Rochelle K. Rosen

Background: In two large studies conducted in Bangladesh, our recently developed artificial intelligence (AI)-based models for assessing dehydration severity in children under five years (DHAKA models) and patients over age five (NIRUDAK models) were significantly more accurate and reliable than the WHO IMCI and IMAI guidelines for diarrhea management. We incorporated these models into a novel mobile health (mHealth) clinical decision support tool (CDST), called “FluidCalc”, with the potential to improve acute diarrhea management by frontline health workers worldwide. Our objective was to assess the barriers and facilitators to uptake and use of our mHealth CDST in both a low-resource setting (Tanzania) and high-resource setting (United States (US)) among healthcare providers and stakeholders. Methods: Qualitative data were collected through focus group discussions (FGDs) with healthcare providers and in-depth interviews (IDIs) with stakeholders and policymakers from February - July 2025 in Tanzania and February - March 2026 in the US. The Consolidated Framework for Implementation Research (CFIR) was used to guide discussions and elicit participant feedback. Audio recordings were transcribed and translated from Swahili to English where applicable, and data were analyzed using framework matrix analysis. Results: 35 providers from different cadres participated in FGDs, and 13 stakeholders participated in IDIs. Facilitators to implementation included FluidCalc’s simplicity, ease of use, and offline functionality. Participants reported that the app could streamline clinical workflows, promote adherence to diarrhea management guidelines, facilitate task shifting, support antibiotic stewardship, and reduce errors in fluid rehydration calculations. FluidCalc was also viewed as a valuable teaching tool, and for supporting less experienced healthcare providers and trainees, and as useful during diarrheal disease outbreaks. Perceived barriers included the need for reliable digital infrastructure, including access to mobile devices, internet connectivity, and dependable electricity and lengthy institutional approval processes. Endorsement and approval from the Ministry of Health and health facility leadership were perceived as essential for successful implementation. Conclusion: Healthcare providers and stakeholders believe FluidCalc has the potential to improve care for patients with acute diarrhea in both high- and low-resource settings. Addressing identified barriers and ensuring reliable digital health infrastructure are needed to support effective integration into patient care. Contributions to literature: FluidCalc is a clinical decision support tool (CDST) for managing acute diarrhea. Few implementation studies have examined CDSTs for diarrhea management across both high-resource and low-resource settings. This study provides comparative insights into factors influencing implementation in two distinct health system contexts. Beyond technical performance and usefulness, CDST uptake depends on clinicians’ perceptions of the tool’s impact on workflow, workload, clinical autonomy, and compatibility with existing health systems. Additionally, organizational context shapes perceptions of digital innovations, helping explain why a tool may be perceived as an opportunity to improve care or as an added implementation burden.

Objectives: To understand the political, economic, social and technological facilitators and barriers in obtaining an HIV diagnosis to inform implementation strategies for HIV diagnostics in the Dominican Republic (DR). Design: In-depth, semi-structured qualitative interviews. Setting: A high complexity public hospital in Santiago de los Caballeros, DR. Participants: A convenience and purposive sample of 36 internal medicine physicians and laboratory personnel involved in sample collection, sample analysis or oversight of biological sample analysis. Results: Using the Social Ecological Model, our results highlighted several interrelated barriers and facilitators to sample analysis at the individual (patient), interpersonal (interactions between laboratory personnel, physicians and patients), organisational (the hospital), community (Santiago de Los Caballeros) and societal (the DR) levels. Some key findings include the importance of psychological support in receiving an HIV diagnosis, how spoken language can be a barrier to care, how inconsistent access to laboratory supplies is a barrier for patients, laboratory personnel and clinicians, and the importance of government public health investment. Conclusions: Employing qualitative methods to investigate a bioengineering challenge yielded rich data on the sociotechnical implementation context of HIV diagnostics in the DR. Several context-relevant suggestions were developed for HIV diagnostic developers which include incorporating psychological support into the diagnosis workflow, delivering information in multiple languages (ie, Haitian Creole and Spanish) and with non-stigmatising phrasing, working with the public sector to develop and implement technologies, and reducing the supply chain reliance on high-income countries to lessen delays in care. These findings can apply to other types of health technologies and settings and demonstrate the importance of utilizing human-centered design to understand implementation context and promote global health equity in health technology development and adoption.

