Key End Users Research Articles

From parachuting to partnership: Fostering collaborative research in protected areas

Abstract Research in protected areas (PAs) is often dominated by scientists from outside the conservation agencies managing them. This can potentially lead to misalignment with local needs, insensitivity to the local context and a lack of investment in and use of local expertise. These issues often arise when international researchers work in another country without local engagement (known as ‘parachute science’). Despite PAs being key end users of actionable science, there is limited understanding of the prevalence and impact of parachute science in these areas. Here, we investigate parachute versus collaborative research in two national parks in the Global South (Kruger National Park, South Africa; Nahuel Huapi National Park, Argentina) and one park from a developed economy (Kakadu National Park, Australia). To explore the prevalence, risks, benefits and complexities of research practices, we analyse the patterns of authorship, funding and acknowledgement in a random sample of peer‐reviewed papers from research conducted in these parks. Our findings show a higher incidence of potential parachute science in Kruger National Park (18% of papers with only out‐of‐country authors) compared to Nahuel Huapi (4%) and Kakadu (2%) national parks. However, the occurrence of internationally collaborative research (national and international authors) was double in Global South parks (35%–38%) than in the Australian park (18%). The study illustrates the potential benefits of international collaboration for PAs, including increased research productivity, expanded funding sources and possibly higher impact and visibility of published studies. PAs in developed countries may have fewer opportunities to obtain those benefits. Most papers, even those with in‐country authors, lacked authors affiliated with the agency managing the PA and often failed to even acknowledge these agencies. This suggests the potential for a different form of parachute science (which we term ‘park parachuting’) in which lack of local involvement may hamper integration of research with management. Synthesis and applications: Establishing conditions that foster collaboration between national and international researchers, and between PA agency staff and external researchers (regardless of their nationality), would enable parks to better serve as catalysts for research collaboration. This collaborative approach can facilitate access to additional funding, enhance research capacity, increase research productivity and amplify research impact.

Applying the Cognitive Walkthrough for Implementation Strategies methodology to inform the redesign of a selection-quality implementation toolkit for use in schools.

Implementation strategies are key to enhancing thetranslation of new innovations but there is a need to systematically design and tailor strategies to match the targeted implementation context and address determinants. There are increasing methods to inform the development and tailoring of implementation strategies to maximize their usability, feasibility, and appropriateness in new settings such as the Cognitive Walkthrough for Implementation Strategies (CWIS) approach. The aim of the current project is to apply the CWIS approach to inform the redesign of a multifaceted selection-quality implementation toolkit entitled Adoption of Curricular supports Toolkit: Systematic Measurement of Appropriateness and Readiness for Translation in Schools (ACT SMARTS) for use in middle and high schools. We systematically applied CWIS as the second part of a community-partnered iterative redesign of ACT SMARTS for schools to evaluate the usability and inform further toolkit redesign areas. We conducted three CWIS user testing sessions with key end users of school district administrators (n = 3), school principals (n = 6), and educators (n = 6). Our CWIS application revealed that end users found ACT SMARTS acceptable and relevant but anticipate usability issues engaging in the ACT SMARTS process. Results informed the identification of eleven usability issues and corresponding redesign solutions to enhance the usability of ACT SMARTS for use in middle and high schools. Results indicated the utility of CWIS in assessing implementation strategy usability in service of informing strategy modification as part of our broader redesign to improve alignment with end user, end recipient, and setting needs. Recommendations regarding the use of this participatory approach are discussed.

Applying the Cognitive Walkthrough for Implementation Strategies Methodology to Inform the Redesign of a Selection-Quality Implementation Toolkit for Use in Schools.

Implementation strategies are key to enhancing translation of new innovations but there is a need to systematically design and tailor strategies to match the targeted implementation context and address determinants. There are increasing methods to inform the redesign and tailoring of implementation strategies to maximize their usability, feasibility, and appropriateness in new settings such as the Cognitive Walkthrough for Implementation Strategies (CWIS) approach. The aim of the current project is to apply the CWIS approach to inform the redesign of a multifaceted selection-quality implementation toolkit entitled ACT SMARTS for use in middle and high schools. We systematically applied CWIS as the second part of a community-partnered iterative redesign of ACT SMARTS for schools to evaluate the usability and inform further toolkit redesign areas. We conducted three CWIS user testing sessions with key end users of school district administrators, school principals, and educators. Our CWIS application revealed that end users found ACT SMARTS acceptable and relevant but anticipate usability issues engaging in the ACT SMARTS process. Results informed the identification of eleven usability issues and corresponding redesign solutions to enhance the usability of ACT SMARTS for use in middle and high schools. Results indicated the utility of CWIS in assessing implementation strategy usability in service of informing strategy tailoring and redesign to improve alignment with user and setting needs. Recommendations regarding the use of this participatory approach are discussed.

