Richard Holden
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Dr. Holden is an engineer, psychologist, and implementation scientist who leads a funded program of applied research on aging and disease care and prevention. His research designs and evaluates technology-based interventions for middle-aged and older adults living with or at risk for chronic disease and disability, including heart failure, dementia, and hypertension. His work on aging and chronic disease appears in multidisciplinary venues including gerontology, cardiology, nursing, informatics, pharmacy, psychology, and engineering journals. Books include the two-volume edited handbook The Patient Factor, on patient ergonomics, the study and design of patient work.
Dr. Holden's research on health and healthcare has earned an international reputation for the application of innovative methods to promote behavior change, self-care adherence, and technology-supported care in diverse populations. These innovations include the use of participatory co-design to involve patients, families, and clinicians in the design of health interventions; the development of mobile applications and advanced sensors to deliver evidence-based decision support; and the application of systems engineering to support patient safety and quality of care. In recognition of his contributions to innovation in health and healthcare, he has received honors from professional societies in human factors, informatics, and safety science, and has served as expert advisor for national organizations including the Leapfrog Group, Mathematica Policy Institute, and AHRQ.
He has developed, adapted, and applied qualitative, quantitative, and mixed method approaches; tools for studying technology (e.g., usability and acceptance measurement instruments); and processes for user-centered design and development. Methods innovations include the Agile Implementation and Agile Innovation processes, Simplified System Usability Scale, the primary care Clinician Workload measure and multilevel model of clinician workload, the Translating Research into Agile Development (TRIAD) approach, SEIPS 2.0 and SEIPS 101 models, 8-point consolidated heuristic evaluation framework, Patient-centered Cognitive Task Analysis method, the 10-step process for biopsychosocial personas development, and various versions of the Technology Acceptance Model (TAM) and TAM components such as contextualized perceived usefulness.
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Item A human factors and ergonomics approach to conceptualizing care work among caregivers of people with dementia(Elsevier, 2022) Werner, Nicole E.; Rutkowski, Rachel A.; Holden, Richard J.; Ponnala, Siddarth; Gilmore-Bykovskyi, AndreaSociety relies upon informal (family, friend) caregivers to provide much of the care to the estimated 43.8 million individuals living with Alzheimer’s disease and related dementias globally. Caregivers rarely receive sufficient training, resources, or support to meet the demands associated with dementia care, which is often associated with increased risk of suboptimal outcomes. Human factors and ergonomics (HFE) can address the call for new approaches to better understand caregiving and support caregiver performance through systematic attention to and design of systems that support the work of caregivers– their care work. Thus, our objective was to perform a work system analysis of care work. We conducted a qualitative study using a Critical Incident Technique interviewing approach and Grounded Dimensional Analysis analytic procedures. Our findings introduce a new conceptual framework for understanding the care work system of dementia caregivers and suggest that care work is influenced by interactions among distinct caregiver goals, the task demands of the care needs of the person with dementia, daily life needs of the caregiver and family, and contextual factors that shape caregivers’ perceptions surrounding care. The initial work system model produced by this study provides a foundation from which future work can further elucidate the care work system, determine how the care work system intersects and coordinates with other work systems such as the patient work system, and design systems that address caregivers’ individual caregiving context.Item Association of Angiotensin II–Stimulating Antihypertensive Use and Cognitive Measures Commonly Evaluated in the Diagnosis of Dementia(Wiley Periodicals LLC, 2025) Keshk, Noha; Khalil, Hussein; Holden, Richard; Campbell, Noll L.Background: In the absence of a cure for dementia, efforts