Ann Blandford

Background: Real-time force feedback is essential in many surgical specialties. While previous research has focused on force measured at the tool-tissue interface, little work has explored the benefits, limitations, or opportunities of measuring force at the surgeon-tool interface. Objective: This study aims to explore scenarios in which surgeons from different medical specialties and experience levels could benefit from receiving feedback on the force exerted at the surgeon-tool (or surgeon-tissue) interface. Methods: Exploratory qualitative research was conducted through interviews with medical practitioners (N=15). This study explored perceptions of a conceptual novel force-sensing surgical glove that could provide real-time feedback in terms of usability, utility, value, and limitations. Opportunities and barriers to implement a sensor of this type in clinical practice were also explored. Participants had experience in anesthetics, dental surgery, plastic and dermatological surgery, general surgery, and obstetrics and gynecology, as these surgical fields all require precise feedback on exerted forces. Results: Participants identified two key areas where a force sensor could yield significant benefits: (1) it could enhance surgical training through objective skill assessment and quantifiable feedback, and (2) it could provide valuable insights into the forces applied during practice, particularly in scenarios where other sensory feedback is masked. Participants appreciated that a sensorized glove that can provide real-time force sensing at the surgeon-tool interface would allow for continued feedback irrespective of the instrument, and integrate seamlessly into their current surgical workflow. Furthermore, as surgeons in some specialisms, for example, dental or obstetrics and gynecology, perform manual tasks, having a sensorized glove would provide feedback in instances where they are physically manipulating tissue. However, participants expressed concerns about accurately defining safe force ranges due to the variability in patients’ anatomical structures and the potential interference with tactile sensation. Conclusions: Surgeons from various clinical practices agreed that force sensing at the surgeon-tool interface could be valuable and provide them with optimal versatility as to when they would adopt force sensing. A sensorized glove could improve decision-making and surgical outcomes when other sources of information guiding force exertion are masked. Conversely, it could be detrimental when the organic information to guide force exertion is distorted when using the sensor. While the choice between interaction modalities is dependent on the accessibility of different senses during surgery, design suggestions as to where sensors are best placed on a sensorized glove are dependent on the instrument used or the type of manual procedure conducted.

Men increasingly turn to digital sources when seeking healthcare information, particularly in fertility care. Ensuring they can easily access and understand relevant information is crucial. This paper investigates whether existing mobile apps are appropriately designed to support men’s experiences in the context of fertility care. We present findings from two studies. 1) an interview study (n=28) and 2) an evaluation of existing mobile apps (n=21) for fertility support. We found that men want to make sense of and find meaning in information and their feelings during their fertility journeys. Whilst many apps contain valuable information to support sense-making, they do not support meaning-making, which tends to occur within a community of peers, a feature notably absent in existing apps. We contribute design recommendations for designers to consider how health apps can meet the information needs of men who experience infertility. This research extends existing literature by exploring the nuanced role of meaning-making in male fertility experiences. We offer a deeper understanding of men’s emotional and informational requirements, providing a critical empirical foundation for developing inclusive and effective digital tools.

Background: Instructional documents are crucial for safely operating medical devices. However, few studies have explicitly considered designing instructions for health care professionals (HCPs). Psychological research suggests that advanced learners with prior expertise in a domain are better able to generalize their existing knowledge to new areas compared to those with little prior expertise, resulting in different informational needs. Objective: We aimed to understand how HCPs learn from and use their existing expertise when interacting with instructions for use to familiarize themselves with a novel medical device. This would allow us to explore how instructional documents could be designed to better accommodate HCPs’ needs as experienced learners with prior knowledge in the domain. Methods: We conducted our studies centered around a novel liver support system, the HepatiCan and its current instructions for use. We conducted 3 user studies, first using semistructured interviews and think-aloud protocols to understand HCPs’ expectations for the process of setting up the HepatiCan and how training for the use of medical devices typically takes place. We followed this up with an observational study to understand HCPs’ actual experience in practice and corresponding instructional design needs. Results: Our results showed that HCPs’ prior expertise allowed them to prioritize key areas for attention, but also led them to make assumptions and potentially skim and miss important information. Visual representations and communication were preferred, as well as designs that supported memorization, as this was an essential function of using instruction manuals. Conclusions: Developers must be aware of what is considered “common” and potentially ignored knowledge within a specific domain in order to clearly emphasize important, safety-relevant information. We also recommend developers focus on using images with attached appendices where possible. This allows advanced users to process information more efficiently without compromising the needs of less familiar users for greater instructional details.

