Battle in the Blood Development of a Mobile Game to Increase Uptake of HIV Services Among Young Key Populations in the Philippines: Mixed Methods Case Study

Background While progress has been made against the UNAIDS 90-90-90 targets, public health gains made in the adult population continue to elude adolescent and young key populations. Progress is not the same in all countries with the Philippines experiencing a sharp rise in HIV infections among young key populations with limited uptake of testing and treatment services. Behaviour change is key to addressing these issues and interventions targeted at this cohort need to be relevant and engaging to successfully compete for their attention, change perceptions, and encourage positive health-related behaviour. The advent and popularity of mobile gaming in the Philippines position digital behaviour change games as a promising platform. Through gameplay, users can traverse a carefully constructed narrative, exposing them to new perspectives around HIV and increasing knowledge of early signs of HIV infection, risk behaviours and available testing and treatment services. While the use of digital games for HIV prevention and detection has rapidly increased in recent times, little is known about game development and effectiveness in low and middle-income (LMIC) contexts. In addition, evidence through randomized control trial design of the effectiveness of games underpinned by cognitive theories of behaviour change is weak, denoting a need to re-think the contribution of these games to the health development field and how we evaluate them. Study Aim To explore the contribution and limitations of a tailored digital game for health aimed at improving HIV-related knowledge, attitudes and practices among young key populations in the Philippines. Objectives 1. To identify appropriate learning objectives and theoretically driven game design relating to HIV prevention and control among young key populations in the Philippines. 2. To develop a playable and acceptable behaviour change game targeted at young key populations in the Philippines. 3. To assess demand and reach of the game among target users. 4. To explore the effect of the game on cognitive and social determinants of HIV service use and behaviour

Evaluation of a game-based training course to build capacity for insecticide resistance management in vector control programmes

Across Africa, malaria control programmes are increasingly challenged with the emergence of insecticide resistance among malaria vector populations. Confronted with this challenge, vector control staff must understand insecticide resistance management, think comprehensively and react positively when confronted with new problems. However, information on the subject is often only available through written guidelines that are difficult to put into practice. Based on the successes and strengths of educational games for health, we developed and evaluated a novel game-based course to fill the gap in training resources for insecticide resistance management. The training was evaluated by analysing results of pre- and post-course knowledge tests and self-efficacy surveys, as well as post-course interviews. At the start of the training, fundamental concepts of insecticide resistance were reviewed through Resistance101, a mobile app game. Subsequently, insecticide resistance management strategies were explored using the simulation game ResistanceSim, which was introduced by mini-lectures and complemented by class discussions and group work. The game-based training was conducted and evaluated in two African countries (Ethiopia and Zambia) using a mixed-methods approach. Quantitative outcome measures included knowledge acquisition and change in self-efficacy. We completed a qualitative inductive thematic analysis of participant interviews to explore the views and experiences of participants with the games and training, and the impact of the training on professional practices and attitudes. The game-based training increased knowledge in the short-term and improved self-efficacy scores. The training increased participants’ knowledge base, stimulated knowledge sharing and changed work practices. The game-based training offers scalable training opportunities that could nurture and capacitate the next generation of professionals in vector control

Landmarks and ant search strategies after interrupted tandem runs

© 2014. Published by The Company of Biologists Ltd. During a tandem run, a single leading ant recruits a single follower to an important resource such as a new nest. To examine this process, we used a motorized gantry, which has not previously been used in ant studies, to track tandem running ants accurately in a large arena and we compared their performance in the presence of different types of landmark. We interrupted tandem runs by taking away the leader and moved a large distant landmark behind the new nest just at the time of this separation. Our aim was to determine what information followers might have obtained from the incomplete tandem run they had followed, and how they behaved after the tandem run had been interrupted. Our results show that former followers search by using composite random strategies with elements of sub-diffusive and diffusive movements. Furthermore, when we provided more landmarks former followers searched for longer. However, when all landmarks were removed completely from the arena, the ants' search duration lasted up to four times longer. Hence, their search strategy changes in the presence or absence of landmarks. Even after extensive search of this kind, former followers headed back to their old nest but did not return along the path of the tandem run they had followed. The combination of the position to which the large distant landmark behind the new nest was moved and the presence or absence of additional landmarks influenced the orientation of the former followers' paths back to the old nest. We also found that these ants exhibit behavioural lateralization in which they possibly use their right eye more than their left eye to recognize landmarks for navigation. Our results suggest that former follower ants learn landmarks during tandem running and use this information to make strategic decisions