towards prevention remain the most worthwhile interventions. Separate from their benefits to control blood pressure, Angiotensin (Ang) II-stimulating antihypertensives may have additional neuroprotective benefits that could reduce the risk of cognitive impairment, compared to Ang II-inhibiting drugs. We aim to evaluate the difference between Ang II- stimulating antihypertensives versus Ang II-inhibiting antihypertensives on cognitive measures indicative of dementia. Method: We conducted a retrospective, cross-sectional analysis of existing data from an ongoing clinical trial, BrainSafe. Baseline cognitive data of 705 participants were linked to two-year pre-enrollment electronic medical records data. Based on their medication use, participants were classified into four groups: control (non-users), Ang II-stimulating antihypertensives users, Ang II-inhibiting antihypertensives users, and mixed users. Individual cognitive test scores were standardized into z-scores, adjusted for demographics, using non-users as the reference group. Compound scores were constructed for specific cognitive domains (i.e., memory, language, processing speed and executive functioning) and global cognitive score was calculated as the average z- score across all domains. To compare cognitive performance across groups, generalized linear models with least squares (LS) means were used. Models were adjusted for covariates, including strong anticholinergic use, number of medications, and average blood pressure measurements. Result: The table describes characteristics of participants. Compared to the control group, Ang II-stimulating antihypertensives users had positive β values for memory (β=0.13, SE=0.13), language (β=0.14, SE=0.14), executive functioning (β=0.02, SE=0.14), processing speed (β=0.04, SE=0.16), and global cognitive score (β=0.11, SE=0.10) (see Figure). In contrast, Ang II-inhibiting antihypertensives users had negative β values for memory (β=-0.01, SE=0.09), language (β=-0.09, SE=0.10),Item Investigating the Best Practices for Engagement in Remote Participatory Design: Mixed Methods Analysis of 4 Remote Studies With Family Caregivers(2024) Jolliff, Anna; Holden, Richard J.; Valdez, Rupa; Coller, Ryan J.; Patel, Himalaya; Zuraw, Matthew; Linden, Anna; Ganci, Aaron; Elliott, Christian; Werner, Nicole E.Background: Digital health interventions are a promising method for delivering timely support to underresourced family caregivers. The uptake of digital health interventions among caregivers may be improved by engaging caregivers in participatory design (PD). In recent years, there has been a shift toward conducting PD remotely, which may enable participation by previously hard-to-reach groups. However, little is known regarding how best to facilitate engagement in remote PD among family caregivers. Objective: This study aims to (1) understand the context, quality, and outcomes of family caregivers’ engagement experiences in remote PD and (2) learn which aspects of the observed PD approach facilitated engagement or need to be improved. Methods: We analyzed qualitative and quantitative data from evaluation and reflection surveys and interviews completed by research and community partners (family caregivers) across 4 remote PD studies. Studies focused on building digital health interventions for family caregivers. For each study, community partners met with research partners for 4 to 5 design sessions across 6 months. After each session, partners completed an evaluation survey. In 1 of the 4 studies, research and community partners completed a reflection survey and interview. Descriptive statistics were used to summarize quantitative evaluation and reflection survey data, while reflexive thematic analysis was used to understand qualitative data. Results: In 62.9% (83/132) of evaluations across projects 1-3, participants described the session as “very effective.” In 74% (28/38) of evaluations for project 4, participants described feeling “extremely satisfied” with the session. Qualitative data relating to the engagement context identified that the identities of partners, the technological context of remote PD, and partners’ understanding of the project and their role all influenced engagement. Within the domain of engagement quality, relationship-building and co-learning; satisfaction with prework, design activities, time allotted, and the final prototype; and inclusivity and the distribution of influence contributed to partners’ experience of engagement. Outcomes of engagement included partners feeling an ongoing interest in the project