Introduction: People from underserved groups experience disproportionately poor sexual health and challenges accessing care. Asynchronous online consultations (a user completes a health questionnaire online, which is reviewed by a clinician) are being used within sexual healthcare to prescribe chlamydia treatment. Users require sufficient health and digital literacy to access online services and use them safely. Methods: We used the PROGRESS-Plus (PROGRESS: Place of Residence, Race/Ethnicity, Occupation, Gender/Sex, Religion, Education, Socio-economic Status, Social Network; Plus: e.g., Age, Sexual Orientation, Disability) framework to guide purposive recruitment of 35 participants from diverse underserved groups, from community settings and sexual health services in contrasting areas of the UK (15 October 2021–18 March 2022). We conducted qualitative semistructured interviews and thematic analyses to derive key barriers and facilitators to using asynchronous online consultations. We applied the Behaviour Change Wheel to specify recommendations to address them. Results: Over half of participants were from the most deprived areas and 40% were from minoritised ethnic groups. Key barriers included: lack of familiarity with online healthcare; perceived need to see a healthcare professional in person; privacy concerns; concerns about difficulty interpreting the questions; discomfort answering personal questions online. Key facilitators included: familiarity with online consultations; perceived low sexually transmitted infection risk; perceived increase in convenience, control and privacy; simple wording and design; and support while completing them. Recommendations included: increasing awareness and familiarity by promoting them offline and online and providing demonstrations and instructions on how to use them; encouraging people to choose them by highlighting available support, equivalence to in-person consultations and privacy and convenience; and reducing attrition by using simple wording and design, providing additional explanations and offering audio and visual alternatives to text. Conclusions: Incorporating these evidence-based, theoretically informed recommendations could widen access to underserved groups and increase the usability and safety of asynchronous online consultations for chlamydia treatment. Recommendations are likely to benefit all users and could be of use across health more broadly.

Background: Community-based optometrists, a major provider of primary eye care in the United Kingdom, are the main source of referrals to hospital eye services. The widespread introduction of optical coherence tomography devices in community practices provides community-based optometrists with an opportunity to identify a broader range of treatable diseases. Standard referral pathways do not effectively filter unnecessary referrals, with misclassification of urgency, and erroneous diagnoses. Objectives: To assess the effectiveness of a teleophthalmology referral pathway between community-based optometrists and hospital eye services for retinal diseases. To measure the accuracy of an artificial intelligence decision support system for diagnosis and referral management of retinal disease. Design: A multicentre, superiority cluster randomised controlled trial to assess the effectiveness of a teleophthalmology referral pathway. A prospective, observational diagnostic accuracy study to measure the performance of artificial intelligence decision support system. A comprehensive economic evaluation was conducted. Settings: United Kingdom-based community optometry practices with an optical coherence tomography device and hospital eye services. Participants: Adults requiring referral for retinal disease at the opinion of the community-based optometrists. Interventions: Community optometry practices were randomised 1 : 1 to standard care or teleophthalmology. Referrals sent via the teleophthalmology platform were remotely reviewed by human experts based at the corresponding hospital eye services. A referral decision was provided within 48 hours. Suitable optical coherence tomography scans were solely processed by artificial intelligence decision support system (the ‘Octane’ model). Main outcome measures: Cluster randomised controlled trial’s primary outcome was the proportion of false-positive referrals (not required or not urgent) per arm in overall participants and in referred-only participants against an independent reference standard. Secondary outcomes included the proportion of wrong diagnosis, wrong referral urgency, false-negative referrals, safely triaged referrals for rare diseases, time from referral to consultation and treatment and cost-effectiveness of teleophthalmology. Primary outcome for the artificial intelligence study was the sensitivity and specificity of artificial intelligence referral decisions against the reference standard. Results: Teleophthalmology significantly reduces the proportion of false-positive urgent referrals by 59% compared to standard care in referred participants. Due to the observed low event rate for false positive referrals, teleophthalmology’s role for reducing false positives overall was inconclusive. No significant difference between arms for safety of referral decisions (false negatives) was found. After accounting for external factors, the time to consultation demonstrated both clinically and statistically significant benefits for the teleophthalmology arm. The time to treatment showed a clinically significant benefit. Of 396 recruited participants, the Octane artificial intelligence model processed images contributed by 204 participants (51.5%). For referral decisions, the model showed comparable sensitivity and specificity against its own preset referral rules (rule-based reference standard) (post hoc analysis), but it showed inferior sensitivity and specificity when compared to human expert assessors making these referral decisions (clinical reference standard) (primary AI analysis). The artificial intelligence model presented challenges relating to its generalisability in a real-world evaluation context. Limitations: Technical limitations in optometry practices, lack of ethnicity data. Conclusions: Asynchronous teleophthalmology reduces the number of unnecessary urgent referrals, the main drivers of increasing hospital capacity pressures, provides more appropriate referral-to-treatment times and is more cost-effective compared to standard care. The Octane artificial intelligence model could not process images from 48.5% of study participants. Compared to hospital-based experts for referral decisions, Octane was less accurate at making routine and urgent referral decisions and of similar accuracy to community optometrists. Future work: Applied health research, human–artificial intelligence interaction and artificial intelligence clinical trial design. Trial registration: This trial is registered as ISRCTN18106677. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR127773) and is published in full in Health Technology Assessment ; Vol. 29, No. 69. See the NIHR Funding and Awards website for further award information.

