User-Centered Design of A Novel Risk Prediction Behavior Change Tool Augmented With an Artificial Intelligence Engine (MyDiabetesIQ): A Sociotechnical Systems Approach.

BACKGROUND: Diabetes and its complications account for 10% of annual health care spending in the United Kingdom. Digital health care interventions (DHIs) can provide scalable care, fostering diabetes self-management and reducing the risk of complications. Tailorability (providing personalized interventions) and usability are key to DHI engagement/effectiveness. User-centered design of DHIs (aligning features to end users' needs) can generate more usable interventions, avoiding unintended consequences and improving user engagement. OBJECTIVE: MyDiabetesIQ (MDIQ) is an artificial intelligence engine intended to predict users' diabetes complications risk. It will underpin a user interface in which users will alter lifestyle parameters to see the impact on their future risks. MDIQ will link to an existing DHI, My Diabetes My Way (MDMW). We describe the user-centered design of the user interface of MDIQ as informed by human factors engineering. METHODS: Current users of MDMW were invited to take part in focus groups to gather their insights about users being shown their likelihood of developing diabetes-related complications and any risks they perceived from using MDIQ. Findings from focus groups informed the development of a prototype MDIQ interface, which was then user-tested through the "think aloud" method, in which users speak aloud about their thoughts/impressions while performing prescribed tasks. Focus group and think aloud transcripts were analyzed thematically, using a combination of inductive and deductive analysis. For think aloud data, a sociotechnical model was used as a framework for thematic analysis. RESULTS: Focus group participants (n=8) felt that some users could become anxious when shown their future complications risks. They highlighted the importance of easy navigation, jargon avoidance, and the use of positive/encouraging language. User testing of the prototype site through think aloud sessions (n=7) highlighted several usability issues. Issues included confusing visual cues and confusion over whether user-updated information fed back to health care teams. Some issues could be compounded for users with limited digital skills. Results from the focus groups and think aloud workshops were used in the development of a live MDIQ platform. CONCLUSIONS: Acting on the input of end users at each iterative stage of a digital tool's development can help to prioritize users throughout the design process, ensuring the alignment of DHI features with user needs. The use of the sociotechnical framework encouraged the consideration of interactions between different sociotechnical dimensions in finding solutions to issues, for example, avoiding the exclusion of users with limited digital skills. Based on user feedback, the tool could scaffold good goal setting, allowing users to balance their palatable future complications risk against acceptable lifestyle changes. Optimal control of diabetes relies heavily on self-management. Tools such as MDMW/ MDIQ can offer personalized support for self-management alongside access to users' electronic health records, potentially helping to delay or reduce long-term complications, thereby providing significant reductions in health care costs.

The Arclight vs. traditional ophthalmoscope: a cross-over trial.

BACKGROUND/OBJECTIVES: To compare skill acquisition of the new, cost-effective Arclight ophthalmoscope, with the traditional ophthalmoscope (TO), in medical students with no prior experience of ophthalmoscopy. SUBJECTS/METHODS: University of Dundee medical students took part in a cross-over trial. Students were divided into two groups and were alternately taught each device using a video tutorial. In period one, Group A was taught the TO first; Group B was taught the Arclight. They were then assessed using simulated objective, structured, clinical, examinations, examining four model heads with lettered fundal photographs of varying sizes of font. Groups crossed over following a 2-week washout period and were taught the second device and reassessed. A questionnaire was distributed to ascertain students' opinions and preferences. RESULTS: Forty medical students participated. Overall, 92.5% of students performed better with the Arclight, irrespective of cross-over trial period. The mean difference in score in period one of the cross-over trial was 16.77 (95% CI: 11.63-21.93), with students performing better with the Arclight (p < 0.0001). The mean difference in score in period two was 8.02 (95% CI: 4.52-11.52), with students performing better with the Arclight (p < 0.0001). In addition, performance with the TO improved by 52.9% following initial exposure to the Arclight. The Arclight was the preferred device by 82.5% of students, and 82.5% of students would choose this device for future practice. CONCLUSION: Students performed better with and preferred the Arclight ophthalmoscope. The Arclight could be considered as a suitable alternative to the TO used for training medical students.

