Introduction: Millions of women worldwide annually undergo manual vacuum aspiration (MVA) with no pain medication, which is a violation of their basic human dignity. We designed a novel device (Chloe SED®) to administer paracervical block (PCB) during MVA in countries where pain medication is not typically given due to the high cost of the necessary tools.

Methods: We conducted a single-blinded, randomized controlled non-inferiority trial including 61 patients at two hospitals in Kisumu, Kenya, to validate Chloe SED® for administration of PCB during MVA. PCB administered with Chloe SED® was compared to PCB administered with a standard spinal needle. Patients requiring MVA were block randomized in blocks of six, each provider completing six PCBs—three with the Chloe SED® and three with the standard spinal needle. The trial was registered with the Kenya Pharmacy and Poisons Board, ECCT/19/03/01 (https://ctr.pharmacyboardkenya.org/applications/index/protocol_no:RUNDVC8xOS8wMy8wMQ__/filter:/investigator:/sites:/pages:5/start_date:/end_date:/disease_condition:/users:/ercs:/stages). An intention-to-treat analysis was completed. The primary outcome was the non-inferiority of the pain score during uterine evacuation with a non-inferiority margin of 2 points on an 11-point numerical rating scale. Secondary outcomes included the non-inferiority of the pain score at four other time points and patient satisfaction.

Results: Chloe SED® showed non-inferiority of the primary outcome with a mean pain score during evacuation of 3.8 [90% confidence interval (CI): 3.1–4.6] compared with the spinal needle at 4.1 (90% CI: 3.5–4.7). Non-inferiority of the pain score was shown at all time points. Most patients expressed a desire for the continued use of the device to administer PCB for MVA. No adverse events were noted.

Conclusion: In summary, the Chloe SED® appears non-inferior to the spinal needle and desirable for the administration of PCB during MVA.@en

Background
The health care sector is among the most carbon-intensive sectors, contributing to societal problems like climate change. Previous research demonstrated that especially the use of personal protective equipment (e.g., aprons) in critical care contributes to this problem. To reduce personal protective equipment waste, new sustainable policies are needed.

Aims
Policies are only effective if people comply. Our aim is to examine whether compliance with sustainable policies in critical care can be increased through behavioural influencing. Specifically, we examined the effectiveness of two sets of nudges (i.e., a Prime + Visual prompt nudge and a Social norm nudge) on decreasing apron usage in an intensive care unit (ICU).

Study Design
We conducted a field experiment with a pre- and post-intervention measurement. Upon the introduction of the new sustainable policy, apron usage data were collected for 9 days before (132 observations) and 9 days after (114 observations) the nudge interventions were implemented.

Results
Neither the Prime + Visual prompt nudge, nor the Social norm nudge decreased apron usage.

Conclusions
While previous studies have found that primes, visual nudges and social norm nudges can increase sustainable behaviour, we did not find evidence for this in our ICU field experiment. Future research is needed to determine whether this null finding reflects reality, or whether it was due to methodological decisions and limitations of the presented experiment.

Relevance to Clinical Practice
The presented study highlights the importance of studying behavioural interventions that were previously proven successful in the lab and in other field contexts, in the complex setting of critical care. Results previously found in other contexts may not generalize directly to a critical care context. The unique characteristics of the critical care context also pose methodological challenges that may have affected the outcomes of this experiment.@en

This research project, part of the Green Intensive Care Unit (ICU) initiative at the Erasmus University Medical Center (EMC), is focused on reducing the environmental impact of syringes at the ICU by designing solutions based on circular economy principles. Based on a Material Flow Analysis of the EMC ICU, syringes and their packaging have been identified as one of the main environmental impact hotspots. Therefore, this project aimed to redesign the syringes, their packaging, and their use, according to circular design strategies suitable for medical products to decrease their environmental impact, while remaining convenient and safe in use for the healthcare staff and patients. Research was executed to understand the context from multiple perspectives. The outcomes demonstrated that decreasing the impact of syringes is not only related to the design of the syringe itself. Manufacturing, preparation, use and disposal, all contribute to the environmental impact of the syringe. Various possible interventions were derived to reduce its impact:

