and female reproductive system. Data collection included student questionnaires, teacher-student interviews, and exam scores. GraphPad Prism software was used for data analysis, and the statistical method was conducted by multiple or unpaired t test. RESULTS: According to the questionnaire results, the flipped classroom teaching design developed using design thinking methods received strong support from the majority of students, with nearly 80% of students providing feedback that they developed multiple abilities during the study process. The interview results indicated that teachers generally believed that using design thinking methods to understand students' real needs, define teaching problems, and devise instructional design solutions, along with testing and promptly adjusting the effectiveness through teaching practices, played a highly positive role in improving teaching and student learning outcomes. A comparison of exam scores showed a significant improvement in the exam scores of the class of 2021 stomatology students in the flipped teaching chapters compared to the class of 2020 stomatology students, and this difference was statistically significant. However, due to the limitation of the experimental chapter scope, there was no significant difference in the overall course grades. CONCLUSION: The study explores the application of design thinking in histology and embryology teaching, revealing its positive impact on innovative teaching strategies and students' learning experience in medical education. Online flipped teaching, developed through design thinking, proves to be an effective and flexible method that enhances student engagement and fosters autonomous learning abilities.

Using design thinking to create and implement a 3D digital library of anatomical specimens.

Design thinking (DT) is a five-stage process (empathize, define, ideate, prototype, and test) that guides the creation of user-centered solutions to complex problems. DT is in common use outside of science but has rarely been applied to anatomical education. The use of DT in this study identified the need for flexible access to anatomical specimens outside of the anatomy laboratory and guided the creation of a digital library of three-dimensional (3D) anatomical specimens (3D Anatomy Viewer). To test whether the resource was fit for purpose, a mixed-methods student evaluation was undertaken. Student surveys (n = 46) were employed using the system usability scale (SUS) and an unvalidated acceptability questionnaire. These verified that 3D Anatomy Viewer was usable (SUS of 72%) and acceptable (agreement range of 77%-93% on all Likert-type survey statements, Cronbach's alpha = 0.929). Supplementary interviews (n = 5) were analyzed through content analysis and revealed three main themes: (1) a credible online supplementary learning resource; (2) learning anatomy with 3D realism and interactivity; (3) user recommendations for expanding the number of anatomical models, test questions, and gamification elements. These data demonstrate that a DT framework can be successfully applied to anatomical education for creation of a practical learning resource. Anatomy educators should consider employing a DT framework where student-centered solutions to learner needs are required.

Nurses' and clients' perspectives after engagement in the co-designing of solutions to improve provider-client relationships in maternal and child healthcare: a human-centered design study in rural Tanzania.

BACKGROUND: There has been a persistent increase in clients' dissatisfaction with providers' competencies in maternal and child healthcare (MCH). Existing interventions have failed to address the complexity of provider-client relationships. Therefore, targeted, contextualized innovative solutions that place providers and clients at the forefront as agents of change in optimizing intervention design and implementation are needed. The study team adopted a co-design strategy as part of Human- Centered Design (HCD) approach, where MCH nurses, clients, and stakeholders partnered to design an intervention package to improve provider-client relationships in rural Tanzania. OBJECTIVE: This paper explored nurses', clients', and MCH stakeholders' perspectives following participation in a co-design stage of the HCD study to generate interventions to strengthen nurse-client relationships in Shinyanga Region. METHODS: A qualitative descriptive design was used. Thirty semi-structured key informant interviews were conducted in the Swahili language with purposefully selected nurses, clients, and MCH stakeholders. The inclusion criterion was participation in consultative workshops to co-design an intervention package to strengthen nurse-client relationships. Data were transcribed and translated simultaneously, managed using NVivo, and analyzed thematically. RESULTS: Three main themes were developed from the analysis, encompassing key learnings from engagement in the co-design process, the potential benefits of co-designing interventions, and co-designing as a tool for behavior change and personal commitment. The key learnings from participation in the co-design process included the acknowledgment that both nurses and clients contributed to tensions within their relationships. Additionally, it was recognized that the benefits of a good nurse-client relationship extend beyond nurses and clients to the health sector. Furthermore, it was learned that improving nurse-client relationships requires interventions targeting nurses, clients, and the health sector. Co-designing was considered beneficial as it offers a promising strategy for designing effective and impactful solutions for addressing many challenges facing the health sector beyond interpersonal relationships. This is because co-designing is regarded as innovative, simple, and friendly, bringing together parties and end-users impacted by the problem to generate feasible and acceptable interventions that contribute to enhanced satisfaction. Furthermore, co-designing was described as facilitating the co-learning of new skills and knowledge among participants. Additionally, co-designing was regarded as a tool for behavior change and personal commitment, influencing changes in participants' own behaviors and cementing a commitment to change their practices even before the implementation of the generated solutions. CONCLUSION: End-users' perspectives after engagement in the co-design process suggest it provides a novel entry point for strengthening provider-client relationships and addressing other health sector challenges. Researchers and interventionists should consider embracing co-design and the HCD approach in general to address health service delivery challenges.