An Assessment of Learning Management System Use in Higher Education: Perspectives from a Comprehensive Sample of Teachers and Students

AbstractLearning Management Systems (LMSs) are underutilized in universities despite them being standard components of higher education. Given this, there is a need to gather the perspectives of students and teachers to examine how these key end-users engage with LMS and utilize its various features and functions. Such an endeavor could aid in addressing the barriers and in promoting the use of LMSs in online teaching and learning. As studies about LMS use with both teacher and student samples are limited, we simultaneously gathered both students’ and teachers’ perceptions of Moodle from all academic faculties at a public university in Hong Kong. Structured qualitative interviews were conducted with eighty-two participants (41 teachers, 41 students) via Zoom. Results suggest that Moodle, while previously viewed as merely a repository of course materials, transitioned from being a supplementary tool to a key information dissemination tool during the pandemic. Despite the availability of collaboration tools, majority of interactions still occur in alternative communication channels. Findings point to students’ and teachers’ need for familiarity, training, and a visually and functionally improved interface to enhance their experience in the LMS. We also found how content and pedagogy influenced how LMS was integrated into teaching, with frequency and manner of LMS use varying between faculties and departments. Given this, tailor-made information and support for each department are needed to maximize LMS use in classes. We suggest the conduct of dialogues involving multiple stakeholders (i.e., teachers, students, administrators, and technical support staff) so that higher education institutions can share best practices on how to improve LMS utilization to enhance the quality of teaching and learning in universities.

Evaluating Pilot Implementation of 'PenCS Flu Topbar' App in Medical Practices to Improve National Immunisation Program-Funded Seasonal Influenza Vaccination in Central Queensland, Australia.

The 'PenCS Flu Topbar' app was deployed in Central Queensland (CQ), Australia, medical practices through a pilot programme in March 2021. We evaluated the app's user experience and examined whether the introduction of 'PenCS Flu Topbar' in medical practices could improve the coverage of NIP-funded influenza vaccinations. We conducted a mixed-method study including a qualitative analysis of in-depth interviews with key end-users and a quantitative analysis of influenza vaccine administrative data. 'PenCS Flu Topbar' app users reported positive experiences identifying patients eligible for NIP-funded seasonal influenza vaccination. A total of 3606 NIP-funded influenza vaccinations was administered in the eight intervention practices, 14% higher than the eight control practices. NIP-funded vaccination coverage within practices was significantly higher in the intervention practices (31.2%) than in the control practices (27.3%) (absolute difference: 3.9%; 95% CI: 2.9%-5.0%; p < 0.001). The coverage was substantially higher in Aboriginal and Torres Strait Islander people aged more than 6 months, pregnant women and children aged 6 months to less than 5 years for the practices where the app was introduced when compared to control practices: incidence rate ratio (IRR) 2.4 (95% CI: 1.8-3.2), IRR 2.7 (95% CI: 1.8-4.2) and IRR 2.3 (1.8-2.9) times higher, respectively. Our evaluation indicated that the 'PenCS Flu Topbar' app is useful for identifying the patients eligible for NIP-funded influenza vaccination and is likely to increase NIP-funded influenza vaccine coverage in the eligible populations. Future impact evaluation including a greater number of practices and a wider geographical area is essential.

