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Background: Sex workers face an epidemic of violence in the United States. However, violence against sex workers in the United States is underreported. Sex workers hesitate to report it to the police because they are frequently punished themselves; therefore, an alternative for reporting is needed., Objective: We aim to apply human-centered design methods to create and evaluate the usability of the prototype interface for ReportVASW (violence against sex worker, VASW) and identify opportunities for improvement., Methods: This study explores ways to improve the prototype of ReportVASW, with particular attention to ways to improve the data collection tool. Evaluation methods included cognitive walkthrough, system usability scale, and heuristic evaluation., Results: End users were enthusiastic about the idea of a website to document violence against sex workers. ReportVASW scored 90 on the system usability scale. The tool scored neutral on consistency, and all other responses were positive toward the app, with most being strong., Conclusions: Many opportunities to improve the interface were identified. Multiple methods identified multiple issues to address. Most changes are not overly complex, and the majority were aesthetic or minor. Further development of the ReportVASW data collection tool is worth pursuing., (© Melissa H Ditmore, Jose Fernando Florez-Arango. Originally published in JMIR Human Factors (https://humanfactors.jmir.org).)

Background: Addressing mental health disparities following COVID-19 requires adaptive, multi-sectoral, equity-focused, and community-based approaches. Mental health task-sharing in gateway settings has been found to address mental health care gaps in low- and middle-income countries, but is not a common practice in the U.S., especially in non-medical settings, such as low-income housing developments (LIH). This research study will evaluate the effectiveness of a multisectoral community-engaged collaborative for task-sharing mental health care on consumer, provider, and implementation outcomes, as well as identify barriers and facilitators for implementation., Methods: In this stepped-wedge randomized controlled trial with technology supplementation, LIH and primary care sites will be randomly assigned to one of five sequences of three implementation strategies: (1) Education and Resources (E&R), which involves online training and resources on basic mental health task-sharing skills, (2) Multisectoral Community Collaborative Care (MCC), which consists of all E&R resources plus additional community responsive implementation supports and participation in a multisectoral coalition and (3) MCC + Technology, which combines the MCC condition resources with a community crowdsourced technology solution to support implementation. The primary outcome is the effectiveness in meeting consumers' needs through direct service (e.g., adequately addressing depression and anxiety symptoms), and through implementation to increase access to mental health care (reach). The secondary outcome examines additional consumer outcomes including health functioning and social risks, as well as implementation outcomes including provider skills, program adoption, and factors related to barriers and facilitators of quality implementation. A total of 700 consumers receiving mental health care at 20 sites will be surveyed at baseline, 6-, and 12-month follow-ups. Additionally, 100 providers will be evaluated at baseline, 6-, 12-, and 24-month follow-ups before training and after randomization., Discussion: We hypothesize that MCC and MCC + Technology conditions will demonstrate significantly higher efficacy in changing primary outcomes compared to E&R, and the MCC + Technology supplement will show significantly higher levels of reach of mental health tasks compared to the MCC condition alone. These findings will demonstrate the feasibility of mental health integration into accessible, non-medical community settings such as LIH. Moreover, it will help establish a multilevel system solution based on community engagement and planning with a multisectoral collaboration that can be sustained community-wide., Trial Registration: NCT05833555 on Clinicaltrials.gov. Registered April 26, 2023., (© 2024. The Author(s).)

Abstract: Postpartum hemorrhage (PPH) is the leading cause of maternal mortality and morbidity. Effective nurse training for PPH management can reduce negative health impacts on childbearing women. This article discusses a framework for the development of an innovative immersive virtual reality simulator for PPH management training. The simulator should consist of: 1) a virtual world, including virtual physical and social environments, and simulated patients, and 2) a smart platform, providing automatic instructions, adaptive scenarios, and intelligent performance debriefing and evaluations. This simulator will provide a realistic virtual environment for nurses to practice PPH management and promote women's health., Competing Interests: The authors have declared no conflict of interest., (Copyright © 2023 National League for Nursing.)