An evaluation of MINDFIT—A student therapeutic running group as a multi-layered intervention in the United Kingdom

Background: Mental health is an ever-increasing concern for UK Universities and is underreported. Creative and dynamic approaches to tackle student wellbeing are important. In 2018, Sheffield Hallam University (SHU) Student Wellbeing Service initiated a pilot study of a therapeutic running programme ‘MINDFIT’ that combined physical activity, led by a counsellor, alongside a psychoeducation approach to support student mental health. Methods: Mixed methods were used which included the Patient Health Questionnaire-9 (PHQ-9), evaluating low mood and depression, and Generalized Anxiety Disorder Scale-7 (GAD-7), evaluating levels of anxiety. Results: A total of 28 students were triaged onto a weekly programme over three semesters. Overall, 86% of the participants completed the programme. A promising reduction in the scores for PHQ-9 and GAD-7 was found at the end of the programme. Focus groups, with student participants, were held to gather qualitative data for analysis. After thematic analysis, three main themes emerged: “Creating a safe community”, “Making progress” and “Pathways to success”. Conclusions: MINDFIT was an effective and engaging multi-layered therapeutic approach. Recommendations identified the importance and effectiveness of the triage process in recruiting students and sustainability of the programme through the continued engagement of students post programme. More research is required to identify the long-term effects of the MINDFIT approach and how applicable it is to higher education contexts

Is the Philippines ready for HIV self-testing?

Background: The Philippines is facing a rapidly rising HIV epidemic among young men who have sex with men (MSM). Testing rates among young populations is poor. HIV self-testing (HIVST) is a promising strategy to address this testing gap. The study’s purpose was to explore the perceived acceptability, feasibility and programmatic challenges of HIVST among key informants and target users. Method: A qualitative study involving semi-structured interviews and focus group discussions (FGD). We interviewed 15 key informants involved with HIV testing programs or policies and 42 target users in six FGD in Metro Manila. We held separate discussions with high socio-economic MSM (n = 12), urban poor MSM (n = 15) and transgender women (TGW) (n = 15). Results were analysed using a thematic framework approach. Results: MSM and TGW welcomed the convenience and privacy HIVST could provide. They preferred an inexpensive accurate blood-based kit attained from reputable sites. Key informants at national and local level equally welcomed HIVST but identified a number of policy and regulatory issues. Both groups articulated the challenge of enrolling those who test reactive using HIVST to further testing and treatment in an environment characterised by acute stigma around HIV. Conclusions: HIVST was found to be highly acceptable to target users and was welcomed as an additional testing approach at national level. Strategic alliances are now needed between stakeholders to proactively deliver a patientcentred HIVST program that could provide an effective, safe means of increasing testing coverage in this escalating context. Keywords: HIV self-testing, Philippines, Men who have sex with men (MSM), Transgender women, TGW, Regulation, Polic

Development of a Mobile Game to Influence Behavior Determinants of HIV Service Uptake Among Key Populations in the Philippines: User-Centered Design Process

