Human-Centered Design Lessons for Implementation Science: Improving the Implementation of a Patient-Centered Care Intervention

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Abstract

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Background:

Evidence-based HIV interventions often fail to reach anticipated impact due to insufficient utilization in real-world health systems. Human-centered design (HCD) represents a novel approach in tailoring innovations to fit end-users, narrowing the gap between efficacious interventions and impact at scale.

Methods:

We combined a narrative literature review of HCD in HIV programs with our experience using HCD to redesign an intervention promoting patient-centered care (PCC) practices among health care workers (HCW) in Zambia. We summarize the use and results of HCD in the global HIV response and share case study insights to advance conceptualization of HCD applications.

Results:

The literature review identified 13 articles (representing 7 studies) on the use of HCD in HIV. All studies featured HCD hallmarks including empathy development, user-driven inquiry, ideation, and iterative refinement. HCD was applied to mHealth design, a management intervention and pre-exposure prophylaxis delivery. Our HCD application addressed a behavioral service delivery target: changing HCW patient-centered beliefs, attitudes, and practices. Through in-depth developer–user interaction, our HCD approach revealed specific HCW support for and resistance to PCC, suggesting intervention revisions to improve feasibility and acceptability and PCC considerations that could inform implementation in transferable settings.

Conclusions:

As both a research and implementation tool, HCD has potential to improve effective implementation of the HIV response, particularly for product development; new intervention introduction; and complex system interventions. Further research on HCD application strengths and limitations is needed. Those promoting PCC may improve implementation success by seeking out resonance and anticipating the challenges our HCD process identified.

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Most cited references 29

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Is the quality of the patient-provider relationship associated with better adherence and health outcomes for patients with HIV?

Mary Beach, Robert Moore, Jeanne Keruly (2006)

Patient-centeredness, originally defined as understanding each patient as a unique person, is widely considered the standard for high-quality interpersonal care. The purpose of our study was to examine the association between patient perception of being "known as a person" and receipt of highly active antiretroviral therapy (HAART), adherence to HAART, and health outcomes among patients with HIV. Cross-sectional analysis. One thousand seven hundred and forty-three patients with HIV. Patient reports that their HIV provider "knows me as a person" and 3 outcomes: receipt of HAART, adherence to HAART, and undetectable serum HIV RNA. Patients who reported that their provider knows them "as a person" were more likely to receive HAART (60% vs 47%, P<.001), be adherent to HAART (76% vs 67%, P=.007), and have undetectable serum HIV RNA (49% vs 39%, P<.001). Patients who reported their provider knows them "as a person" were also older (mean 38.0 vs 36.6 years, P<.001), reported higher quality-of-life (mean LASA score 71.1 vs 64.8, P<.001), had been followed in clinic longer (mean 64.4 vs 61.7 months, P=.008), missed fewer appointments (mean proportion missed appointments 0.124 vs 0.144, P<.001), reported more positive beliefs about HAART therapy (39% vs 28% strongly believed HIV medications could help them live longer, P<.008), reported less social stress (50% vs 62% did not eat regular meals, P<.001) and were less likely to use illicit drugs or alcohol (22% vs 33% used drugs, P<.001; 42% vs 53% used alcohol, P<.001). Controlling for patient age, sex, race/ethnicity, quality-of-life, length of time in clinic, missed appointments, health beliefs, social stress, and illicit drug and alcohol use, patients who reported their provider knows them "as a person" had higher odds of receiving HAART (odds ratio [OR] 1.41, 95% confidence interval [CI] 1.19 to 1.65), adhering to HAART (OR 1.33, 95% CI 1.02 to 1.72), and having undetectable serum HIV RNA (1.20, 95% CI 1.02 to 1.41). We found that a single item measuring the essence of patient-centeredness-the patients' perception of being "known as a person"-is significantly and independently associated with receiving HAART, adhering to HAART, and having undetectable serum HIV RNA. These results support the hypothesis that the quality of patient-physician relationship is directly related to the health of patients.

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The therapeutic implications of timely linkage and early retention in HIV care.