Rationale and development of an e-health application to deliver patient-centered care during treatment for recently diagnosed multiple myeloma patients: pilot study of the MM E-coach

BackgroundPatients with multiple myeloma (MM) increasingly face complicated treatment regimens. E-health may support patients and healthcare providers in enhancing a patient-centered healthcare approach. Therefore, we aimed to develop a patient-centered multi-modality e-health application, to assess the application for usability and end-user experiences.MethodsThe application was developed following an iterative “action-based” methodology using the design thinking approach. Key end users participated, and relevant stakeholders were consulted in the development process. First, the care pathway was evaluated, the focus of development was determined, and a solution ideated during recurring multidisciplinary meetings. Second, a prototype was tested and improved. Third, a subsequent prototype was evaluated during a pilot study with patients and healthcare professionals on usability, usage, and experiences.ResultsThe multi-modality application, named the “MM E-coach,” consisted of a newly developed medication module, patient-reported outcome (PRO) questionnaire assessments, a messaging service, alerts, information provision, and a personal care plan. The median system usability score was 60 on a scale of 0–100. Patients appreciated the medication overview, healthcare professionals appreciated the outpatient clinic preparation module, and both appreciated the messaging service. Additional recommendations for improvement mostly revolved around the flexibility of functionalities and look and feel of the application.ConclusionsThe MM E-coach has the potential to provide patient-centered care by supporting patients and caregivers during MM treatment and is a promising application to be implemented in the MM care pathway. A randomized clinical trial was initiated to study its clinical effectiveness.

Dissemination of public health research to prevent non-communicable diseases: a scoping review

BackgroundDissemination is a critical element of the knowledge translation pathway, and a necessary step to ensure research evidence is adopted and implemented by key end users in order to improve health outcomes. However, evidence-based guidance to inform dissemination activities in research is limited. This scoping review aimed to identify and describe the scientific literature examining strategies to disseminate public health evidence related to the prevention of non-communicable diseases.MethodsMedline, PsycInfo and EBSCO Search Ultimate were searched in May 2021 for studies published between January 2000 and the search date that reported on the dissemination of evidence to end users of public health evidence, within the context of the prevention of non-communicable diseases. Studies were synthesised according to the four components of Brownson and colleagues’ Model for Dissemination of Research (source, message, channel and audience), as well as by study design.ResultsOf the 107 included studies, only 14% (n = 15) directly tested dissemination strategies using experimental designs. The remainder primarily reported on dissemination preferences of different populations, or outcomes such as awareness, knowledge and intentions to adopt following evidence dissemination. Evidence related to diet, physical activity and/or obesity prevention was the most disseminated topic. Researchers were the source of disseminated evidence in over half the studies, and study findings/knowledge summaries were more frequently disseminated as the message compared to guidelines or an evidence-based program/intervention. A broad range of dissemination channels were utilised, although peer-reviewed publications/conferences and presentations/workshops predominated. Practitioners were the most commonly reported target audience.ConclusionsThere is a significant gap in the peer reviewed literature, with few experimental studies published that analyse and evaluate the effect of different sources, messages and target audiences on the determinants of uptake of public health evidence for prevention. Such studies are important as they can help inform and improve the effectiveness of current and future dissemination practices in public health contexts.

Exploring the Patient Experience with Patient-Reported Outcomes: A Qualitative, Multistakeholder Study.

Although the literature provides guidance regarding patient-reported outcome (PRO) implementation barriers, patients' perspectives are underreported. This study aimed to improve the understanding of patient experiences with PRO tools through examining perceptions of and attitudes toward PROs and expectations of data use after collection. Ethnographic human-centered design approaches were used to conduct free-form interviews. Two case studies of existing PRO use in clinics also were examined. Unstructured thematic analyses were performed using notes taken during these interviews. Patients generally reported a good understanding of the need for PRO collection, both for research and clinical use. Many expected that results would be acted upon by the clinicians promptly. Thematic analyses identified the following patient perception topics: transparency, individualization to patient needs, timely response, different "identities" while accessing care locally compared with at a destination center, and preference for brief PROs. Design and implementation of PRO assessments into patient care should include the patients as key end users. Transparency of the purpose for data collection is critical for broader patient adoption. Ensuring that only necessary and sufficient data are collected for clinical action, and associated research may help minimize burden and maximize patient participation.

Validity evidence for the Quality of Assessment for Learning score: a quality metric for supervisor comments in Competency Based Medical Education.