1.
Adapting the infection prevention protocol and behaviour of the staff;

2.
Separating infectious waste from general hospital waste;

3.
Redesigning the syringe itself;

4.
Optimising the filling process of syringes.

The final design is an optimised filling process for prefilled sterilised syringes (PFSs), based on circular strategies such as reduce, reuse, rethink and repurpose. Interventions include: eliminating a redundant sterilisation phase, reducing residual medication and changing from steam to gamma sterilisation. This resulted in decreasing the amount of waste, material, energy and water consumption, while offering similar convenience and safety for the staff and patients of the ICU.@en

Introduction
Schistosomiasis is a significant public health concern, especially in Sub-Saharan Africa. Conventional microscopy is the standard diagnostic method in resource-limited settings, but with limitations, such as the need for expert microscopists. An automated digital microscope with artificial intelligence (Schistoscope), offers a potential solution. This field study aimed to validate the diagnostic performance of the Schistoscope for detecting and quantifying Schistosoma haematobium eggs in urine compared to conventional microscopy and to a composite reference standard (CRS) consisting of real-time PCR and the up-converting particle (UCP) lateral flow (LF) test for the detection of schistosome circulating anodic antigen (CAA).

Methods
Based on a non-inferiority concept, the Schistoscope was evaluated in two parts: study A, consisting of 339 freshly collected urine samples and study B, consisting of 798 fresh urine samples that were also banked as slides for analysis with the Schistoscope. In both studies, the Schistoscope, conventional microscopy, real-time PCR and UCP-LF CAA were performed and samples with all the diagnostic test results were included in the analysis. All diagnostic procedures were performed in a laboratory located in a rural area of Gabon, endemic for S. haematobium.

Results
In study A and B, the Schistoscope demonstrated a sensitivity of 83.1% and 96.3% compared to conventional microscopy, and 62.9% and 78.0% compared to the CRS. The sensitivity of conventional microscopy in study A and B compared to the CRS was 61.9% and 75.2%, respectively, comparable to the Schistoscope. The specificity of the Schistoscope in study A (78.8%) was significantly lower than that of conventional microscopy (96.4%) based on the CRS but comparable in study B (90.9% and 98.0%, respectively).

Conclusion
Overall, the performance of the Schistoscope was non-inferior to conventional microscopy with a comparable sensitivity, although the specificity varied. The Schistoscope shows promising diagnostic accuracy, particularly for samples with moderate to higher infection intensities as well as for banked sample slides, highlighting the potential for retrospective analysis in resource-limited settings.@en

As the transition to sustainable energy intensifies, hydrogen emerges as a pivotal medium in mitigating climate change and improving energy security. While its applicability across various sectors is undeniable, its integration into established energy systems presents multifaceted challenges. This study investigates the complexities of integrating hydrogen into the Netherlands' energy systems. Beyond technological advancements, the successful design and rollout of a hydrogen supply chain require coordination and collaboration among a myriad of stakeholders. Through a mixed-methods approach, this study combines findings from a broad literature review, policy document analyses, evaluation of 59 field projects, and engaging dialogues with 33 key stakeholders from different sectors. This investigation led to the identification and categorization of key players in the Dutch hydrogen sector, revealing their interconnected roles and the challenges encountered in the hydrogen integration process. The study further categorized the identified challenges faced by stakeholders into five core domains: technical, infrastructural (including supply chain), socioeconomic, environmental, and institutional, with associated factors. Prominent challenges include transportation infrastructure upgrades, high initial costs and scalability, effective storage methods, safety and cybersecurity measures, storage and distribution infrastructure, security of supply, and public acceptance. This study contributes to the hydrogen integration discourse, offering insights for academics, industry, and policymakers. Its detailed stakeholder analysis, holistic categorization of challenges across five domains, and a stakeholder-centric approach grounded in real-world dialogues offer applicable frameworks beyond its primary context. In this vein, it guides future research and decisions, and its approach is adaptable for different regions or sectors, emphasizing comprehensive transition strategies.@en