Background: By July 2020, large numbers of post-COVID patients were experiencing symptoms for weeks or months, but traditional National Health Service models of rehabilitation service delivery could not meet demand. Objectives: Design and deploy a digital health intervention to provide digitally delivered, remotely supported rehabilitation to long COVID patients on complicated and evolving pathways. Methods: The multidisciplinary team combined established research methods based on engineering and computer science (considering safety, stability and user requirements) with those based on biomedical and health service research (considering effectiveness and population impact). Qualitative data comprised recordings of meetings between study team members and clinicians and semistructured interviews with clinician and patient users. Quantitative data comprised referral, registration and usage rates; demographic and clinical characteristics of patients; and patient-reported outcome measures. Results: We created a modifiable digital health intervention, ‘Living With COVID Recovery ^TM developed by Living With Ltd’, London, UK, that continues to be used by National Health Service trusts. The digital health intervention included integration into a clinical pathway, a clinician-facing dashboard, two-way messaging and a patient-facing app with information and evidence-based treatments. We aimed to register 1000 users. By study completion on 20 December 2022, there were 9781 patients invited, of whom 7679 (78.5%) had registered, at 33 National Health Service clinics. Limitations: Data came from patients at long COVID clinics, however data were unlikely to be representative of people with long COVID. We could not observe clinics under lockdown and had limited access to patient digital health intervention users or to people not engaging with the digital health intervention. Patient user data were incomplete, with inconsistent patient-reported outcome measure and other questionnaire data completion and no data on initial severity of disease, vaccination status, comorbidities or other individual circumstances. Conclusions: Long COVID can be extremely debilitating, comparable to stage IV lung cancer in relation to fatigue and health-related quality of life. Care and rehabilitation should address the management of fatigue and reflect the impact of social disadvantage on symptom severity. With sufficient resources, a digital health intervention can be developed quickly and effectively using agile methodology and bringing together a genuinely multidisciplinary team, including, importantly, an industry partner. Digital health intervention product design and deployment are both important in getting National Health Service trusts, healthcare professionals and patients to engage with a digital health intervention. Projects should work closely with all user groups. Lockdown and the unmet need of a new patient group encouraged those who might otherwise have been reluctant to try a digital health intervention. Many patients and clinics accepted this digital remote support, which helped patients feel cared for while reducing strain on health services. This may encourage acceptance of other digital health intervention, although medical record integration remains a deterrent to clinics. Future work: This research focused on the development, deployment and evaluation of a digitally enabled rehabilitation programme for long COVID. Clinical effectiveness will be assessed within the Symptoms, Trajectory, Inequalities and Management: Understanding Long-COVID to Address and Transform Existing Integrated Care Pathways (UCL, London, UK) study. Funding: This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR132243.