Kimberly Ulett, James Raper, Sarah Abroms … (2009)

Following HIV diagnosis, linkage to outpatient treatment, antiretroviral initiation, and longitudinal retention in care represent the foundation for successful treatment. While prior studies have evaluated these processes in isolation, a systematic evaluation of successive steps in the same cohort of patients has not yet been performed. To ensure optimal long-term outcomes, a better understanding of the interplay of these processes is needed. Therefore, a retrospective cohort study of patients initiating outpatient care at the University of Alabama at Birmingham 1917 HIV=AIDS Clinic between January 2000 and December 2005 was undertaken. Multivariable models determined factors associated with: late diagnosis=linkage to care (initial CD4 < 350 cells=mm3), timely antiretroviral initiation, and retention across the first two years of care. Delayed linkage was observed in two-thirds of the overall sample (n = 567) and was associated with older age (odds ratio [OR] = 1.31 per 10 years; 95%confidence interval [CI] = 1.06-1.62) and African American race (OR = 2.45; 95% CI = 1.60-3.74). Attending all clinic visits (hazard ratio [HR] = 6.45; 95% CI = 4.47-9.31) and lower initial CD4 counts led to earlier antiretroviral initiation. Worse retention in the first 2 years was associated with younger age (OR = 0.68 per 10 years;95% CI = 0.56-0.83), higher baseline CD4 count, and substance abuse (OR = 1.78; 95% CI = 1.16-2.73). Interventions to improve timely HIV diagnosis and linkage to care should focus on older patients and African Americans while efforts to improve retention should address younger patients, those with higher baseline CD4 counts, and substance abuse. Missed clinic visits represent an important obstacle to the timely initiation of antiretroviral therapy. These data inform development of interventions to improve linkage and retention in HIV care, an emerging area of growing importance.

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Higher quality communication and relationships are associated with improved patient engagement in HIV care.

Tabor Flickinger, Somnath Saha, Richard Moore … (2013)

Patient retention in HIV care may be influenced by patient-provider interactions. In an urban, academic HIV clinic, 1363 patients rated the quality of communication and relationships with their providers on 5 domains. We used linear regressions to investigate associations between these 5 domains and appointment adherence. In multivariate analysis, patients kept more appointments if providers treated them with dignity and respect, listened carefully to them, explained in ways they could understand, and knew them as persons. Being involved in decisions was not significantly associated with appointment adherence. Enhancing providers' skills in effective communication and relationship building may improve patient retention in HIV care.

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Author and article information

Journal

Journal ID (nlm-ta): J Acquir Immune Defic Syndr

Journal ID (iso-abbrev): J. Acquir. Immune Defic. Syndr

Journal ID (publisher-id): qai

Title: Journal of Acquired Immune Deficiency Syndromes (1999)

Publisher: JAIDS Journal of Acquired Immune Deficiency Syndromes

ISSN (Print): 1525-4135

ISSN (Electronic): 1944-7884

Publication date (Print): December 2019

Publication date (Electronic): 26 November 2019

Volume: 82

Issue: 3

Pages: S230-S243

Affiliations

[a ]Department of Interna6onal Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD;

[b ]Centre for Infectious Disease Research in Zambia, Lusaka, Zambia;

[c ]Georgetown University, Washington, DC;

[d ]University of California San Francisco, San Francisco, CA;

[e ]The Bill & Melinda Gates Foundation, Seattle, WA; and

[f ]D'EVA Consulting, Washington, DC.

Author notes

Correspondence to: Laura K. Beres, MPH, Department of Interna6onal Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, E5031, Baltimore, MD 21205 (e-mail: laura.beres@ 123456jhu.edu ).

Article

Publisher ID: QAIV20394 Accession ID: 00010

DOI: 10.1097/QAI.0000000000002216

PMC ID: 6880397

PubMed ID: 31764259

SO-VID: 46a63e04-d733-43af-9c4c-96d266558ec3

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This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Keywords: hiv,human-centered design,implementation,zambia

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Keywords: hiv, human-centered design, implementation, zambia

Human-Centered Design Lessons for Implementation Science: Improving the Implementation of a Patient-Centered Care Intervention

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Most cited references 29

Is the quality of the patient-provider relationship associated with better adherence and health outcomes for patients with HIV?

The therapeutic implications of timely linkage and early retention in HIV care.

Higher quality communication and relationships are associated with improved patient engagement in HIV care.

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