Competency based medical education (CBME) relies on supervisor narrative comments contained within entrustable professional activities (EPA) for programmatic assessment, but the quality of these supervisor comments is unassessed. There is validity evidence supporting the QuAL (Quality of Assessment for Learning) score for rating the usefulness of short narrative comments in direct observation. We sought to establish validity evidence for the QuAL score to rate the quality of supervisor narrative comments contained within an EPA by surveying the key end-users of EPA narrative comments: residents, academic advisors, and competence committee members. In 2020, the authors randomly selected 52 de-identified narrative comments from two emergency medicine EPA databases using purposeful sampling. Six collaborators (two residents, two academic advisors, and two competence committee members) were recruited from each of four EM Residency Programs (Saskatchewan, McMaster, Ottawa, and Calgary) to rate these comments with a utility score and the QuAL score. Correlation between utility and QuAL score were calculated using Pearson's correlation coefficient. Sources of variance and reliability were calculated using a generalizability study. All collaborators (n = 24) completed the full study. The QuAL score had a high positive correlation with the utility score amongst the residents (r = 0.80) and academic advisors (r = 0.75) and a moderately high correlation amongst competence committee members (r = 0.68). The generalizability study found that the major source of variance was the comment indicating the tool performs well across raters. The QuAL score may serve as an outcome measure for program evaluation of supervisors, and as a resource for faculty development.

P03: RATIONALE AND DEVELOPMENT OF AN E-HEALTH APPLICATION TO DELIVER PATIENT CENTERED CARE DURING TREATMENT FOR MULTIPLE MYELOMA IN THE NETHERLANDS.

Patients with newly diagnosed Multiple Myeloma (NDMM) face increasingly complicated treatment regimens, including many medications. E-health may support patients and health care providers during treatment, enhancing patient centered care delivery. Therefore, we aimed to develop a multi-modality e-health application. Furthermore, we aimed to assess the application for usability and end-user experiences and to formulate additional requirements for improvement. The application was developed following an iterative action-based methodology, the Design Thinking approach. Key end-users, including patients, hematologists, pharmacists and nurse specialists, were actively involved. Additional stakeholders, including information technology specialists, secretaries and managers, were consulted during an iterative development process. Before developing the application, the care pathway was evaluated and the ideal care pathway was defined, including integrating an e-health application. Second, the focus of development was determined and a solution ideated during recurring multidisciplinary meetings. Third, mockup display sketches of the intended application modules were recurrently discussed and optimized. Fourth, prototypes were tested and improved. Finally, a final prototype was tested during a pilot study with 18 patients and 7 healthcare professionals, evaluating usability, usage and qualitative experiences. The application, ‘MM E-coach’, consisted of a newly developed medication module (Figure 1), patient reported outcomes (PROs) and experiences questionnaire assessments, a messaging service, threshold-based alerts, information provision and a personal care plan. Following 8 weeks of use, the median system usability scale score was 60. Patients appreciated the medication overview and the healthcare professionals the outpatient clinic preparation module. Both appreciated the messaging service. Several recommendations for improvement were made, for example adding new or more flexible functionalities and improving the application view at a glance. The MM E-coach has the potential to provide patient-centered care by supporting patients and caregivers during Multiple Myeloma treatment and is a promising application to be implemented in the Multiple Myeloma care pathway. Following the recommended improvements, a randomized clinical trial is being conducted to evaluate the clinical effectiveness in hospital practice.

Stakeholder perspectives on digital behavioral health applications targeting adolescent depression and suicidality: Policymaker, provider, and community insights.