Background: In Fiji and other South Pacific island countries, depression and suicide are of great concern. There is a pressing need to rapidly identify those at risk and provide treatment as soon as possible., Objective: Design, develop and test a mobile health tool that enables CHNs to easily and rapidly identify individuals at risk for suicide and depression and provide guidelines for their treatment., Methods: Using Android Studio, a native app called ASRaDA was developed that encoded two validated scales: Center for Epidemiological Studies-Depression (CES-D), and Suicide Behavior Questionnaire-Revised (SBQ-R). The usability of the app was measured using the System Usability Scale by community health nurses in Fiji., Results: Out of a maximim possible of 100 on SUS, ASRaDA was scored at 86.79., Conclusion: Mobile tools with high usability can be designed to aid community health nurses in Fiji and Pacific island counties rapidly identify those at risk for depression and suicide.

Background: Displeasure with the functionality of clinical decision support systems (CDSSs) is considered the primary challenge in CDSS development. A major difficulty in CDSS design is matching the functionality to the desired and actual clinical workflow. Computer-interpretable guidelines (CIGs) are used to formalize medical knowledge in clinical practice guidelines (CPGs) in a computable language. However, existing CIG frameworks require a specific interpreter for each CIG language, hindering the ease of implementation and interoperability., Objective: This paper aims to describe a different approach to the representation of clinical knowledge and data. We intended to change the clinician's perception of a CDSS with sufficient expressivity of the representation while maintaining a small communication and software footprint for both a web application and a mobile app. This approach was originally intended to create a readable and minimal syntax for a web CDSS and future mobile app for antenatal care guidelines with improved human-computer interaction and enhanced usability by aligning the system behavior with clinical workflow., Methods: We designed and implemented an architecture design for our CDSS, which uses the model-view-controller (MVC) architecture and a knowledge engine in the MVC architecture based on XML. The knowledge engine design also integrated the requirement of matching clinical care workflow that was desired in the CDSS. For this component of the design task, we used a work ontology analysis of the CPGs for antenatal care in our particular target clinical settings., Results: In comparison to other common CIGs used for CDSSs, our XML approach can be used to take advantage of the flexible format of XML to facilitate the electronic sharing of structured data. More importantly, we can take advantage of its flexibility to standardize CIG structure design in a low-level specification language that is ubiquitous, universal, computationally efficient, integrable with web technologies, and human readable., Conclusions: Our knowledge representation framework incorporates fundamental elements of other CIGs used in CDSSs in medicine and proved adequate to encode a number of antenatal health care CPGs and their associated clinical workflows. The framework appears general enough to be used with other CPGs in medicine. XML proved to be a language expressive enough to describe planning problems in a computable form and restrictive and expressive enough to implement in a clinical system. It can also be effective for mobile apps, where intermittent communication requires a small footprint and an autonomous app. This approach can be used to incorporate overlapping capabilities of more specialized CIGs in medicine., (©Ever Augusto Torres Silva, Sebastian Uribe, Jack Smith, Ivan Felipe Luna Gomez, Jose Fernando Florez-Arango. Originally published in JMIR Formative Research (http://formative.jmir.org), 16.10.2020.)

Serious games have been used to increase the accuracy and usege of clinical guidelines during routine clinical practice. This document presents the development of a serious game called SIM-GIC, a video game designed to simulate virtual patients and evaluate the decision making of players based on computer-interpretable clinical guidelines. The system is currently being developed with a content focus on antenatal care guidelines, where a number of obstetric guidelines were coded in XML files.

Introduction: The increasing use of Health Information Technology (HIT) can add substantially to workload on clinical providers. Current methods for assessing workload do not take into account the nature of clinical cases and the use of HIT tools while solving them. Methods: The Clinical Case Demand Index (CCDI), consisting of a summary score and visual representation, was developed to meet this need. Consistency with current perceived workload measures was evaluated in a Randomized Control Trial of a mobile health system. Results: CCDI is significantly correlated with existing workload measures and inversely related to provider performance. Discussion: CCDI combines subjective and objective characteristics of clinical cases along with cognitive and clinical dimensions. Applications include evaluation of HIT tools, clinician scheduling, medical education. Conclusion: CCDI supports comparative effectiveness research of HIT tools. In addition, CCDI could have numerous applications including training, clinical trials, design of clinical workflows, and others.