Opportunities in digital distribution place mobile games as a promising platform for games for health. However, designing a game that can compete in the saturated mobile games market and deliver persuasive health messages can feel like an insurmountable challenge. Although user-centered design is widely advocated, factors such as the user's subject domain expertise, budget constraints, and poor data collection methods can restrict the benefits of user involvement. OBJECTIVE: This study aimed to develop a playable and acceptable game for health, targeted at young key populations in the Philippines. METHODS: Authors identified a range of user-centered design methods to be used in tandem from published literature. The resulting design process involved a phased approach, with 40 primary and secondary users engaged during the initial ideation and prototype testing stages. Selected methods included participatory design workshops, playtests, playability heuristics, and focus group discussions. Subject domain experts were allocated roles in the development team. Data were analyzed using a framework approach. Conceptual frameworks in health intervention acceptability and game design guided the analysis. In-game events were captured through the Unity Analytics service to monitor uptake and game use over a 12-month period. RESULTS: Early user involvement revealed a strong desire for online multiplayer gameplay, yet most reported that access to this type of game was restricted because of technical and economic constraints. A role-playing game (RPG) with combat elements was identified as a very appealing gameplay style. Findings guided us to a game that could be played offline and that blended RPG elements, such as narrative and turn-based combat, with match-3 puzzles. Although the game received a positive response during playtests, gameplay was at times perceived as repetitive and predicted to only appeal to casual gamers. Knowledge transfer was predominantly achieved through interpretation of the game's narrative, highlighting this as an important design element. Uptake of the game was positive; between December 1, 2017, and December 1, 2018, 3325 unique device installs were reported globally. Game metrics provided evidence of adoption by young key populations in the Philippines. Game uptake and use were substantially higher in regions where direct engagement with target users took place. CONCLUSIONS: User-centered design activities supported the identification of important contextual requirements. Multiple data collection methods enabled triangulation of findings to mediate the inherent biases of the different techniques. Game acceptance is dependent on the ability of the development team to implement design solutions that address the needs and desires of target users. If target users are expected to develop design solutions, they must have adequate expertise and a significant role within the development team. Facilitating meaningful partnerships between health professionals, the games industry, and end users will support the games for health industry as it matures

Pursuing health systems strengthening through disease-specific programme grants: experiences in Tanzania and Sierra Leone

Introduction Disease-specific ‘vertical’ programmes and health system strengthening (HSS) ‘horizontal’ programmes are not mutually exclusive; programmes may be implemented with the dual objectives of achieving both disease-specific and broader HSS outcomes. However, there remains an ongoing need for research into how dual objective programmes are operationalised for optimum results. Methods A qualitative study encompassing four grantee programmes from two partner countries, Tanzania and Sierra Leone, in the Comic Relief and GlaxoSmithKline ‘Fighting Malaria, Improving Health’ partnership. Purposive sampling maximised variation in terms of geographical location, programme aims and activities, grantee type and operational sector. Data were collected via semi-structured interviews. Data analysis was informed by a general inductive approach. Results 51 interviews were conducted across the four grantees. Grantee organisations structured and operated their respective projects in a manner generally supportive of HSS objectives. This was revealed through commonalities identified across the four grantee organisations in terms of their respective approach to achieving their HSS objectives, and experienced tensions in pursuit of these objectives. Commonalities included: (1) using short-term funding for long-term initiatives; (2) benefits of being embedded in the local health system; (3) donor flexibility to enable grantee responsiveness; (4) the need for modest expectations; and (5) the importance of micro-innovation. Conclusion Health systems strengthening may be pursued through disease-specific programme grants; however, the respective practice of both the funder and grantee organisation appears to be a key influence on whether HSS will be realised as well as the overall extent of HSS possible

ResistanceSim: development and acceptability study of a serious game to improve understanding of insecticide resistance management in vector control programmes.

The use of insecticides is the cornerstone of effective malaria vector control. However, the last two decades has seen the ubiquitous use of insecticides, predominantly pyrethroids, causing widespread insecticide resistance and compromising the effectiveness of vector control. Considerable efforts to develop new active ingredients and interventions are underway. However, it is essential to deploy strategies to mitigate the impact of insecticide resistance now, both to maintain the efficacy of currently available tools as well as to ensure the sustainability of new tools as they come to market. Although the World Health Organization disseminated best practice guidelines for insecticide resistance management (IRM), Rollback Malaria's Vector Control Working Group identified the lack of practical knowledge of IRM as the primary gap in the translation of evidence into policy. ResistanceSim is a capacity strengthening tool designed to address this gap. The development process involved frequent stakeholder consultation, including two separate workshops. These workshops defined the learning objectives, target audience, and the role of mathematical models in the game. Software development phases were interspersed with frequent user testing, resulting in an iterative design process. User feedback was evaluated via questionnaires with Likert-scale and open-ended questions. The game was regularly evaluated by subject-area experts through meetings of an external advisory panel. Through these processes, a series of learning domains were identified and a set of specific learning objectives for each domain were defined to be communicated to vector control programme personnel. A simple "game model" was proposed that produces realistic outputs based on player strategy and also runs in real-time. Early testing sessions revealed numerous usability issues that prevented adequate player engagement. After extensive revisions, later testing sessions indicated that the tool would be a valuable addition to IRM training