Ghana is a country facing a rapid increase in type 2 diabetes (T2D), yet resources are stretched and addressing the causes and consequences of T2D on individuals and communities is challenging. Participatory Learning and Action (PLA) is a community intervention that can improve health following a cycle of identifying problems with communities, planning and implementing solutions to address the problems, and reflecting on them. This approach has proved effective in addressing T2D and other health outcomes in low resource settings. This paper reflects and reports on the development and pilot implementation of PLA to address T2D in a poor urban area of Accra (Ga Mashie), from the perspective of the research team. Drawing on discussions, research notes and team meetings, we report on the process of the intervention development and implementation, challenges, lessons learned and the extent of participation. PLA proved feasible and popular. We (the research group) worked closely with community members through a community advisory group and workshops. Problems identified included low knowledge of risk behaviours and structural factors. Solutions implemented were a series of community events focusing on knowledge and raising awareness. Challenges included: time constraints, logistical difficulties, ensuring decisions were not over-influenced by researchers and sustainability. Our findings indicate that the successful implementation of interventions requires careful organisation, reflection throughout and needs to be built on genuine trusting relationships. The insights gained from this study offer valuable lessons on how PLA may be implemented and considerations needed for similar settings.

Background: Although many digital health interventions have been studied in human-computer interaction, long-term engagement remains a challenge. Microinterventions that leverage small but meaningful steps toward health outcomes have been proposed as a method for providing flexible and engaging, yet short and focused, interventions. One way to mitigate the potentially limiting scope of each microintervention is through narratives combining multiple different microinterventions over time to facilitate greater effects and engagement. As an emerging field of research, significant focus has thus far been placed on the creation and testing of individual microinterventions with little consideration for the consolidated experience, that is, the narrative over time. A more concise terminology and framework could make it easier to design, evaluate, and compare systems for microinterventions, facilitate collaboration in the field, and foster communication across required disciplines. Objective: This paper aims to provide a framework for the creation of microintervention systems and the narratives served by these through their microinterventions. Methods: To synthesize a framework, we carried out a critical interpretive synthesis involving reciprocal translational analysis, refutational synthesis, and lines-of-argument synthesis, based on a systematic review of microintervention literature following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines across the Association for Computing Machinery Digital Library, PubMed, Scopus, and Web of Science. To assess the resulting framework, we applied it retroactively back onto the literature. Results: Based on a review including 35 studies, of which 80% (n=28) were published after 2020, we present and rationalize the Design for Microintervention Software Technology (D-MIST) framework, which can be used to better classify, design, and evaluate microinterventions. D-MIST defines a microintervention system on three levels: (1) the narrative, (2) the microintervention, and (3) the event. The narrative is the consolidated experience of engaging with multiple microinterventions over time, supporting a narrative goal, for example, a clinical goal. A microintervention is a highly focused intervention consisting of self-contained events aiming to facilitate small but meaningful steps toward the narrative goal. The event attempts a positive momentary change through a resource, for example, an exercise. Events may, for example, be designed for single use, present variations to facilitate engagement, or present order-dependent sequential resources. We additionally discuss supporting constructs, such as decision rules, conceptual models, and the system’s interaction model, that is, how the system interacts with the user through its design and other actors to create a consolidated narrative. Conclusions: The resulting D-MIST framework, based on current state-of-the-art literature, describes the components of microintervention systems and how these contribute to a consolidated experience. Based hereon, we suggest opportunities for personalization of microintervention systems, discuss design guidelines, and the roles of actors in creating health narratives aiming to obtain better distal health outcomes.