This project aims to reduce the environmental impact of the Intensive Care Unit (ICU) of the Erasmus Medical Center (EMC). Systemic design research was executed to map the current waste flow created by the ICU. Literature review, interviews and observations were performed to gather information about the healthcare protocols, hospital procurement process, intubation practices and used devices and consumables. This resulted in a set of challenges which were used to ideate from different perspectives to improve the sustainability of the ICU. A set of opportunities to introduce circularity within the ICU were defined. These opportunities ranged from waste separation to the reduction of the disposal of unused products. The selected circular opportunity was intubation, needed when patients cannot breathe by themselves. For this, a video laryngoscope, which is composed of various plastics, a video camera, and a led light, is used for only a few minutes and disposed of (and incinerated) directly afterwards. The aim of the second part of this research project was: Can we design a circular intubation procedure as a catalyzer for systemic change towards circular ICUs? One of the proposed circular strategies for the video laryngoscope is the reprocessing of intubation devices used at the ICU itself. A transition model toward reprocessing using UV-C radiation technique was further developed. Compared to current reprocessing procedures, UV-C disinfection consumes no water and less electricity and offers the possibility of decentralized reprocessing within the ICU department itself. This project aims to provoke conversations between the hospital, manufacturers and other stakeholders about how the healthcare sector could start reprocessing valuable medical devices towards a circular ICU.@en

Traditionally, automated slide scanning involves capturing a rectangular grid of field-of-view (FoV) images which can be stitched together to create whole slide images, while the autofocusing algorithm captures a focal stack of images
to determine the best in-focus image. However, these methods can be timeconsuming due to the need for X-, Y- and Z-axis movements of the digital microscope while capturing multiple FoV images. In this paper, we propose a solution to minimise these redundancies by presenting an optimal procedure for automated slide scanning of circular membrane filters on a glass slide. We achieve this by following an optimal path in the sample plane, ensuring that only FoVs overlapping the filter membrane are captured. To capture the best infocus FoV image, we utilise a hill-climbing approach that tracks the peak of the mean of Gaussian gradient of the captured FoVs images along the Z-axis. We implemented this procedure to optimise the efficiency of the Schistoscope, an automated digital microscope developed to diagnose urogenital schistosomiasis by imaging Schistosoma haematobium eggs on 13 or 25 mm membrane filters. Our improved method reduces the automated slide scanning time by 63.18%and 72.52% for the respective filter sizes. This advancement greatly supportsthe practicality of the Schistoscope in large-scale schistosomiasis monitoringand evaluation programs in endemic regions. This will save time, resources andalso accelerate generation of data that is critical in achieving the targets for schistosomiasis elimination.@en

The accomplishment of Sustainable Development Goals (SDGs) is intrinsically connected to improving livelihoods in the Rural Global South (RGS). RGS livelihoods are complex, showing multiple dimensions beyond mere economic considerations. However, many related development policies (over)simplify livelihoods to income thresholds, leading to flawed interventions. Adequate strategies to address RGS livelihoods require a much deeper understanding of their various dimensions and complexities. Q methodology (Q) is a powerful participatory research technique that enables the systematic study of different viewpoints on subjective topics. Moreover, it has the potential to identify and reveal previously unheard narratives, thus allowing us to question the traditional understandings of RGS livelihoods. Yet, as a time- and assistance-intensive technique, its implementation faces methodological challenges that are currently overlooked and ought to be considered. We selected and reviewed 50 Q studies applied to different forms of RGS livelihoods. First, we discuss several on-field Q limitations associated with the physical, logistical, social, and cultural constraints. Second, we draw on good practices and strategies to cope with these limitations. Notwithstanding the limitations and strategies, we advocate building Q capacities and the gender-balanced empowerment of local researchers. This may contribute to a better understanding of the nuances and challenges of RGS livelihoods.@en

This research and design project is part of the Green ICU initiative and focused on reducing the environmental impact of gloves at the Intensive Care Unit (ICU) of the Erasmus Medical Center (EMC). At the ICU of the EMC around 108 gloves are used per patient per day; to protect the user (healthcare staff) from infections. The high frequency of use and the resource-intensive production define disposable nitrile gloves as one of the ‘hotspots’ contributing to the environmental impact created by the ICU. This research and design project addressed the problem from three different perspectives: user-centred, product-centred and supply-centred. The extensive research resulted in three design directions on how to reduce the environmental impact of gloves. Subsequently, all insights from the research were brought together into five design building blocks. These design building blocks provided guidance for the design phase of the project. The project resulted in a redesign of the current glove dispensers. The final design is named ‘GloVe’, a vertical dispense system. By incorporating the five building blocks, the design can provide benefits for multiple stakeholders within the healthcare system. It reduces the environmental impact of gloves in the ICU by dispensing one glove at a time. Furthermore, the gloves are dispensed at the cuff, which comes in little contact with the patient. The vertical movement is pleasant to the user. The use of colour for different sizes makes it clear to the care assistant which box should go in which holder. Also, nurses will see at a glance, which size gloves they are dispensing. The small V-shaped opening makes the undesirable behaviour, of placing gloves back, almost impossible.@en