Navigating the complexities of mobile medical app development from idea to launch, a guide for clinicians and biomedical researchers.

With today's pace of rapid technological advancement, many patient issues in modern medicine are increasingly solvable by mobile app solutions, which also have the potential to transform how clinical research is conducted. However, many critical challenges in the app development process impede bringing these translational technologies to patients, caused in large part by the lack of knowledge among clinicians and biomedical researchers of "what it takes" to design, develop, and maintain a successful medical app. Indeed, problems requiring mobile app solutions are often nuanced, requiring more than just clinical expertise, and issues such as the cost and effort required to develop and maintain a well-designed, sustainable, and scalable mobile app are frequently underestimated. To bridge this skill set gap, we established an academic unit of designers, software engineers, and scientists that leverage human-centered design methodologies and multi-disciplinary collaboration to develop clinically viable smartphone apps. In this report, we discuss major misconceptions clinicians and biomedical researchers often hold regarding medical app development, the steps we took to establish this unit to address these issues and the best practices and lessons learned from successfully ideating, developing, and launching medical apps. Overall, this report will serve as a blueprint for clinicians and biomedical researchers looking to better benefit their patients or colleagues via medical mobile apps.

From evidence to implementation of lifestyle behaviour in cancer prevention and control: A Preventive Medicine Golden Jubilee Commentary.

Preventive interventions targeting tobacco, alcohol, healthy diets and physical activity are key strategies to tackle the most pressing health challenges in modern society. A major gap remains in how to translate research evidence into population-level behaviour change to reduce the disease burden. We use the case for the role of physical activity-related behaviour and cancer to illustrate the iterative, multidirectional, and transdisciplinary nature of translational research. The issues we address in this context are generalizable and applicable to other behavioral risk factors and non-communicable diseases. There is now solid evidence that physical activity reduces cancer risk and improves outcomes after cancer diagnosis. Here we provide a framework for how to implement this knowledge into real-world settings. We provide the rationale for combining systems, causal and design thinking to develop interventions that can be implemented for this type of behaviour change. The proposed model is iterative, multidirectional and transdisciplinary. We identify major knowledge gaps in epidemiology and science of behaviour change on physical activity and cancer control and propose approaches to suggest priorities for future research.

Co-creation of information materials within the assent process: From theory to practice.

INTRODUCTION: The informed consent process is key to safeguarding the autonomy of the participant in medical research. For this process to be valid, the information presented to the potential participant should meet their needs and be understood by them. The i-CONSENT project has developed 'Guidelines for adapting the informed consent process in clinical trials' which aim to improve informed consent so that they are easier to understand and better adapted to the needs and preferences of the target population. The best way to tailor information to the characteristics and preferences of the target population is to involve the community itself. METHODS: Following guidelines developed by i-CONSENT, assent materials were co-created for a mock clinical trial of the human papillomavirus vaccine in adolescents. During the process, two design thinking sessions were conducted involving a total of 10 children and 5 parents. The objectives of the sessions were to find out the children's opinion of the informed consent (assent in their case) process in clinical trials, identify the parts that were most difficult to understand and alternatives for their presentation and wording, identify the preferred formats for receiving the information and the main characteristics of these formats, design a video explaining the clinical trial and evaluate a tool for assessing comprehension. RESULTS: Assent materials were co-created in three formats: a web-based material following a layered approach; a video in story format; a pdf document with an innovative way of presenting information compared to traditional assent documents. In addition, the Comprehension of Assent Questionnaire was co-designed, based on the Quality of Informed Consent questionnaire. CONCLUSION: The design thinking methodology has proven to be an easy and useful tool for involving children in designing information tailored to their needs and preferences. PATIENT OR PUBLIC CONTRIBUTION: A sample of the target population participated in the design and piloting of the materials created using design thinking methodology. In addition, patient representatives participated in the design and evaluation of the guidelines developed by the i-CONSENT project that were followed for the development of the materials in this study.