Objective: To explore the demographic factors and the level of knowledge related to information and communication technologies of potential users of a palliative care information system., Methods: The Task, User, Representation, Functionality (TURF) framework was applied to characterize potential users (patients and caregivers) of an information system for palliative care in a private clinic in Medellin, Colombia, through a survey., Results: We analyzed 35 patients and 39 caregivers. The majority were women, that lived in urban area and belonged to middle-income socioeconomic stratum. Caregivers, in contrast to patients, are common users of information and communication technologies., Conclusion: An information system should focus on the needs of caregivers, and it would be targeted to subjects facing challenges related to technology adoption; information and communication technologies are interesting and important tools for the improvement of health team.

One of the ways to develop health simulations is through the use of computers. This paper presents the use of Intelligent Computer-aided Instruction (ICAI) for the development of an interactive simulator for learning Cardio Pulmonary Resucitation (CPR) which incorporates online tutorials, training and evaluation.

Background: Currently, in developing countries, there is considerable interest in using mobile phones as job-aids for community health workers (CHWs) to improve the care they provide. However, acceptance of new technologies can be inhibited if the workload imposed is perceived as excessive compared to existing methods., Objective: To compare perceived workload of CHWs using clinical care guidelines presented on mobile phones versus using conventional paper-based guidelines., Methods: Validated clinical practice guidelines were developed as Interactive Structured Rich-Medical guidelines (ISRMGs) on Windows Mobile 6.5 mobile phones. A prospective randomized controlled study was performed in Colombia in which 50 CHWs used the ISRMGs, and paper-based materials with the same information, in a cross-over design to diagnose and treat 15 matched pairs of medical cases presented on Human Patient simulators. The NASA Task Load Index, a validated measure of perceived workload, was administered and results compared by means of a mixed model analysis., Results: When using the ISRMGs on mobile phones the health workers reported statistically significant decreases in mental demand, frustration, and overall workload as compared to using paper-based job-aids., Conclusions: Use of ISRMGs on mobile phones by community health workers in developing countries has the potential to decrease their perceived workload, fatigue, and enhance their ability to provide better care for more patients.

Purpose: To compare agreement between mosaicked and seven field photographs for classification of the diabetic retinopathy (DR) severity., Methods: Mosaic digital (MosD) images were compared with seven field stereo film (7FF) and stereo digital (7FD) photographs from a 152-eye cohort with full-spectrum Early Treatment of Diabetic Retinopathy severity levels for agreement on severity level, DR presence with ascending severity thresholds, DR index lesion presence, and classification repeatability., Results: There was a substantial agreement classifying the Early Treatment Diabetic Retinopathy Study DR severity level between MosD and 7FF (kunweighted = 0.59, klinear weighted = 0.83), MosD and 7FD (κ = 0.62, κ weighted = 0.86), and 7FD and 7FF (κ = 0.62, κ weighted = 0.86) images. Marginal homogeneity analyses found no significant difference between MosD and 7FF (P = 0.44, Bhapkar's test). Kappa between MosD and 7FF ranged from 0.75 to 0.91 for the presence or absence of DR at 8 ascending severity thresholds. Repeatability among readers using MosD images was similar to repeatability among those using 7FF or 7FD. Repeatability among readers using MosD and 7FF images at various severity thresholds was similar. Kappa between MosD and 7FF grading for identifying DR lesions ranged from 0.61 to 1.00., Conclusion: Mosaic images are generally comparable with standard seven-field photographs for classifying DR severity.