Stakeholders’ hopes and concerns about the COVID-19 vaccines in Southeastern Nigeria: a qualitative study

Background Equitable access and high uptake of safe and effective vaccines is critical to ending the COVID-19 pandemic. To ensure the success of these vaccines, particularly in many developing and under-developed parts of the world, the concerns of local communities including fears, potency, and levels of acceptance should be addressed. This study assessed community stakeholders’ perceptions in parts of Southeastern Nigeria about COVID-19 vaccine, towards engaging them effectively to ensure the success of the vaccination campaigns. Methods A qualitative study was conducted involving fourteen stakeholders from the Southeastern geo-political zone of Nigeria selected using purposive sampling. In-depth semi-structured individual interviews lasting about 30 min were used to collect data. Data analysis was informed by a general inductive approach. Results Stakeholders hoped that the development and roll out of the vaccines will bring COVID -19 to an end, will help to maintain good health and allow people get back to normal life. On the other hand, stakeholders expressed their concerns and worries about the “speed” with which the vaccines are being produced, possibility of future adverse effects from vaccination, misinformation, and level of preparedness in the health system to implement the vaccine campaign. Conclusions This study identified that more needs to be done to improve perceptions of those who influence health decisions in communities towards COVID-19 vaccines. This includes firstly, the involvement of the community and religious leaders in vaccine promotion. Secondly, it is imperative to develop and disseminate persuasive messaging on vaccine effectiveness and safety targeted at both health professionals, policymakers, and the community which are culturally sensitive and address identified concerns among health workers. Thirdly, the health systems should be strengthened and system-level interventions that directly target one or more of the WHO’s six health system building blocks: service delivery, health workforce, health information systems, access to essential medicines, financing, and leadership/governance

Association of anticipated HIV testing stigma and provider mistrust on preference for HIV self-testing among cisgender men who have sex with men in the Philippines

Background: New HIV infections in the Philippines are increasing at an alarming rate. However, over three quarters of men who have sex with men (MSM) have never been tested for HIV. HIV self-testing (HIVST) may increase overall testing rates by removing barriers, particularly fear of stigmatization and mistrust of providers. This study aimed to determine if these factors are associated with preference for HIVST among Filipino cisgender MSM (cis-MSM), and whether there is an interaction between anticipated HIV testing stigma and provider mistrust on preference for HIVST. Methods: We conducted secondary analysis of a one-time survey of 803 cis-MSM who were recruited using purposive sampling from online MSM dating sites and MSM-themed bar locations in Metro Manila, Philippines. Summary statistics were computed to describe participant characteristics. Multivariable modified Poisson regression analyses were conducted to determine if anticipated HIV testing stigma and provider mistrust were associated with preference for HIVST among cis-MSM. Other variables such as age, education, monthly income, relationship status, HIV serostatus, and knowing where to get HIV testing were the minimal sufficient adjustment set in the analyses. Results: Average age of participants was 28.6 years (SD = 8.0); most had received college degrees (73%) and were employed (80%). Most respondents (81%) preferred facility-based testing, while 19% preferred HIVST. A high percentage of participants reported anticipated HIV testing stigma (66%) and provider mistrust (44%). Anticipated HIV testing stigma (aPR = 1.51; 95% CI = 1.01–2.25, p = 0.046) and provider mistrust (aPR = 1.49; 95% CI = 1.07–2.09, p = 0.020) were independently associated with a preference for HIVST. There was a positive, additive interaction between provider mistrust and anticipated HIV testing stigma on preference for HIVST (RERI = 1.13, 95% CI: 0.20–2.06; p = 0.017), indicating that the association between anticipated HIV testing stigma and preference for HIVST is greater among those with provider mistrust compared to those without provider mistrust. Conclusions: HIVST should be offered as a supplement to traditional facility-based HIV testing services in the Philippines to expand testing and reach individuals who may not undergo testing due to anticipated HIV testing stigma and provider mistrust