With adolescent depression and suicidality increasing, technology-based interventions may help address mental health needs. The Enhancing Treatment and Utilization for Depression and Emergent Suicidality (ETUDES) Center supports development of technology interventions to help primary care providers target these problems. To successfully develop and integrate such interventions into primary care, iterative engagement of stakeholders is necessary. This paper outlines our stakeholder engagement process, a qualitative analysis of feedback and outcomes, and how feedback was incorporated to develop Center interventions. Stakeholder panels represented key end-users of ETUDES Center interventions (adolescents, young adults, parents, and healthcare providers) and their advocates at the organizational/policy level. Meetings were held throughout intervention development and at annual retreats. Detailed meeting notes were collected and summarized by the stakeholder engagement team in real time, after which action items were generated and reviewed by the full research team. Using a content analysis approach, all stakeholder feedback summaries were coded using a prespecified codebook organized by recurring topics. Codes were organized under the Consolidated Framework for Implementation Research (CFIR). Anonymous stakeholder feedback surveys assessed relevance of topics, meeting effectiveness, and stakeholder involvement. Stakeholder meetings provided feedback on topics such as representation, language, access to care, and stigma. Relevant feedback and recommendations were incorporated into subsequent iterations of the interventions and their implementation. Mean stakeholder ratings of meeting proceedings on a 0-3 Likert scale ranged from 1.70 (SD = 0.10) for participation to 2.43 (SD = 0.08) for effectiveness in addressing meeting agenda. The iterative engagement approach yielded practical feedback from stakeholders about ETUDES Center interventions. The team organized feedback to identify barriers and facilitators to using Center interventions and to generate action items, which were transposed onto components of an implementation strategy, supplemented by the CFIR-ERIC Implementation Strategy Matching Tool. Stakeholder feedback will direct the future development of an integrated intervention and guide further stakeholder engagement in developing technologies for adolescent mental health.Plain Language Summary: Depression and suicide in teens have been on the rise for the past several years. Primary care may be an ideal place to address these concerns because most teens have a primary care provider (PCP) who can offer a confidential place for both teens and their caregivers. Our Center develops technology-based interventions to help PCPs address teen depression and suicidality. Multiple barriers may hinder PCPs in addressing teen depression and suicidality. This paper describes how we engaged multiple types of stakeholders-or individuals with an interest in adolescent mental health-to ask for their feedback over a series of meetings, to help us improve the fit of our interventions to this population. Stakeholders included providers, community members like parents and mental health advocates, youth, and policymakers. We learned what was most important to them-including concerns about equitable access (e.g., providing broadband internet to families who do not have it so they can still participate) and legal risks or failures for the technology to identify suicidality. In this paper, we describe our process for not only recruiting and engaging stakeholders but also for planning action based on their feedback. Similar processes could be used by other researchers and clinical organizations seeking to incorporate technology into mental health interventions.

A user-centered approach to developing a new tool measuring the behavioural and social drivers of vaccination

BackgroundChildren around the world remain under-vaccinated for many reasons. To develop effective vaccine delivery programmes and monitor intervention impact, vaccine programme implementers need to understand reasons for under-vaccination within their local context. The World Health Organization (WHO) Working Group on the Behavioural and Social Drivers of Vaccination (BeSD) is developing standardised tools for assessing childhood vaccine acceptance and uptake that can be used across regions and countries. The tools will include: (1) a validated survey; (2) qualitative interview guides; and (3) corresponding user guidance. We report a user-centred needs assessment of key end-users of the BeSD tools. MethodsTwenty qualitative interviews (Apr-Aug 2019) with purposively sampled vaccine programme managers, partners and stakeholders from UNICEF and WHO country and regional offices. The interviews assessed current systems, practices and challenges in data utilisation and reflections on how the BeSD tools might be optimised. Framework analysis was used to code the interviews. ResultsRegarding current practices, participants described a variety of settings, data systems, and frequencies of vaccination attitude measurement. They reported that the majority of data used is quantitative, and there is appetite for increased use of qualitative data. Capacity for conducting studies on social/behavioural drivers of vaccination was high in some jurisdictions and needed in others. Issues include barriers to collecting such data and variability in sources. Reflecting on the tools, participants described the need to explore the attitudes and practices of healthcare workers in addition to parents and caregivers. Participants were supportive of the proposed mixed-methods structure of the tools and training in their usage, and highlighted the need for balance between tool standardisation and flexibility to adapt locally. ConclusionsA user-centred approach in developing the BeSD tools has given valuable direction to their design, bringing the use of behavioural and social data to the heart of programme planning.

Evaluation of a Digital Health Initiative in Illicit Substance Use: Cross-sectional Survey Study.