We present a qualitative data collection tool, the Qualitative Agenda with Intent Statements (QAIS), initially developed within the context of a multinational clinical trial and since refined to accommodate and support state-of-the-science qualitative and mixed methodologies. The original trial occurred at a time when what we now know as patient-oriented health research was a novel idea without clear procedures or tools. Our objective in the original study was to collect qualitative focus group data across multiple sites: each site had its own facilitators. Additionally, focus groups were to be held in various languages and cultural contexts. This necessitated appropriate communication styles and attention to significantly varied participant understandings and meaning-making with regards to the experiences being discussed. To create a data collection tool that allowed facilitators at each site to collect specific data required for the trial and respect cultural mores and linguistic needs, we crafted an innovative qualitative agenda that incorporates “ intent statements.” Intent Statements characterize the scope of the inquiry and describe the particular concepts or constructs to be considered, whether in individual interviews, focus groups, or other study contexts. They are designed to (1) guide consistency of data collected across multiple facilitators, sites, and cultures, (2) document the scope of inquiry to ethics review boards, (3) aid in training facilitators, (4) support initiation of deductive coding structure development, (5) provide definitions/descriptions and rationale to coders and analysts, especially those who may not have participated in data collection, and (6) record intent and scope of data collection to articulate boundaries of the data in any secondary analyses. Since the original clinical trial, we have used the tool in numerous studies and trained over 100 qualitative and mixed methods scholars in its use. Our experience has taught us that the tool provides an opportunity to collect rigorous, rich, and meaningful data with the potential to transform health-related research into truly patient-centered endeavors. We present the format, along with its training and use considerations.

BACKGROUND Psychiatric neurosurgery, including deep brain stimulation (DBS) and neuroablative procedures, has shown significant promise in treating severe, intractable Obsessive-Compulsive Disorder (OCD). The emergence of innovative neurostimulation techniques and neuroablation targets has catalyzed discussions in mainstream media. Online chat forums such as Reddit and Quora serve as particularly valuable resources for gauging public perception of medical interventions and technologies, making them crucial for researchers and clinicians in understanding how these procedures are viewed by the public. OBJECTIVE This study aims to evaluate public perceptions of psychiatric neurosurgery for OCD, as expressed in online chat forums, and to identify prevalent discussion topics and misinformation. METHODS We conducted a qualitative thematic analysis of 254 online posts discussing psychiatric neurosurgery for OCD, posted between 2008 and 2020 on popular forums. Three independent reviewers coded the posts, determining key discussion topics, characteristics, and misinformation. The data were analyzed using Applied Thematic Analysis (ATA) to identify structural and interpretive components and statistical analyses to quantify post characteristics. RESULTS There has been a burgeoning interest in psychiatric neurosurgery for OCD on these forums since 2008, with analyzed posts amassing over 25,000 cumulative online views. Thematic analysis identified three primary discussion topics: the efficacy of neurosurgical procedures, the existence of these procedures as treatment options, and their associated risks and benefits. Notably, statistical analysis found that 30.6% of posts contained misinformation, with a significantly higher rate of inaccuracies in posts expressing negative views of surgery compared to those expressing neutral or positive views (p=0.0079). Posts often began with users seeking information or sharing personal experiences, highlighting a gap between public perception and clinical evidence. CONCLUSIONS Our findings reveal significant interest and engagement in online discussions about psychiatric neurosurgery for OCD, accompanied by substantial misinformation. These insights underscore the need for targeted educational interventions to bridge the gap between public perception and clinical evidence. Addressing misinformation and enhancing public understanding could improve patient outcomes and referral patterns for those considering psychiatric neurosurgery. This study provides valuable data for clinicians aiming to better comprehend and navigate public concerns and misconceptions in this rapidly evolving field.