Co-creating digital educational resources to enhance quality in student nurses' clinical education in nursing homes: Report of a co-creative process.

AIM: To report a methodological, co-creative approach for developing an interactive digital educational resource to enhance the quality of student nurses' clinical education in nursing homes and to elucidate the lessons learned from this approach. DESIGN: This study applied a co-design methodology that builds on participatory design principles. METHODS: Co-creating the digital educational resource included multiple sequential and interactive phases inspired by the design thinking framework. Workshops were employed as the primary co-creative activity. RESULTS: Seven separate homogenous or joint heterogeneous workshops were conducted with student nurses, nurse educators, registered nurse mentors and e-learning designers (n = 36) during the active stakeholder engagement phases to inform the educational content, design and functionality of the digital educational resource. These were informed by, and grounded in, learning theory and principles. CONCLUSION: Co-creative approaches in nursing education are an essential avenue for further research. We still lack systematic knowledge about the impact and benefits of co-created initiatives, stakeholders' motivations, barriers, facilitators to participation and the role of context in supporting effective co-creative processes to increase the quality of nursing education. IMPACT: This paper demonstrates how digital educational initiatives to enhance quality in clinical nursing education can be co-created with key stakeholders through a novel methodological approach inspired by design thinking. To date, the methodological development process of co-created educational interventions has received limited attention and compared with the content and theoretical underpinnings of such interventions, has rarely been addressed. Therefore, this paper facilitates knowledge exchange and documents vital aspects to consider when co-creating digital educational initiatives incorporating multistakeholder perspectives. This promotes a stronger academic-practice partnership to impact and enhance the quality of clinical nursing education in nursing homes. PUBLIC CONTRIBUTIONS: Student nurses, nurse educators, and registered nurse mentors worked alongside researchers and e-learning designers in the co-creative process.

Measuring design thinking competence in Taiwanese nursing students: a cross-cultural instrument adaptation.

BACKGROUND: Design thinking (DT) competence, a creative problem-solving ability, has been investigated extensively among college students in various professional fields within the western cultures. No instrument, however, is available for assessing DT competence in nursing students, particularly, those in non-western cultures. OBJECTIVE: To adapt and validate the use of Creative Synthesis Inventory (CSI) assessing the four components (i.e., visualization, discovery, prototyping, and evaluation) of DT competence in nursing students in Taiwan. DESIGN: Cross-sectional, mixed methodological design combining qualitative and quantitative strategies. PARTICIPANTS: A 19-item CSI was administered to a total of 520 nursing students from two campuses of a science and technology university in Taiwan. The data collection was conducted between September 2020 and June 2022. METHODS: The cross-cultural adaptation and validation of CSI-Taiwan was done in two phases: Phase I included content validity check, translation, and cross-cultural adaptation. Phase II involved pilot testing and psychometric evaluation. RESULTS: A first-order confirmatory factor analysis validated the four-component structure, namely visualization, discovery, prototyping, and evaluation, of an 18-item CSI-Taiwan (model fit indices: χ2/df = 3.953, NNFI = 0.942, CFI = 0.956, TLI = 0.947, SRMR = 0.035, and RMSEA = 0.075). A second-order confirmatory factor analysis further indicated that the four components converged on a unitary construct of DT competence (model fit indices: χ2/df = 4.082, NNFI = 0.935, CFI = 0.949, TLI = 0.940, SRMR = 0.040, and RMSEA = 0.080). Moreover, the CSI-Taiwan also demonstrated satisfactory reliability and validity. Together these results validated the construct of DT competence and its components as theorized. CONCLUSIONS: The CSI-Taiwan was a reliable and valid self-report instrument to be used by Taiwanese nursing students.

Developing an Artificial Intelligence-Driven Nudge Intervention to Improve Medication Adherence: A Human-Centred Design Approach.