BackgroundThe Cracks in the Ice (CITI) community toolkit was developed to provide evidence-based, up-to-date information and resources about crystal methamphetamine to Australians. Given the high rates of internet use in the community and the potential for misinformation, CITI has the potential to play an important role in improving knowledge and challenging misconceptions surrounding crystal methamphetamine.ObjectiveThis study aims to determine (1) whether the CITI toolkit is achieving its aim of disseminating evidence-based information and resources to people who use crystal methamphetamine, their family and friends, health professionals, and the general community and (2) examine the association between the use of CITI and the knowledge and attitudes about crystal methamphetamine.MethodsA cross-sectional web-based survey, open to Australian residents (aged ≥18 years), was conducted from November 2018 to March 2019. People who had previously visited the website (referred to as “website visitors” in this study) and those who had not (“naïve”) were recruited. At baseline, knowledge, attitudes, and demographics were assessed. CITI website visitors then completed a series of site evaluation questions, including the System Usability Scale (SUS), and naïve participants were asked to undertake a guided site tour of a replicated version of the site before completing the evaluation questions and repeating knowledge and attitude scales.ResultsOf a total 2108 participants, 564 (26.7%) reported lifetime use of crystal methamphetamine, 434 (20.6%) were family/friends, 288 (13.7%) were health professionals, and 822 (38.9%) were community members. The average SUS score was 73.49 (SD 13.30), indicating good site usability. Health professionals reported significantly higher SUS scores than community members (P=.02) and people who used crystal methamphetamine (P<.001). Website visitors had significantly higher baseline knowledge than naïve participants (P<.001). Among naïve participants, knowledge scores increased following exposure to the website (mean 15.2, SE 0.05) compared to baseline (mean 14.4, SE 0.05; P<.001). The largest shifts in knowledge were observed for items related to prevalence, legal issues, and the effects of the drug. Stigmatizing attitude scores among the naïve group were significantly lower following exposure to CITI (mean 41.97, SE 0.21) compared to baseline (mean 44.3, SE 0.21; P<.001).ConclusionsThis study provides an innovative evaluation of a national eHealth resource. CITI is achieving its aim of disseminating evidence-based, nonstigmatizing, and useful information and resources about crystal methamphetamine to key end user groups and has received good usability scores across its target groups. Interaction with CITI led to immediate improvements in knowledge about crystal methamphetamine and a decrease in stigmatizing attitudes. CITI demonstrates the important role of digital information and support platforms for translating evidence into practice and improving knowledge and reducing stigma.

Identifying critical features of type two diabetes prevention interventions: A Delphi study with key stakeholders.

AimsThis study aims to identify critically important features of digital type two diabetes mellitus (T2DM) prevention interventions.MethodsA stakeholder mapping exercise was undertaken to identify key end-user and professional stakeholders, followed by a three-round Delphi procedure to generate and evaluate evidence statements related to the critical elements of digital T2DM prevention interventions in terms of product (intervention), price (funding models/financial cost), place (distribution/delivery channels), and promotion (target audiences).ResultsEnd-user (n = 38) and professional (n = 38) stakeholders including patients, dietitians, credentialed diabetes educators, nurses, medical doctors, research scientists, and exercise physiologists participated in the Delphi study. Fifty-two critical intervention characteristics were identified. Future interventions should address diet, physical activity, mental health (e.g. stress, diabetes-related distress), and functional health literacy, while advancing behaviour change support. Programs should be delivered digitally or used multiple delivery modes, target a range of population subgroups including children, and be based on collaborative efforts between national and local and government and non-government funded organisations.ConclusionsOur findings highlight strong support for digital health to address T2DM in Australia and identify future directions for T2DM prevention interventions. The study also demonstrates the feasibility and value of stakeholder-led intervention development processes.

Discussing diabetes, palliative and end of life care: choosing the 'right' language.

Palliative care and advance care planning are important components of diabetes and other chronic disease management plans. Most people with diabetes do not have conversations about palliative/end of life (EOL) care or advance care directives; often because diabetes clinicians are reluctant to discuss these issues. Guidelines for conversations and decision aids can assist shared decision-making for both clinicians and patients. The aim was to co-design information with older people with diabetes, families and clinicians to facilitate conversations about palliative and EOL care and to identify the language (words) people with diabetes, families and diabetes clinicians use to discuss death and dying. We co-designed and tailored the information with advisory groups: (I) older people with diabetes/families, (II) interdisciplinary expert clinicians and undertook a scoping literature review to identify relevant content. The penultimate versions were independently evaluated in focus groups and via written feedback from representative stakeholder clinicians, people with diabetes and international experts in communication, palliative care and diabetes. The information met design and language criteria: 62 people participated in focus groups (48 clinicians, 14 older people with diabetes and 4 family members). There were important differences between people with diabetes and diabetes clinicians concerning the words used to refer to death: 'the language of death'. Diabetes clinicians choose soft words/euphemisms such as 'passed away' and 'gone' and indicated they mirrored patient language. People with diabetes preferred clear language and indicated euphemisms were confusing and misleading. Diabetes clinicians, rarely encountered death in their practice and indicated they lacked education about how to discuss diabetes EOL care. Co-design with key end-users improved relevance to these groups. Diabetes clinicians prefer to use euphemisms for death and would benefit from education and strategies to help them initiate conversations about EOL diabetes care.