Design thinking is an innovation approach for organisations aiming to solve complex and open-ended problems, including those arising in the transition from a linear to a circular economic system. Although the importance has been recognised in business and academia, to date, insight is lacking on how design thinking can be applied within circular innovation specifically. We investigate the following research question: How can design thinking tools catalyse sustainable circular innovation? Based on the literature, we first create a framework that characterises design thinking principles, criteria and phases that could support circular innovation. The design thinking phases are ideate and design, implement and test, and evaluate and improve. The criteria include desirability, feasibility, viability and sustainability, and circularity. Finally, we identify the following principles that make design thinking suitable to tackle complex circular innovation challenges: human-centred, future-oriented, holistic, co-creative, and experimental. Consequently, against this framework, we map 11 tools that are suitable to catalyse circular innovation theory into practice through design thinking. Finally, we reflect on the future of research and practice around this subject.

@en

Together we must reduce the impact of the healthcare sector and shift towards a circular economy. This paper describes the shift of three ICU environmental hotspots: gloves, gowns, and CRRT bags.@en

Designing new and inclusive diagnostic tools to detect Neglected Tropical Diseases (NTDs) to achieve rational disease control requires a co-design process where end-users’ input is important. Failure to involve all potential end-users in new diagnostics for NTDs can result in low use and adoption failure, leading to persistent infection hot spots and ineffective disease control. There are different categories of potential end-users of new diagnostic tools for NTD control, and it is unclear if there are differences between the user efficiency, effectiveness, perception, and acceptability across these end-user categories. This study evaluated the usability, user perception, contextual factors affecting the user’s experience, and acceptability of a new digital optical diagnostic device for NTDs across three types of potential end users. A total of 21 participants were tested. Laboratory scientists, technicians, and Community Health Extension Workers (CHEWs) in training achieved similar scores on the usability and user perception questionnaires with no statistically significant difference between end-user categories. All participants also have high scores for the user perception domains which strongly correlate with the acceptability of the AiDx NTDx Assist device. This study indicates that, by providing digital diagnostic tools in combination with minimal training and support, CHEWs undergoing training and, by extension, CHEWs post-training, can be involved in the diagnoses of NTDs, potentially enhancing a community’s capabilities to diagnose, treat, and control NTDs. @en

Distributed hydrogen infrastructures have emerged as a complementary element in the quest for sustainable energy solutions, with potential applications in regions featuring high industrial demands and spatially resolved negative residual loads. These infrastructures can contribute to the decarbonization of electricity, heating, and transport sectors while enhancing local renewable energy consumption and supporting energy storage and demand-side management. However, their development presents unique design challenges, calling for a comprehensive understanding of stakeholder roles and relationships in the evolving ecosystem. This study examines stakeholder network dynamics within the distributed hydrogen ecosystem, focusing on the Netherlands' built environments. Through the analysis of 16 case studies, we employ Social Network Analysis (SNA) to identify and analyse stakeholder network involved in the early design and implementation of distributed hydrogen infrastructures. Our findings highlight emerging roles and interests due to the rise of such infrastructures, emphasizing the need for adaptable stakeholder relations. Design plays a critical role in this context, enabling stakeholders to navigate challenges, innovate, and foster collaboration. The paper explores stakeholder categories, providing insights into their interactions and coordination strategies. Ultimately, our study offers valuable guidance to practitioners and policymakers, promoting stakeholder collaboration for successful distributed hydrogen infrastructure deployment in pursuit of a sustainable, low-carbon energy future.@en

A growing awareness of health as a human right, mainly in low- and middle-income countries, is promoting universal health access for increasing numbers of people. Universal access to health to a large extent depends on access to medical equipment and medical staff. In this chapter, we focus on the access to medical equipment, more specifically, equipment for diagnostics and how frugal innovation and distributed manufacturing can contribute to an increase of access to these devices. We present a case study of a frugal design for a centrifuge for sample preparation for schistosomiasis. This neglected tropical disease impacts the lives of over 240 million people, mainly in sub-Saharan Africa@en