after its conclusion, gratitude for participation, and a sense of meaning and self-esteem. Conclusions: These results indicate high satisfaction with remote PD processes and few losses specific to remote PD. The results also demonstrate specific ways in which processes can be changed to improve partner engagement and outcomes. Community partners should be involved from study inception in defining the problem to be solved, the approach used, and their roles within the project. Throughout the design process, online tools may be used to check partners’ satisfaction with design processes and perceptions of inclusivity and power-sharing. Emphasis should be placed on increasing the psychosocial benefits of engagement (eg, sense of community and purpose) and increasing opportunities to participate in disseminating findings and in future studies.Item Which activity tracker features matter to you? Older Black participants living with memory challenges and care partner preferences(Oxford University Press, 2026) Lassell, Rebecca K. F.; Carey, Christopher J.; Sample, Lola; Elftmann, Hanley; Gitlin, Laura N.; Harezlak, Jaroslaw; Holden, Richard J.; Pearson, Amber L.; Jordan, Evan; Keith, NiCole; Unroe, KathleenThere is a need to understand Black older adults’ perceptions and attitudes about commercial activity trackers to measure and monitor outcomes in clinical trials. We sought to identify the preferred activity tracker features of Black older adults living with memory challenges or dementia and their care partners. Utilizing a mixed-methods convergent parallel design, 9 participants were recruited from Eskenazi Health in Indianapolis, Indiana. Data were collected through 2 focus groups with participants (n = 3) and care partners (n = 4), and a group interview with 1 participant and 2 care partners. The focus groups were guided by semi-structured interviews, whereas participants interacted with 4 common consumer activity tracking devices (Fitbit Inspire 3, Apple Watch SE, Polar Watch, Oura Ring Heritage). Audio recordings were analyzed using the Rapid Identification of Themes from Audio Recordings method. Participants ranked each device based on comfort, convenience, and features (eg, tracked outcomes of activity, distance/GPS, and respiratory rate). Device rankings were summarized with descriptive statistics. Participants with memory challenges rated Apple Watch SE highest, with mean scores in comfort (4.3), convenience (3.3), and features (4.3). Care partners rated Fitbit Inspire 3 highest in comfort and Apple Watch SE for convenience and features. Qualitative findings highlighted physical attributes and comfort (large screen size), convenience (viewing progress), and features (having an emergency button and GPS). Findings can guide the selection of activity trackers in future research for this population and may increase wear time and adherence in clinical trials.Item Co-creating and Mapping an Exclusive Breastfeeding Framework among Latino Populations in the United States: An Integrated Framework Adaptation Process and Scoping Review(Elsevier, 2025) Pena, Armando; Barnsfather, Zoe; Miller, Alison M; Alvarado, Ashley; Reinoso, Deanna; Klitzman, Melissa; Neeley, Ann Marie; Linares, Ana Maria; Harkov, Katherine; Phillips, Tess; Santiago, Amanda; Spencer, Christine; Betti, Fernanda; Patterson, Julie A; Casanova, Ines; Baquerizo, Karla; Snow, Kiran; Mays, Angelica Maria; Lopez, Shannon; Leeper, Courtnie; Douglass, Rose; Lynch, Emily; Kolb, Freedom; Cleary, Erin M; Crites, Kundai; Minix, Amy; Holden, Richard JIncreasing exclusive breastfeeding among Latino populations has the potential to reduce health disparities. There is a need for a multilevel and multidomain framework of exclusive breastfeeding determinants. This study aimed to co-create an exclusive breastfeeding determinants framework among Latino populations and map this framework using the current literature. Our community coalition convened in working groups to adapt a multilevel and multidomain determinants framework with 20 cells (4 levels × 5 domains) for exclusive breastfeeding among Latino populations. We documented all referenced determinants in working groups, and 2 independent raters deductively and inductively analyzed these specific determinants into themes by cell (level domain). An integrated scoping review mapped the determinants addressed in the literature of exclusive breastfeeding interventions among Latinos in the United States onto the framework cells. Two independent raters transcribed intervention descriptions verbatim and deductively analyzed the