Designing for two: How enhancing human-centered design with behavioral nudges unlocked breakthroughs to promote young women's psychological safety and access to reproductive care in Tanzania.

Adolescent girls and young women (AGYW; ages 15-24) in sub-Saharan Africa face many barriers to accessing preventive sexual and reproductive health (SRH) services. We drew upon the strengths of two complementary approaches, human-centered design and behavioral economics, to craft a holistic, highly-tailored, and empathetic intervention to motivate AGYW to seek contraception and HIV self-test kits at community drug shops. To encourage engagement, we embedded "nudge" strategies at different opportunity points (uncovered during our design research) along the care-seeking and service delivery journey. Our Malkia Klabu intervention is a loyalty program designed to enhance drug shops' role as SRH providers through which AGYW earned punches for shop purchases redeemable for small prizes; free SRH products could be requested at any time. From our 4-month pilot in Shinyanga, Tanzania, we assess the extent to which different behavioral nudge strategies motivated behaviors as predicted by synthesizing findings from (1) in-depth interviews with AGYW and shopkeepers, (2) shop program records, (3) shop observations, and (4) customer exit surveys. Overall, we find that AGYW and shopkeepers were motivated by many intervention features as intended and consistent with hypothesized mechanisms. We found strong evidence of social norms for helping to spread awareness of Malkia Klabu among peers, prize incentives for drawing AGYW back to shops, and the opt-out default membership gift of an HIV self-test kit for encouraging testing uptake and exploration of contraceptives. Shopkeepers in both arms noted increased community status from distributing HIV self-testing kits (ego). Malkia Klabu shopkeepers experienced increased customer traffic and business revenues (incentives), which reduced shopkeepers' gatekeeping tendencies and earned them additional recognition as champions of AGYW well-being. Integrating human-centered design and behavioral economics was effective for developing an innovative and effective intervention that simultaneously met the different needs of economic actors in support of public health priorities.

Seasonal, geographic, and antimicrobial resistance patterns in microbial keratitis: 4-year experience in eastern Pennsylvania.

PURPOSE: The aim of this study was to review the demographics, causative organisms, seasonal and geographic variation, and antimicrobial resistance patterns of microbial keratitis at our institution over a 4-year period. METHODS: Electronic medical records of all patients with microbial keratitis who underwent corneal culturing at a single institution in eastern Pennsylvania between January 1, 2009 and December 31, 2012 were reviewed. RESULTS: A total of 311 patients representing 323 instances of infectious keratitis were analyzed. The most frequently implicated organisms in contact lens-related infections were Pseudomonas aeruginosa for bacteria and Fusarium species for fungus, compared with Staphylococcus aureus and Candida species in non-contact lens-associated bacterial infections. Bacterial keratitis occurred most frequently in spring and least frequently in winter (P = 0.024). Patients who live in large fringe metro (suburban) areas accounted for the highest proportion of infectious keratitis cases. P. aeruginosa and methicillin-sensitive S. aureus isolates were highly susceptible to fluoroquinolones, whereas 32% of coagulase-negative staphylococcus isolates tested were resistant to moxifloxacin and gatifloxacin, and all methicillin-resistant S. aureus organisms tested were resistant to these 2 fluoroquinolones. No organisms tested were resistant to tobramycin, gentamicin, or vancomycin. No fungal infections tested were resistant to voriconazole. CONCLUSIONS: Most infectious keratitis occurred in nonwinter months and in patients from suburban counties. Although fluoroquinolones were effective against the most common bacteria, staphylococcal species exhibited a high rate of resistance, representing a therapeutic challenge given the increasing use of fluoroquinolones as first-line monotherapy. No organisms tested were resistant to tobramycin, gentamicin, vancomycin, or voriconazole.