Purpose: To evaluate digital photography parameters affecting comparability with the Early Treatment Diabetic Retinopathy Study (ETDRS) film protocol for diabetic retinopathy (DR) severity grading., Methods: ETDRS protocol photographs and four variations of digital images (uncompressed stereoscopic, compressed stereoscopic, uncompressed monoscopic, and uncompressed monoscopic wide-angle mosaic) of 152 eyes were independently evaluated by using ETDRS classifications. Digital formats were compared to film and each other for agreement on severity level, DR presence at ascending threshold, presence of the DR index lesion, and repeatability of grading. Study parameters included image resolution sufficient to distinguish small lesions, color balancing of digital images to film, documenting essential ETDRS classification retinal regions, similar magnification, and supplementary green-channel viewing., Results: The κ statistic was substantial or near substantial between all digital formats and film for classifying severity levels (κ = 0.59-0.62; κ(w) [linear weighted] = 0.83-0.87). The distribution of DR levels in all digital formats was not significantly different from that of the film (Bhapkar test, P = 0.09-0.44). The κ among digital formats for severity level was also substantial or near substantial (κ = 0.58-0.76, κ(w) = 0.82-0.92). Differences between digital formats and film for grading severity level, severity threshold, or index lesions were not significant. The repeatability of grading between readers using film and all digital formats was also similar., Conclusions: Digital format variations compared favorably with film for DR classification. Translating film characteristics (resolution, color/contrast) and protocol (magnification, retinal regions) to digital equivalents and augmentation of full color with green-channel viewing most likely contributed to the results.

Objective: To study and analyze the possible benefits on performance of community health workers using point-of-care clinical guidelines implemented as interactive rich media job aids on small-format mobile platforms., Design: A crossover study with one intervention (rich media job aids) and one control (traditional job aids), two periods, with 50 community health workers, each subject solving a total 15 standardized cases per period per period (30 cases in total per subject)., Measurements: Error rate per case and task, protocol compliance., Results: A total of 1394 cases were evaluated. Intervention reduces errors by an average of 33.15% (p = 0.001) and increases protocol compliance 30.18% (p < 0.001). Limitations Medical cases were presented on human patient simulators in a laboratory setting, not on real patients., Conclusion: These results indicate encouraging prospects for mHealth technologies in general, and the use of rich media clinical guidelines on cell phones in particular, for the improvement of community health worker performance in developing countries.

Purpose: To assess agreement between evaluations of monoscopic and stereoscopic digital images versus stereo film photographs in diabetic macular edema (DME)., Methods: A 152-eye group of digital monoscopic macular images (seven-field sets and wide-angle mosaics) were compared with digital stereoscopic images (uncompressed and compressed seven-field sets) and stereo 35-mm film photos (Early Treatment Diabetic Retinopathy Study protocol) for the presence of hard exudates (HE), retinal thickening (RT), clinically significant macular edema (CSME), and RT at the center of the macular (RTCM)., Results: Agreement, according to the κ statistic, was almost perfect in identifying HE and RT between all digital formats and stereo film (HE, κ = 0.81-0.87; RT, κ = 0.87-0.92). Distribution in all digital formats was not significantly different from that in film (Bhapkar test: HE, P = 0.20-0.40; RT, P = 0.06-1.0). CSME and RTCM grading differences were either significant or trended toward significance. The readers detected CSME and RTCM in film images more often than in digital formats. In identifying DME features, agreement between evaluations of monoscopic digital formats and film was similar to that between stereo digital formats and film, and the performance of uncompressed images versus film was similar to that of compressed images versus film. Repeatability between readers was similar in evaluations of film and all digital formats. Repeatability in identifying RTCM was lower than that of other DME components in film and all digital formats., Conclusions: Stereoscopic digital formats are equivalent to monoscopic for DME evaluation, but digital photography is not as sensitive as film in detecting CSME and RTCM.

