A Mobile App to Screen for Neurocognitive Impairment: Preliminary Validation of NeuroScreen Among HIV-Infected South African Adults

Abstract

BackgroundNeurocognitive impairment (NCI) is one of the most common complications of HIV infection, and has serious medical and functional consequences. South Africa has 7 million people living with HIV (PLHIV) with up to three-quarters of antiretroviral therapy (ART)-naïve individuals having NCI. South Africa’s health system struggles to meet the care needs of its millions of PLHIV; screening for NCI is typically neglected due to limited clinical staff trained to administer, score, and interpret neuropsychological tests, as well as long test batteries and limited screening tools for South African populations. Without accurate, clinically useful, and relatively brief NCI screening tests that can be administered by all levels of clinical staff, critical opportunities to provide psychoeducation, behavioral planning, additional ART adherence support, and adjuvant therapies for NCI (when they become available) are missed. To address these challenges and gap in care, we developed an mHealth app screening tool, NeuroScreen, to detect NCI that can be administered by all levels of clinical staff, including lay health workers.ObjectiveThe purpose of this study was to examine sensitivity and specificity of an adapted version of NeuroScreen to detect NCI (as determined by a gold standard neuropsychological test battery administered by a trained research psychometrist) among HIV-infected South Africans when administered by a lay health worker.MethodsA total of 102 HIV-infected black South African adults who had initiated ART at least 12 months prior were administered NeuroScreen and a gold standard neuropsychological test battery in the participants’ choice of language (ie, English or isiXhosa). Three composite z scores were calculated for NeuroScreen: (1) sum of all individual test scores, (2) sum of all individual test scores and error scores from four tests, and (3) sum of four tests (abbreviated version). Global deficit scores were calculated for the gold standard battery where a score of 0.5 or greater indicated the presence of NCI.ResultsThe mean age of participants was 33.31 (SD 7.46) years, most (59.8%, 61/102) had at least 12 years of education, and 81.4% (83/102) of the sample was female. Gold standard test battery results indicated that 26.5% (27/102) of the sample had NCI. Sensitivity and specificity of age-, education-, and sex-adjusted NeuroScreen scores were 81.48% and 74.67% for composite score 1, 81.48% and 81.33% for composite score 2, and 92.59% and 70.67% for composite score 3, respectively.ConclusionsNeuroScreen, a highly automated, easy-to-use, tablet-based screening test to detect NCI among English- and isiXhosa-speaking South African HIV patients demonstrated robust sensitivity and specificity to detect NCI when administered by lay health workers. NeuroScreen could help make screening for NCI more feasible. However, additional research is needed with larger samples and normative test performance data are needed.

A systematic review of research on neuropsychological measures in psychotic disorders from low and middle-income countries: The question of clinical utility

“…This raises concern about the clinical utility of these measures in LMICs, where there are few specialized staff ( Evans-Lacko et al, 2019 ; Mugisha et al, 2017 ; Semrau et al, 2015 ). mHealth apps may be more cost-efficient and feasible for delivery by non-specialized staff ( Istepanian et al, 2004 ; Nicholas et al, n.d. ; Robbins et al, 2018 ). Evidence suggests that tests delivered via mHealth applications are more efficient, accurate, accessible and interactive than assessments delivered via pen and paper ( Bakkour et al, 2014 ).…”

Training Cognitive Functions Using Mobile Apps in Breast Cancer Patients: Systematic Review

“…Sixteen studies were excluded from the present systematic review because they did not use mobile applications to train cognitive functions [20,43,[52][53][54][55][56][44][45][46][47][48][49][50][51]. Eleven studies were excluded because they used mobile applications only to assess -and not to train -cognitive functions [57,58,67,[59][60][61][62][63][64][65][66]. Our eleven selected studies focus on the cognitive domains of attention, memory, problem solving, cognitive control, executive function, visuospatial function, and language (as reported in Table 1).…”

Home-versus acquired-language test performance on the Hopkins Verbal Learning Test-Revised among multilingual South Africans

“…As part of a larger research study (Robbins et al, 2018), 112 Black South African adult isiXhosa first language speakers (49% men) were recruited from a peri-urban primary healthcare clinic in Cape Town, South Africa. Inclusion criteria were: 1) HIV-negative status; 2) age 18 years or older; 3) isiXhosa-speaking; and 4) capacity for informed consent.…”

“…The isiXhosa version was originally used in studies characterizing the prevalence of HIV-Associated Neurocognitive Disorders (HAND) among HIV+ South African adults (Joska et al, 2011;Joska et al, 2012). More recently, the isiXhosa version of the HVLT-R has been used as part of a neuropsychological test battery to compare with a new tablet-based screening test to detect neurocognitive impairment in this population (Robbins et al, 2018). However, most adaptations of the HVLT-R, including the isiXhosa variant, have not reported on multiple, important linguistic and demographic characteristics known to influence test performance.…”