Introduction People from underserved groups experience disproportionately poor sexual health and challenges accessing care. Asynchronous online consultations (a user completes a health questionnaire online, which is reviewed by a clinician) are being used within sexual healthcare to prescribe chlamydia treatment. Users require sufficient health and digital literacy to access online services and use them safely. Methods We used the PROGRESS-Plus framework to guide purposive recruitment of 35 participants from diverse underserved groups, from community settings and sexual health services in contrasting areas of the UK (15/10/21-18/03/22). We conducted qualitative semi-structured interviews and thematic analyses to derive key barriers and facilitators to using asynchronous online consultations. We used the Behaviour Change Wheel to specify recommendations to address them. Results Over half of participants were from the most deprived areas and 40% were from minoritised ethnic groups. Key barriers included: lack of familiarity with online healthcare; perceived need to see a healthcare professional in person; privacy concerns; concerns about difficulty interpreting the questions; discomfort answering personal questions online. Key facilitators included: familiarity with online consultations; perceived low sexually transmitted infection (STI) risk; perceived increase in convenience, control, and privacy; simple wording and design; and support whilst completing them. Recommendations included: increasing awareness and familiarity by promoting them offline and online, and providing demonstrations and instructions on how to use them; encouraging people to choose them by highlighting available support, equivalence to in-person consultations, and privacy and convenience; and reducing attrition by using simple wording and design, providing additional explanations, and offering audio and visual alternatives to text. Conclusions Incorporating these evidence-based, theoretically informed recommendations could widen access to underserved groups, and increase the usability and safety of asynchronous online consultations for chlamydia treatment. Recommendations are likely to benefit all users and could be of use across health more broadly. Main Messages Some sexual health services provide chlamydia treatment through asynchronous online consultations, where patients complete an online health questionnaire which is reviewed by a clinician before issuing a prescription, without the need for direct interaction with a healthcare professional. Safe and effective use of asynchronous online consultations requires adequate digital and health literacy but there is limited evidence on how to design these consultations inclusively, posing a risk of excluding underserved groups and exacerbating health inequalities. Among people from underserved groups, we found key barriers to using asynchronous online consultations included: a lack of familiarity with online healthcare; perceived need to see a healthcare professional in person; privacy concerns; concern about difficulty interpreting the questions; discomfort answering personal questions online. Key facilitators included: familiarity with online consultations; perceived low STI risk; perceived increase in convenience, control, and privacy; simplicity in consultation wording and design; and support whilst completing them. Recommendations include: increasing awareness and familiarity by promoting asynchronous online consultations offline (e.g. in GP practices) and online (e.g., social media), and providing demonstrations/instructions on how to use them; encouraging uptake by highlighting options for support, equivalence to in-person consultations, and privacy and convenience; and reducing attrition by using simple wording and design, providing additional explanations, and offering audio/visual alternatives to text.

BACKGROUND Real-time force feedback is essential in many surgical specialties. While previous research has focused on force measured at the tool-tissue interface, little work has explored the benefits, limitations, or opportunities of measuring force at the surgeon-tool interface. OBJECTIVE This study aims to explore scenarios in which surgeons from different medical specialties and experience levels could benefit from receiving feedback on the force exerted at the surgeon-tool (or surgeon-tissue) interface. METHODS Exploratory qualitative research was conducted through interviews with medical practitioners (n=15). This study explored perceptions of an exemplar novel force-sensing surgical glove that provided real-time feedback in terms of usability, utility, value, and limitations. Opportunities and barriers for the sensor’s implementation in clinical practice were also explored. Participants had experience in anaesthetics, dental surgery, plastic and dermatological surgery, general surgery, and obstetrics and gynaecology as these surgical fields all require precise feedback on exerted forces. RESULTS Participants identified two key areas where the force sensor could yield significant benefits; (1) It could enhance surgical training through objective skill assessment and quantifiable feedback; and (2) it could provide valuable insights into the forces applied during practice, particularly in scenarios where other sensory feedback is masked. Participants appreciated that a sensorised glove that can provide real-time force sensing at the surgeon-tool interface would allow for continued feedback irrespective of the instrument and integrate seamlessly into their current surgical workflow. Furthermore, as surgeons in some specialisms, e.g., Dental or Obstetrics and Gynaecology, perform manual tasks, having a sensorised glove will provide feedback in instances where they are physically manipulating tissue. However, participants expressed concerns about accurately defining safe force ranges due to the variability in patients’ anatomical structures and the potential interference with tactile sensation. CONCLUSIONS Surgeons from various clinical practices agreed that force-sensing at the surgeon-tool interface could be valuable and provide them with optimal versatility as to when they would adopt force-sensing. The sensorised glove could improve decision making and surgical outcomes when other sources of information guiding force exertion are masked. Conversely, it could be detrimental when organic information to guide force exertion is distorted when using the sensor. While the choice between interaction modalities is dependent on the accessibility of different senses during surgery, design suggestions as to where sensors are best placed on a sensorised glove are dependent on the instrument used or type of manual procedure conducted.