Writing ‘usable’ Nuclear Power Plant (NPP) safety cases using bowtie methodology

Historically, the majority of Nuclear Power Plants (NPP) Safety Cases have been produced and implemented under highly prescriptive regulatory regimes, with emphasis placed on demonstrations of the robustness of the facility’s design basis against a set of deterministic criteria and technical standards and rules set by the Regulatory Body. This has resulted in Safety Cases that are technically sound, but at the same time too complex and not easily accessible to and usable by persons responsible for ensuring safe operations; i.e. operations and maintenance staff who are in direct control of the plant as well as managers who are accountable for safety – the key end-users.Shortcomings regarding the ‘usability’ of the Safety Cases are not new and have been the subject of discussion in recent years. They are deeply rooted in the way these documents are produced and implemented. It means that in order to overcome these difficulties attention should be focused primarily on the Safety Case process, affording it the same importance that is given to the final product – the documented Safety Case. This paper explores the advantages that incorporation of the Bowtie risk management methodology into the Safety Case (production) strategy can bring to the delivery of a fit-for-purpose, accessible and usable Safety Case, supporting current efforts undertaken by the nuclear industry to ensure ‘Right First Time Safety Cases’.The paper also suggests that the conduct of Bowtie workshops - in the author’s opinion, the most important part of the Bowtie building process – provides vital input from the people who have most knowledge and experience of the plant and its current operational status. It enables the Bowtie diagrams to reflect the ‘operational reality’ in the plant, by providing a real picture of the actual barrier condition and, more importantly, to identify those barriers that need to be strengthened. The latter will have a direct effect on the usability of the resultant Safety Case product during plant operation.A generic Advanced Boiling Water Reactor (ABWR) design has been taken as an example to highlight the claimed advantages. The paper reflects how Bowtie diagrams can be built within a workshop setting that depicts how a particular accident scenario can be managed through appropriate barriers and controls. It also shows how the use of Bowtie diagrams can make the Safety Case process a true ‘aid’ to thinking and deliver a final product that is accessible and easy-to-understand by key end-users.

Identifying Persuasive Design Principles and Behavior Change Techniques Supporting End User Values and Needs in eHealth Interventions for Long-Term Weight Loss Maintenance: Qualitative Study.

BackgroundAn increasing number of eHealth interventions aim to support healthy behaviors that facilitate weight loss. However, there is limited evidence of the effectiveness of the interventions and little focus on weight loss maintenance. Knowledge about end user values and needs is essential to create meaningful and effective eHealth interventions, and to identify persuasive system design (PSD) principles and behavior change techniques (BCTs) that may contribute to the behavior change required for successful long-term weight loss maintenance.ObjectiveThis study aimed to provide insight into the design of eHealth interventions supporting behavior change for long-term weight maintenance. The study sought to identify the values and needs of people with obesity aiming to maintain weight after weight loss, and to identify PSD principles, BCTs, and design requirements that potentially enable an eHealth intervention to meet end user values and needs.MethodsThis study presents the concept of integrating PSD principles and BCTs into the design process of eHealth interventions to meet user values and needs. In this study, individual interviews and focus groups were conducted with people with obesity (n=23) and other key stakeholders (n=27) to explore end user values and needs related to weight loss maintenance. Design thinking methods were applied during the focus group sessions to identify design elements and to explore how eHealth solutions can support the needs to achieve sustainable weight loss maintenance. The PSD model and behavior change taxonomy by Michie were used to identify PSD principles and BCT clusters to meet end user values and needs.ResultsA total of 8 key end user values were identified, reflecting user needs for weight loss maintenance support: self-management, personalized care, autonomy, feel supported, positive self-image, motivation, happiness, and health. Goals and planning, feedback and monitoring, repetition and substitution, shaping knowledge, social support, identity, and self-belief were some of the BCT clusters identified to address these concepts, together with PSD principles such as personalization, tailoring, self-monitoring, praise, and suggestions.ConclusionsThe process of translating end user values and needs into design elements or features of eHealth technologies is an important part of the design process. To our knowledge, this is the first study to explore how PSD principles and BCTs can be integrated when designing eHealth self-management interventions for long-term weight loss maintenance. End users and other key stakeholders highlighted important factors to be considered in the design of eHealth interventions supporting sustained behavior change. The PSD principles and BCTs identified provide insights and suggestions about design elements and features to include for supporting weight loss maintenance. The findings indicate that a combination of BCTs and PSD principles may be needed in evidence-based eHealth interventions to stimulate motivation and adherence to support healthy behaviors and sustained weight loss maintenance.Trial RegistrationClinicalTrials.gov NCT04537988; https://clinicaltrials.gov/ct2/show/NCT04537988