text using our list of determinants as the codebook. Inductive analysis allowed for emerging determinants. We mapped determinants that were addressed by theme. A total of 111 specific determinants were referenced in working groups that were categorized into 53 determinant themes. Most studies addressed Individual-level determinants at each domain (n = 11–16 studies) except for Built Environment (n = 3). At the Interpersonal level, Behavior (n = 11) and Health Care System (n = 16) domains were predominantly addressed. At the Community level, Built Environment (n = 14) and Health Care System (n = 15) domains were addressed. Most studies at the Societal level addressed the Health Care System domain but none addressed Biological, Behavior, or Built Environment domains. Extension of care, culturally relevant care, knowledge and skills, mother–infant bonding, and practitioner–dyad relationship were referenced the most of all 56 themes (n ≥ 13 each). Increasing exclusive breastfeeding among Latinos is a multifaceted challenge. Innovative areas for future work include Biological and Sociocultural domains beyond the Individual level as well as most domains at the Societal level.Item Bosses Are Human (Too): Agile Behavioral Nudges for Managing Up(Wiley, 2026) Holden, Richard J.; Azar, Jose M.; Boustani, MalazArticle regarding managing up in leadership positionsItem OTC SENIOR STATION: CONSUMER-FACING TECHNOLOGY TO PROMOTE MEDICATION SAFETY(Oxford University Press, 2023) Hill, Jordan; Ganci, Aaron; Patel, Himalaya; Campbell, Noll; Chui, Michelle; Abebe, Ephrem; Holden, RichardOver-the-counter (OTC) medications with anticholinergic effects (e.g. doxylamine, diphenhydramine) are widely used by older adults, despite their association with an increased risk of Alzheimer’s disease and related dementias (ADRD). Authoritative bodies, such as the American Geriatrics Society and National Academy of Medicine, recommend discouraging the use of both prescription and OTC anticholinergics. However, most interventions previously developed and tested have targeted only prescription anticholinergics despite the use rate of OTC anticholinergics being higher in older adult populations. Consumer-facing technology may be ideal for addressing OTC anticholinergic use as it is cost effective, scalable, and can address the constraints of relying on busy pharmacists to intervene during older adult OTC medication purchases; this has become especially relevant as pharmacies face staffing shortages, increasing pharmacist workload and requiring pharmacies adjust their hours of operation. Our interdisciplinary team of pharmacists, engineers, and designers engaged both older adults and pharmacy staff in the co-design of “OTC Senior Station”: a user-centered, consumer-facing kiosk to be placed in community pharmacies to promote reduced anticholinergic use by older adults. Kiosk users are prompted to input brief information, which is used to present safer alternatives to OTC anticholinergics (e.g., for insomnia management). This poster will present OTC Senior Station--what we believe to be the first consumer-facing technology to target OTC anticholinergic use—the participatory design methods used to create it, and the results of studies to assess its usability with older adults.Item FoodRx: A mixed–methods approach to improving food insecurity in cancer care(Wiley, 2025) Yang, Jocelyn; Rivera, Rebecca; Rockwell, Rebecca; Holden, Richard; Clark, Daniel; Schleyer, TitusBackground: One in four cancer survivors report food insecurity. Cancer's devastating financial hardship is a major social and healthcare concern due to the importance of nutrition in cancer care. Objective: We aimed to understand the barriers to and facilitators for addressing food insecurity in the cancer care workflow in the academic health center of the United States' largest allopathic medical school and National Cancer Institute–designated comprehensive cancer center. Methods: Electronic health records (EHR) were extracted from the Indiana University Health Data Warehouse for patients of all ages with a cancer diagnosis between 01/01/2021 and 05/15/2024. EHR data included patient demographic and clinical characteristics. Univariable analyses of dietitian and social work referrals utilized binary logistic regression models. Qualitative data collection is underway via focus groups with oncology clinicians through September 30, 2024. A systems engineering tool is used to characterize the clinical work system factors for addressing food insecurity in cancer care: people, environments, tasks, tools, and