To improve medication adherence, we co-developed a digital, artificial intelligence (AI)-driven nudge intervention with stakeholders (patients, providers, and technologists). We used a human-centred design approach to incorporate user needs in creating an AI-driven nudge tool. We report the findings of the first stage of a multi-phase project: understanding user needs and ideating solutions. We interviewed healthcare providers (n = 10) and patients (n = 10). Providers also rated example nudge interventions in a survey. Stakeholders felt the intervention could address existing deficits in medication adherence tracking and were optimistic about the solution. Participants identified flexibility of the intervention, including mode of delivery, intervention intensity, and the ability to stratify to user ability and needs, as critical success factors. Reminder nudges and provision of healthcare worker contact were rated highly by all. Conversely, patients perceived incentive-based nudges poorly. Finally, participants suggested that user burden could be minimised by leveraging existing software (rather than creating a new App) and simplifying or automating the data entry requirements where feasible. Stakeholder interviews generated in-depth data on the perspectives and requirements for the proposed solution. The participatory approach will enable us to incorporate user needs into the design and improve the utility of the intervention. Our findings show that an AI-driven nudge tool is an acceptable and appropriate solution, assuming it is flexible to user requirements.

Human-centred design thinking and public health education: A scoping review.

ISSUE ADDRESSED: Human-centred design thinking (HCDT) is gaining traction to develop appropriate public health interventions. The HCDT process helps frame problems with intention and encourages experimentation through collaboration. Public health graduates need an expanded toolkit to solve both the complex known problems of today, and the adaptability to solve the unknown problems of tomorrow. But how is the health promotion workforce being prepared with this innovation capability? This scoping review aims to provide a pedagogical understanding of teaching HCDT in public health education. METHODS: The Arksey & O'Malley framework is used to structure this review. Peer-reviewed articles written from 2000 to 2023 across eight databases were analysed. The data extracted included: author/year, setting, aim/purpose, participants, HCDT framework, HCDT methods, outcomes and challenges. RESULTS: Nine relevant publications were included from a total of 208 records. The first reported use of HCDT in public health and health promotion teaching was in 2015. Teaching inspiration drew from established HCDT frameworks: d.school and IDEO which promote the iterative process of empathy/inspiration, ideation and testing/implementation. CONCLUSIONS: HCDT has been used for both designing public health curricula and for teaching students to apply it in their practice. First, HCDT methods can be used to problem-solve teaching and learning issues such as creating inviting learning environments and designing an HCDT unit. Second, the teaching of HCDT can prepare and equip the public health workforce to solve problems requiring tailored solutions from an empathetic and iterative stance working as a team. The teaching and practice of HCDT exemplifies the process of social innovation in health promotion. SO WHAT?: As an emerging field, future studies and applications should include clarifying and evaluating the HCDT stages used. More publications will enable a fuller understanding and potentially advocate the necessity of teaching and learning HCDT in public health and health promotion.

[ENTREPRENEURSHIP AND INTRAPRENEURSHIP IN PUBLIC HEALTH: A THEORETICAL REVIEW].

The article considers theoretical approaches to determining the essence and characteristics of the organization of entrepreneurial activity in the field of public health. The emphasis is on innovative entrepreneurship, which involves entering new, often unknown or untested markets, which are characterized by high uncertainty. Innovation-driven entrepreneurship does not necessarily require new high-tech advances - rather, it is a new recombination that creates a new way of doing a certain set of activities. It is noted that intrapreneurship, which is based on innovative developments of employees of medical organizations, is also a form of entrepreneurial activity in the field of public health.

Assessment of functioning in Dutch primary care: Development study of a consultation tool for patients with chronic conditions and multimorbidity.

BACKGROUND: In primary care, a shift from a disease-oriented approach for patients with multimorbidity towards a more person-centred approach is needed. AIM: To transform a self-report questionnaire for patients with chronic conditions in primary care, the Primary Care Functioning Scale (PCFS), into an understandable, visually attractive and feasible consultation tool for patients and health care providers. The consultation tool consists of a web-based version of the PCFS, which is filled in by the patient and is processed to a feedback report that summarizes and visualizes the main findings. The feedback report can be discussed with the patient to facilitate a more person-centred conversation for patients with chronic conditions and multimorbidity in general practice. DESIGN AND SETTING: In this qualitative study, we developed the consultation tool by using design thinking in a participatory developmental process. METHODS: In the first phase, we constructed five different feedback report templates to summarize and display the results of a completed PCFS questionnaire in a series of two expert meetings with patients and general practitioners (GPs). In the second phase, we performed an exploratory qualitative interview study involving dyads of patients with chronic conditions and their practice nurses. In an iterative process, we explored their experiences with the consultation tool. RESULTS: Patients, as well as GPs, preferred a clear manner of presenting the results of the questionnaire in a feedback report. In 18 interviews with patients and practice nurses during three different interview rounds, we adjusted the feedback report and consultation tool based on the input from patients and practice nurses. After the final interview round, patients and practice nurses consented that the consultation tool was useful for having a more in-depth consultation about functioning and patients' preferences when integrated into the regularly scheduled consultations. CONCLUSION: We were able to develop an understandable and feasible consultation tool that is applicable in already existing chronic disease management programmes in general practice in the Netherlands. PATIENT OR PUBLIC CONTRIBUTION: To increase the understandability and feasibility of the consultation tool, we collaborated with end-users and actively involved patients, GPs and practice nurses in a participatory development process.