Background: A total of 12 modifiable risk factors account for 40% of dementia cases globally, yet population adherence to health behaviors associated with these factors is low. Midlife is a critical window for dementia prevention, as brain pathology often begins to accumulate years or decades before the onset of symptoms. Although multidomain behavioral interventions have been efficacious in reducing the risk of cognitive decline, adherence is low. Intrapersonal factors, such as health beliefs, are known mediators of the relationship between knowledge and health behavior. Objective: In keeping with stage I of the National Institutes of Health (NIH) Stage Model for Behavioral Intervention Development, this study will use mixed methods to (1) develop an enhanced health education intervention, including an explanatory method for communicating information about dementia risk and personal health beliefs, and (2) conduct a pilot randomized controlled trial (n=20 per intervention arm) over 8 weeks to assess the feasibility of delivering the enhanced intervention versus basic health education alone. Methods: Phase 1 will involve focus groups and individual qualitative interviews. Focus groups will be analyzed using (1) a descriptive framework matrix analysis and (2) interpretive data review by the research team. Individual qualitative interviews will be coded using applied thematic analysis using a phenomenographic approach. Phase 2 will involve a pilot randomized controlled trial. Proximal outcomes (measured at baseline, 4 weeks, and 8 weeks) include the perceived threat of Alzheimer disease, dementia awareness, and self-efficacy. Results: This project was funded in August 2022. Data collection began in 2023 and is projected to be completed in 2025. Conclusions: Study findings will reveal the feasibility of delivering an 8-week multidomain health education intervention for primary prevention of dementia in midlife and will provide preliminary evidence of mechanisms of change. Trial Registration: ClinicalTrials.gov NCT05599425; https://clinicaltrials.gov/study/NCT05599425 International Registered Report Identifier (IRRID): DERR1-10.2196/60395

BACKGROUND A total of 12 modifiable risk factors account for 40% of dementia cases globally, yet population adherence to health behaviors associated with these factors is low. Midlife is a critical window for dementia prevention, as brain pathology often begins to accumulate years or decades before the onset of symptoms. Although multidomain behavioral interventions have been efficacious in reducing the risk of cognitive decline, adherence is low. Intrapersonal factors, such as health beliefs, are known mediators of the relationship between knowledge and health behavior. OBJECTIVE In keeping with stage I of the National Institutes of Health (NIH) Stage Model for Behavioral Intervention Development, this study will use mixed methods to (1) develop an enhanced health education intervention, including an explanatory method for communicating information about dementia risk and personal health beliefs, and (2) conduct a pilot randomized controlled trial (n=20 per intervention arm) over 8 weeks to assess the feasibility of delivering the enhanced intervention versus basic health education alone. METHODS Phase 1 will involve focus groups and individual qualitative interviews. Focus groups will be analyzed using (1) a descriptive framework matrix analysis and (2) interpretive data review by the research team. Individual qualitative interviews will be coded using applied thematic analysis using a phenomenographic approach. Phase 2 will involve a pilot randomized controlled trial. Proximal outcomes (measured at baseline, 4 weeks, and 8 weeks) include the perceived threat of Alzheimer disease, dementia awareness, and self-efficacy. RESULTS This project was funded in August 2022. Data collection began in 2023 and is projected to be completed in 2025. CONCLUSIONS Study findings will reveal the feasibility of delivering an 8-week multidomain health education intervention for primary prevention of dementia in midlife and will provide preliminary evidence of mechanisms of change. CLINICALTRIAL ClinicalTrials.gov NCT05599425; https://clinicaltrials.gov/study/NCT05599425 INTERNATIONAL REGISTERED REPORT DERR1-10.2196/60395

Objective: Framework Analysis (FA) and Applied Thematic Analysis (ATA) are qualitative methods that have not been as widely used/cited compared to content analysis or grounded theory. This paper compares methods of FA with ATA for mobile health (mHealth) research. The same qualitative data were analyzed separately using each methodology. The methods, utility, and results of each are compared, and recommendations made for their effective use. Methods: Formative qualitative data were collected in eight focus group discussions with physicians and nurses from three hospitals in Bangladesh. Focus groups were conducted via video conference in the local language, Bangla, and audio recorded. Audio recordings were used to complete a FA of participants’ opinions about key features of novel mHealth application (app) designed to support clinical management in patients with acute diarrhea, called FluidCalc: Rehydration Calculator for Acute Diarrhea. The resulting framework analysis was shared with the app design team and used to guide iterative development of the product for a validation study of the app. Subsequently, focus group audio recordings were transcribed in Bangla then translated into English for ATA; transcripts and codes were entered into NVivo qualitative analysis software. Code summaries and thematic memos explored the clinical utility of FluidCalc including clinicians’ attitudes about using this decision support tool. Results: Each of the two methods contributes differently to the research goal and have different implications for an mHealth research timeline. Recommendations for the effective use of each method in app development include: using FA for data reduction where specific outcomes are needed to make programming and design decisions and using ATA to capture the more nuanced issues that guide use, product implementation, training, and workflow. Conclusions: By describing how both analytical methods were used in this context, this paper provides guidance and an illustration for use of these two methods, specifically in mHealth design.