IMCI and ETAT integration at a primary healthcare facility in Malawi: a human factors approach.

BACKGROUND: Integrated Management of Childhood Illness (IMCI) and Emergency Triage, Assessment and Treatment (ETAT) are guidelines developed by the World Health Organization to reach targets for reducing under-5 mortality. They were set out in the Millennium Development Goals. Each guideline was established separately so the purpose of this study was to understand how these systems have been integrated in a primary care setting and identify barriers and facilitators to this integration using a systems approach. METHOD: Interviews were carried out with members of staff of different levels within a primary healthcare clinic in Malawi. Along with observations from the clinic this provided a well-rounded view of the running of the clinic. This data was then analysed using the SEIPS 2.0 work systems framework. The work system elements specified in this model were used to identify and categorise themes that influenced the clinic's efficiency. RESULTS: A process map of the flow of patients through the clinic was created, showing the tasks undertaken and the interactions between staff and patients. In their interviews, staff identified several organisational elements that served as barriers to the implementation of care. They included workload, available resources, ineffective time management, delegation of roles and adaptation of care. In terms of the external environment there was a lack of clarity over the two sets of guidelines and how they were to be integrated which was a key barrier to the process. Under the heading of tools and technology a lack of guideline copies was identified as a barrier. However, the health passport system and other forms of recording were highlighted as being important facilitators. Other issues highlighted were the lack of transport provided, challenges regarding teamwork and attitudes of members of staff, patient factors such as their beliefs and regard for the care and education provided by the clinic. CONCLUSIONS: This study provides the first information on the challenges and issues involved in combining IMCI and ETAT and identified a number of barriers. These barriers included a lack of resources, staff training and heavy workload. This provided areas to work on in order to improve implementation.

A qualitative study into the perceived barriers of accessing healthcare among a vulnerable population involved with a community centre in Romania.

BACKGROUND: Minority vulnerable communities, such as the European Roma, often face numerous barriers to accessing healthcare services, resulting in negative health outcomes. Both these barriers and outcomes have been reported extensively in the literature. However, reports on barriers faced by European non-Roma native communities are limited. The "Health Care Access Barriers" (HCAB) model identifies pertinent financial, structural and cognitive barriers that can be measured and potentially modified. The present study thus aims to explore the barriers to accessing healthcare for a vulnerable population of mixed ethnicity from a charity community centre in Romania, as perceived by the centre's family users and staff members, and assess whether these reflect the barriers identified from the HCAB model. METHODS: Eleven community members whose children attend the centre and seven staff members working at the centre participated in face-to-face semi-structured interviews, exploring personal experiences and views on accessing healthcare. The interviews were transcribed and analysed using an initial deductive and secondary inductive approach to identify HCAB themes and other emerging themes and subthemes. RESULTS: Identified themes from both groups aligned with HCAB's themes of financial, structural and cognitive barriers and emergent subthemes important to the specific population were identified. Specifically, financial barriers related mostly to health insurance and bribery issues, structural barriers related mostly to service availability and accessibility, and cognitive barriers related mostly to healthcare professionals' attitudes and discrimination and the vulnerable population's lack of education and health literacy. A unique theme of psychological barriers emerged from both groups with associated subthemes of mistrust, hopelessness, fear and anxiety of this vulnerable population. CONCLUSION: The current study highlights healthcare access barriers to a vulnerable non-Roma native population involved with a charity community centre in Romania. The "Healthcare Access Barriers for Vulnerable Populations" (HABVP) model is proposed as an adaption to the existing HCAB model to account for the unique perceived barriers to healthcare for this population. Recommendations for future resolution of these identified barriers are proposed.

Comparative evaluation of a novel solar powered low-cost ophthalmoscope (Arclight) by eye healthcare workers in Malawi.