their interactions. Rapid qualitative analysis is applied to iteratively collect and analyze data until saturation using content and thematic analysis guided by the Sort and Sift Think and Shift approach. Results: Food insecure cancer survivors (n = 984) were 49% and 81% more likely to be referred to a dietitian [OR 1.49; 95% CI (0.83, 2.69); p = 0.040] or a social worker [OR 1.81; 95% CI (1.08, 3.04); p = 0.004], respectively, compared to food secure peers (n = 18,260). Quantitative results informed semi–structured focus group and interview questions. Two focus groups have been conducted with n = 4 physicians and n = 3 advanced practice providers in oncology. Emerging themes include long travel distances for patients and not knowing what resources are available where patients live. Conclusion: These comprehensive findings highlight gaps and opportunities from a healthcare workflow lens for informing the co–design, implementation, and evaluation of food insecurity interventions embedded in cancer care.Item Physical and Mental Health Differences Reported by Three Age Groups of Older Adults With Diabetes(Sage, 2022) Lee, Jungjoo; Kim, Junhyung; Holden, RichardMost studies have classified older adults with diabetes into one group despite substantial variation in health status across different stages of late adulthood. In this study, we examined difference in self-reported physical and mental health among three age groups of older adults with diabetes. Using data from the 2016 National Social Life, Health and Aging Project, Wave 3, we classified 424 individuals diagnosed with diabetes into three age groups, young-old (YO): 50–64 years; middle-old (MO): 65–74; and oldest old (OO): 75+ years. A one-way multivariate analysis of covariance was used to assess group differences, followed by univariate analyses. The results indicate that the YO group reported significantly lower physical health and higher depression than the MO group and higher levels of loneliness than the MO and OO groups. These findings indicate that physical and mental health may differ among different age groups of older adults with diabetes and suggest that the YO might be more vulnerable to diminished physical and mental health than the other age groups.Item Older Adult Misuse of Over-the-Counter Medications: Effectiveness of a Novel Pharmacy-Based Intervention to Improve Patient Safety(Wolters Kluwer Health, Inc., 2025) Gilson, Aaron M.; Chloadek, Jason S.; Stone, Jamie A.; Watterson, Taylor L.; Lehnbom, Elin C.; Hoffins, Emily L.; Berbakov, Maria E.; Moon, Jukrin; Jacobson, Nora A.; Holden, Richard J.; Gangon, Ronald E.; Walbrandt Pigarelli, Denise L.; Welch, Lauren L.; Portillo, Edward C.; Shiyanbola, Olayinka O.; Gollhardt, Joel; Walker, Kenneth; Chui, Michelle A.Older adults’ (ages ≥65) inappropriate over-the-counter medications (OTC) use is prevalent, comprising Drug-Age, Drug-Drug, Drug-Disease, and Drug-Label types. Given that pharmacies sell many OTCs, structurally redesigning pharmacy aisles for improving patient safety (Senior Safe) was conceived to mitigate older adult OTC misuse, using Stop Signs and Behind-the-Counter Signs for high-risk OTCs. This study determined whether Senior Safe reduced high-risk OTCs misuse, while secondarily evaluating misuse changes for all OTCs. A randomized controlled trial design matched and randomly allocated 20 health system community pharmacies to control or intervention groups. All 288 study participants completed an OTC choice task in which they chose a hypothetical symptom scenario (pain, sleep, cough/cold/allergy), selected an OTC, and described how they would use it at symptom onset and if symptoms persisted or worsened. Reported OTC use was evaluated for each misuse type. Intervention and control sites were compared for each misuse type using multivariate modeling. For high-risk OTCs, Drug-Age and Drug-Drug misuse were more likely in control sites (OR = 2.752, P = 0.004; OR = 6.199, P = 0.003, respectively), whereas Drug-Disease and Drug-Label misuse had too few occurrences in intervention sites for statistical comparisons. For all OTCs, only Drug-Age misuse was more likely for control sites (OR = 5.120, P = 0.001). Adults aged 85+ years had the greatest likelihood of all misuse types. Results demonstrated that older adults frequently reported multiple misuse types, highlighting safety concerns. Senior Safe reduced high-risk OTC misuse, especially for older adults younger than 85 years. Cumulatively, these findings provide insights into practice recommendations supported through regulatory guidance.