Introduction: Acute diarrhea remains a leading cause of morbidity and mortality with over 6.3 billion cases and 1.3 million deaths annually. Despite the existence of standardized guidelines for diarrhea management, wide variability in clinical practice exists, particularly in resource-limited settings. The goal of this study was to qualitatively explore how diarrhea management in Bangladesh varies according to resource availability, clinical setting, and provider roles. Methodology: This was a secondary analysis of a cross-sectional qualitative study conducted in three diverse hospital settings (district hospital, subdistrict hospital, and specialty diarrhea research hospital) in Bangladesh. A total of eight focus group discussions with nurses and physicians were conducted. Applied thematic analysis was used to identify themes regarding variations in diarrhea management. Results: Of the 27 focus group participants, 14 were nurses and 13 doctors; 15 worked in a private diarrhea specialty hospital and 12 worked in government district or subdistrict hospitals. Several key themes emerged from the qualitative data analysis: 1) priorities in the clinical assessment of diarrhea 2) use of guidelines versus clinical judgment; 3) variability in clinician roles and between clinical settings influences care delivery; 4) impact of resource availability on diarrhea management; and 5) perceptions of community health workers’ role in diarrhea management. Conclusions: Findings from this study may aid in informing interventions to improve and standardize diarrhea management in resource-constrained settings. Resource availability, practices regarding diarrhea assessment and treatment, provider experience, and variability in provider roles are essential considerations when developing clinical tools in low- and middle- income countries.

Background: The COVID-19 pandemic provided a unique opportunity to examine social media and technology use during a time in which technology served as adolescents’ primary form of socialization. The literature is mixed regarding how increased screen time during this period affected adolescent mental health and well-being. The mechanisms by which screen time use affected adolescent psychosocial outcomes are also unknown. Objective: We aimed to deepen our understanding of how social media and technology use, social connectivity, and emotional well-being intersected during pandemic-related school closures. Methods: English-speaking adolescents aged 13 to 17 years were recruited on Instagram for a brief screening survey; 39 participants were purposefully selected to complete a semistructured interview regarding their social media and technology use during the pandemic. Interview summaries were abstracted from recordings, and deductive codes were created for the primary question stems. These codes were subsequently reviewed for the main themes. Results: The main themes were as follows: adolescent social media and technology use during school closures usually allowed for more and easier social connectivity, but the amount and relative ease of connectivity differed according to purpose and type of use. Emotions, particularly those of stress and happiness, were connected to whether adolescents actively or passively engaged with social media and technology. Conclusions: Our results suggest a nuanced relationship among social media and technology use, adolescent social support, and emotional well-being, including during the pandemic. Specifically, how adolescents use or engage with web-based platforms greatly influences their ability to connect with others and their feelings of stress and happiness. In the context of the COVID-19 pandemic and as technology in general remains at the core of the adolescent experience, future research should continue to examine how adolescents navigate and use web-based spaces in beneficial and harmful ways. This will inform education and interventions that foster healthy social media and technological habits.

Introduction: Medications for addiction treatment (MAT) are the evidence-based standard of care for treatment of opioid use disorder (OUD), but stigma continues to surround their use. We conducted an exploratory study to characterize perceptions of different types of MAT among people who use drugs.Methods: We conducted this qualitative study in adults with a history of non-medical opioid use who presented to an emergency department for complications of OUD. A semi-structured interview that explored knowledge, perceptions, and attitudes toward MAT was administered, and applied thematic analysis conducted.Results: We enrolled 20 adults. All participants had prior experience with MAT. Among participants indicating a preferred treatment modality, buprenorphine was the commonly favored agent. Previous experience with prolonged withdrawal symptoms upon MAT discontinuation and the perception of “trading one drug for another” were common reasons for reluctance to engage in agonist or partial-agonist therapy. While some participants preferred treatment with naltrexone, others were unwilling to initiate antagonist therapy due to fear of precipitated withdrawal. Most participants strongly considered the aversive nature of MAT discontinuation as a barrier to initiating treatment. Participants overall viewed MAT positively, but many had strong preferences for a particular agent.Conclusion: The anticipation of withdrawal symptoms during initiation and cessation of treatment affected willingness to engage in a specific therapy. Future educational materials for people who use drugs may focus on comparisons of respective benefits and drawbacks of agonists, partial agonists, and antagonists. Emergency clinicians must be prepared to answer questions about MAT discontinuation to effectively engage patients with OUD.