This study compared a novel low-cost solar powered direct ophthalmoscope called the Arclight with a traditional direct ophthalmoscope (TDO). After appropriate training, 25 Malawian eye healthcare workers were asked to examine 12 retinal images placed in a teaching manikin head with both the Arclight ophthalmoscope and a traditional direct ophthalmoscope (Keeler Professional V.2.8). Participants were scored on their ability to identify clinical signs, to make a diagnosis and how long they took to make a diagnosis. They were also asked to score each ophthalmoscope for 'ease of use'. Statistically significant differences were found in favour of the Arclight in the number of clinical signs identified, correct diagnoses made and ease of use. The ophthalmoscopes were equally effective as a screening tool for diabetic retinopathy, and there was no statistically difference in time to diagnosis. The authors conclude that the Arclight offers an easy to use, low cost alternative to the traditional direct ophthalmoscope to meet the demands for screening and diagnosis of visually impairing eye disorders in low-income and middle-income countries.

Learning from errors: assessing final year medical students' reflection on safety improvement, five year cohort study.

BACKGROUND: Investigation of real incidents has been consistently identified by expert reviews and student surveys as a potentially valuable teaching resource for medical students. The aim of this study was to adapt a published method to measure resident doctors' reflection on quality improvement and evaluate this as an assessment tool for medical students. METHODS: The design is a cohort study. Medical students were prepared with a tutorial in team based learning format and an online Managing Incident Review course. The reliability of the modified Mayo Evaluation of Reflection on Improvement tool (mMERIT) was analysed with Generalizability G-theory. Long term sustainability of assessment of incident review with mMERIT was tested over five consecutive years. RESULTS: A total of 824 students have completed an incident review using 167 incidents from NHS Tayside's online reporting system. In order to address the academic practice gap students were supervised by Senior Charge Nurses or Consultants on the wards where the incidents had been reported. Inter-rater reliability was considered sufficiently high to have one assessor for each student report. There was no evidence of a gradient in student marks across the academic year. Marks were significantly higher for students who used Section Questions to structure their reports compared with those who did not. In Year 1 of the study 21 (14%) of 153 mMERIT reports were graded as concern. All 21 of these students achieved the required standard on resubmission. Rates of resubmission were lower (3% to 7%) in subsequent years. CONCLUSIONS: We have shown that mMERIT has high reliability with one rater. mMERIT can be used by students as part of a suite of feedback to help supplement their self-assessment on their learning needs and develop insightful practice to drive their development of quality, safety and person centred professional practice. Incident review addresses the need for workplace based learning and use of real life examples of mistakes, which has been identified by previous studies of education about patient safety in medical schools.

Paediatric burns in LMICs: An evaluation of the barriers and facilitators faced by staff involved in burns education training programmes in Blantyre, Malawi.

BACKGROUND: A burn prevention and education programme - the Reduction of Burn and Scald Mortality and Morbidity in Children in Malawi project - was implemented from January 2010-2013 in Queen Elizabeth Central Hospital, Malawi. This study aimed to investigate the barriers and facilitators of implementing education-training programmes. METHODS: Semi-structured interviews with 14 Scottish and Malawian staff delivering and receiving teaching at training education programmes were conducted. All interviews were recorded, transcribed and analysed using thematic analysis. RESULTS: Overarching barriers and facilitators were similar for both sets of staff. Scottish participants recognised that limited experience working in LMICs narrowed the challenges they anticipated. Time was a significant barrier to implementation of training courses for both sets of participants. Lack of hands on practical experience was the greatest barrier to implementing the skills learnt for Malawian staff. Sustainability was a significant facilitator to successful implementation of training programmes. Encouraging involvement of Malawian staff in the co-ordination and delivery of teaching enabled those who attend courses to teach others. CONCLUSIONS: A recognition of and response to the barriers and facilitators associated with introducing paediatric burn education training programmes can contribute to the development of sustainable programme implementation in Malawi and other LMICs.

Safety culture in anaesthesiology: basic concepts and practical application.

This article starts from a social science viewpoint and reviews the concepts and measurement of safety culture and climate in their original industrial settings and in health care. Typical items measured and generic characteristics of a positive safety culture are described. The role of personality, professional group membership and anaesthesiology-specific knowledge and expertise in shaping notions of risk and safety and safety behaviour are discussed. The difficulties of changing human behaviour are outlined, and the pivotal role which anaesthesiologists can play in promoting a positive safety culture, both individually and within their teams and organisations, is highlighted.