Purpose: To assess agreement between digital and film photography for research classification of diabetic retinopathy severity., Methods: Digital and film photographs from a 152-eye cohort with a full spectrum of Early Treatment Diabetic Retinopathy Study (ETDRS) severity levels were assessed for repeatability of grading within each image medium and for agreement on ETDRS discrete severity levels, ascending severity thresholds, and presence or absence of diabetic retinopathy index lesions, between digital and 35-mm slides (film). Digital photographs were color balanced to match film., Results: There was substantial agreement (κ = 0.61, κ(w) [linear weighted] = 0.87) in classification of ETDRS diabetic retinopathy severity levels between digital images and film. Marginal homogeneity analyses found no significant difference in frequency distributions on the severity scale (P = 0.21, Bhapkar test). The κ results ranged from 0.72 to 0.95 for presence or absence of eight ascending diabetic retinopathy severity thresholds. Repeatability of grading between readers viewing digital images was equal to or better than that obtained with film (pair-wise interreader κ for digital images ranged from 0.47 to 0.57 and for film from 0.43 to 0.57. The κ results for identifying diabetic retinopathy lesions ranged from moderate to almost perfect. Moderate agreement of intraretinal microvascular abnormalities and venous beading between digital images and film accounted for slightly lower concordance for severity thresholds ≥47 and for slightly lower interreader agreement within digital and film images at severity thresholds ≥43 and ≥47., Conclusions: Under controlled circumstances, digital photography can equal the reliability of 35-mm slides for research classification of ETDRS severity level.

Purpose: To compare research grading of diabetic retinopathy (DR) severity level from compressed digital images versus uncompressed images and film., Methods: Compressed (JPEG2000, 37:1) digital images (C) were compared with uncompressed digital (U) and film (F) stereoscopic photographs from a 152-eye cohort with full-spectrum Early Treatment Diabetic Retinopathy Study severity levels for agreement on severity level, DR presence with ascending severity threshold, presence of DR index lesions, and repeatability of grading., Results: Classification of Early Treatment Diabetic Retinopathy Study severity levels from C images agreed substantially with results from F images (κ = 0.60, κ(w) [linear weighted] = 0.86) and uncompressed digital images (κ = 0.76, κ(w) = 0.92). For agreement of uncompressed digital versus F images, κ = 0.62 and κ(w) = 0.86. Distribution of Early Treatment Diabetic Retinopathy Study levels was not significantly different between C and F images (P = 0.09, Bhapkar's test for marginal homogeneity). For presence/absence of DR at 8 ascending severity thresholds, agreement between C and F was "almost perfect" (κ ≥ 0.8). Agreement on severity level between readers with C images was at least as good as that with uncompressed digital image or F. Repeatability of severity threshold grading between readers was similar using C or F images. For identifying individual DR lesions, agreement between C and F ranged from "moderate" to "perfect." Agreement of grading venous beading from C was slightly lower than from F., Conclusion: Full Early Treatment Diabetic Retinopathy Study scale DR severity level grading using C images is comparable to that using U images or film.

Purpose: To assess agreement between monoscopic and stereoscopic photography for research classification of the severity of diabetic retinopathy (DR)., Methods: Monoscopic digital (MD) images were compared with stereo digital (SD) and film (SF) photographs from a 152-eye cohort with full-spectrum Early Treatment Diabetic Retinopathy Study (ETDRS) severity levels for agreement on severity level, DR presence with ascending severity threshold, presence of DR index lesions, and repeatability of grading., Results: There was substantial agreement classifying ETDRS DR severity levels between MD and SF (kappa = 0.65, kappa(w) [linear weighted] = 0.87), MD and SD (kappa = 0.66, kappa(w) = 0.87), and SD and SF (kappa = 0.62, kappa(w) = 0.86) images. Marginal homogeneity analyses found no significant difference between MD and SF images (P = 0.53, Bhapkar test). The kappa agreement between MD and SF ranged from 0.80 to 0.94 for the presence or absence of eight ascending DR severity thresholds. Repeatability between the readers of the MD images was equal to or better than that of the readers of SD or SF images. Severity threshold grading repeatability between readers was similar with the MD and SF images. The kappa agreement between MD and SF for identifying diabetic retinopathy lesions ranged from moderate to almost perfect. The kappa comparisons showed that performance of grading new vessels on the disc in MD images was slightly lower than that with the SF images., Conclusions: Monoscopic photography can equal the reliability of stereo photography for full ETDRS DR severity scale grading.