Delivering Sustained, Coordinated, and Integrated Observations of the Southern Ocean for Global Impact

The Southern Ocean is disproportionately important in its effect on the Earth system, impacting climatic, biogeochemical and ecological systems, which makes recent observed changes to this system cause for global concern. The enhanced understanding and improvements in predictive skill needed for understanding and projecting future states of the Southern Ocean require sustained observations. Over the last decade, the Southern Ocean Observing System (SOOS) has established networks for enhancing regional coordination and research community groups to advance development of observing system capabilities. These networks support delivery of the SOOS 20-year vision, which is to develop a circumpolar system that ensures time series of key variables, and deliver the greatest impact from data to all key end-users. Although the Southern Ocean remains one of the least-observed ocean regions, enhanced international coordination and advances in autonomous platforms have resulted in progress towards addressing the need for sustained observations of this region. Since 2009, the Southern Ocean community has deployed over 5700 observational platforms south of 40°S. Large-scale, multi-year or sustained, multidisciplinary efforts have been supported and are now delivering observations of essential variables at space and time scales that enable assessment of changes being observed in Southern Ocean systems. The improved observational coverage, however, is predominantly for the open ocean, encompasses the summer, consists of primarily physical oceanographic variables and covers surface to 2000 m. Significant gaps remain in observations of the ice-impacted ocean, the sea ice, depths more than 2000 m, the air-sea-ice interface, biogeochemical and biological variables, and for seasons other than summer. Addressing these data gaps in a sustained way requires parallel advances in coordination networks, cyberinfrastructure and data management tools, observational platform and sensor technology, platform interrogation and data-transmission technologies, modeling frameworks, and internationally agreed sampling requirements of key variables. This paper presents a community statement on the major scientific and observational progress of the last decade, and importantly, an assessment of key priorities for the coming decade, towards achieving the SOOS vision and delivering essential data to all end users.

Primary Care Women’s Health Screening: A Case Study of a Community Engaged Human Centered Design Approach to Enhancing the Screening Process

To apply a Human Centered Design (HCD) approach to co-designing a comprehensive women's health screening tool with community partners. Evidenced-based health screenings for behaviors and risks are important tools in primary health care and disease prevention, especially for women. However, numerous barriers limit the effective implementation of comprehensive health screenings, and often lead to excluding important risks such as intimate partner violence (IPV). Utilizing a human centered design approach (HCD), Mountain Area Health Education Center (MAHEC, NC USA) developed a community co-designed 9-topic health screening for women. Key end-users were recruited to participate in the design process, including women who identified IPV as a health issue in their community, Spanish speaking women, domestic violence program organizers, and MAHEC staff. A total of 21 participants collaborated during three design sessions on two specific goals: 1) creating a comprehensive women's health screening tool from the existing tools that were in use in our clinics at the time, and 2) incorporating IPV screening. Through the HCD sessions, participants highlighted the impact of what they termed "Triple T: time, trust and talk" on the effectiveness of women's health screening. Our co-designed women's health screening tool is a first step towards addressing screening barriers from both primary care provider's and community women's perspectives. Future research will explore the facilitators of and barriers to implementing the tools in different primary care settings. Future work should also more systematically examine whether and how screening processes may reinforce or contribute to women's feelings of being stereotyped, and how screening processes can be designed to avoid stereotype threat, which has the potential to reduce the effectiveness of screenings intended to promote women's health.

Nurturing natural capital

Nurturing natural capital