Development of a simple and effective online training for health workers: results from a pilot in Nigeria.

BACKGROUND: Health workers (HWs) in Africa face challenges accessing and learning from existing online training opportunities. To address these challenges, we developed a modular, self-paced, mobile-ready and work-relevant online course covering foundational infection prevention and control (IPC) concepts. Here, we evaluate the first pilot of this course, conducted with HWs in Nigeria. METHODS: We used a learner-centered design and prototyping process to create a new approach to delivering online training for HWs. The resulting course comprised 10 self-paced modules optimized for use on mobile devices. Modules presented IPC vignettes in which learning was driven by short assessment questions with feedback. Learners were recruited by distributing a link to the training through Nigeria-based email lists, WhatsApp groups and similar networks of HWs, managers and allied professionals. The course was open to learners for 8 weeks. We tracked question responses and time on task with platform analytics and assessed learning gains with pre- and post-testing. Significance was evaluated with the Wilcoxon signed-rank test, and effect size was calculated using Cohen's d. RESULTS: Three hundred seventy-two learners, with roles across the health system, enrolled in the training; 59% completed all 10 modules and earned a certificate. Baseline knowledge of foundational IPC concepts was low, as measured by pre-test scores (29%). Post-test scores were significantly higher at 54% (effect size 1.22, 95% confidence interval 1.00-1.44). Learning gains were significant both among learners with low pre-test scores and among those who scored higher on the pre-test. We used the Net Promoter Score (NPS), a common user experience metric, to evaluate the training. The NPS was + 62, which is slightly higher than published scores of other self-paced online learning experiences. CONCLUSIONS: High completion rates, significant learning gains and positive feedback indicate that self-paced, mobile-ready training that emphasizes short, low-stakes assessment questions can be an effective, scalable way to train HWs who choose to enroll. Low pre-test scores suggest that there are gaps in IPC knowledge among this learner population.

Deconstructing design thinking as a tool for the implementation of a population health initiative.

BACKGROUND: The translation of evidence-based practices and rapid uptake of innovations into global health practice is challenging. Design thinking is a consultative process involving multiple stakeholders and has been identified as a promising solution to create and apply implementation strategies in complex environments like health systems. METHODS: We conducted a process evaluation of a real-world example, namely an initiative to innovate hypertension screening, diagnosis and care in São Paulo, Brazil. The parameters of the evaluation were informed by a specification rubric and categorization system, recommended for the investigation of implementation strategies, and the double-diamond conceptual framework to describe and examine the strategic architecture and nature of the design thinking approach, with particular emphasis on identifying potential areas of "value-add" particular to the approach. The retrospective evaluation was performed by an independent partner who had not been involved in the setting up and implementation of the design thinking process. RESULTS: The evaluation unveiled a dense catalogue of strategically driven, mostly theoretically based, activities involving all identified health system stakeholders including patients. Narrative reconstruction illuminated the systematic and coherent nature of this approach, with different resulting actions progressively accounting for all relevant layers of the health system to engineer a broad selection of specific implementation solutions. The relevance of the identified features and the mechanics used to promote more successful implementation practices was manifested in several distinct ways: design thinking offered a clear direction on which innovations really mattered and when, as well as several new dimensions for consideration in the development of an innovation mindset amongst stakeholders. It thereby promoted relationship quality in terms of familiarity and trust, and commitment to evidence-based enquiry and action. Design thinking was also able to navigate the territory between the need for intervention "fidelity" versus "adaptation" and provide the operational know-how to face familiar implementation hurdles. Lastly, it brought a new kind of skill set to the public health stakeholders that incorporated diplomacy, multidisciplinary approaches and management sciences-skills that are considered necessary but not yet widely taught as part of public health training. CONCLUSIONS: Design thinking is a sound and viable tool to use as part of an implementation strategy for engaging with health system stakeholders and successfully translating evidence-based practices and new innovations into routine practice, thereby addressing an important knowledge-practice gap and, more broadly, contributing to the strategic repertoire available to implementation science.