Healthcare facilities in low-resource settings in Sub-Saharan Africa are plagued with issues of non-functional and obsolete medical devices, which ultimately end up prematurely disposed of as waste. With increasing healthcare demands, stopping medical device disposal is imperative. One way to achieve this is to leverage circular economy principles in designing medical devices. Circular economy principles aim to retain products and their constituent materials to be reused over time in the economic system. However, to what extent this has been applied in designing medical devices specifically for low-resource settings in Sub-Saharan Africa is missing in literature. Based on a systematic review of 29 out of 1,799 screened scientific papers, we identified the use of circular economy principles of durability, maintenance, repair, and upgrade in designing medical devices for this setting. Whether these principles were intentionally applied from a circular economy approach could not be inferred in this study. The motivational basis for using these principles was to ensure medical device longevity to providing healthcare. No attention was given to the circular economy principles of refurbishment, remanufacturing, and recycling, ensuring that device components and constituent materials are recovered. These study findings serve as a launchpad for exploring how circular principles can be used to support the design of medical devices for low-resource settings in Sub-Saharan Africa. Academicians and designers of medical devices can leverage this research to contribute towards developing medical devices that support access to healthcare for people in low-resource settings and preserve earth’s finite resources@en

Underfunded healthcare infrastructures in low-resource settings in sub-Saharan Africa have resulted in a lack of medical devices crucial to provide healthcare for all. A representative example of this scenario is medical devices to administer paracervical blocks during gynaecological procedures. Devices needed for this procedure are usually unavailable or expensive. Without these devices, providing paracervical blocks for women in need is impossible resulting in compromising the quality of care for women requiring gynaecological procedures such as loop electrosurgical excision, treatment of miscarriage, or incomplete abortion. In that perspective, interventions that can be integrated into the healthcare system in low-resource settings to provide women needing paracervical blocks remain urgent. Based on a context-specific approach while leveraging circular economy design principles, this research catalogues the development of a new medical device called Chloe SED® that can be used to support the provision of paracervical blocks. Chloe SED®, priced at US$ 1.5 per device when produced in polypropylene, US$ 10 in polyetheretherketone, and US$ 15 in aluminium, is attached to any 10-cc syringe in low-resource settings to provide paracervical blocks. The device is designed for durability, repairability, maintainability, upgradeability, and recyclability to address environmental sustainability issues in the healthcare domain. Achieving the design of Chloe SED® from a context-specific and circular economy approach revealed correlations between the material choice to manufacture the device, the device's initial cost, product durability and reuse cycle, reprocessing method and cost, and environmental impact. These correlations can be seen as interconnected conflicting or divergent trade-offs that need to be continually assessed to deliver a medical device that provides healthcare for all with limited environmental impact. The study findings are intended to be seen as efforts to make available medical devices to support women's access to reproductive health services.@en

Smallholder farmers (SFs) are cornerstone actors in eradicating poverty and hunger. Companies have recently focused on SFs as potential customers and suppliers. Several hindrances yet prevent SFs to be commercially viable actors. In this respect, sustainable business models (SBMs) bring opportunities for companies to increase profit, improve SFs' livelihoods, and promote environmental sustainability. Recognizing these opportunities, the Dutch company aQysta provides the Barsha pump (BP) as a sustainable irrigation solution for SFs. The challenges for BP adoption that remain for SFs illustrate that there is still limited understanding of how SBMs can support companies in engaging with SFs. To expand this understanding, we conducted a multiple-case analysis of 10 organizations providing SF-tailored products and/or services. Based on this analysis, we have drawn lessons for aQysta (and similar companies) to improve the BP's value proposition and we elaborate on the implications of this study for other organizations engaging commercially with SFs.

@en

Vacuum-Assisted wound care (VAC) is effective for treating complex wounds, but is hardly available in low-resource settings. An affordable, portable and safe VAC device was developed to treat patients with chronic and complex wounds: the Wound Care (WOCA) Pump. The WOCA safely controls the pressure accurately (+/- 10%) between -70 and -125 mmHg for a total component cost of USD 150. In this research important steps were taken to make VAC therapy more accessible, affordable and safe for marginalised patients in low-resource settings. Next research will aim to assess its safe clinical use.@en