Developing patient-centred information for back pain sufferers

Information needs, expectations, and treatment preference of patients considering spinal surgery: A case-control survey

STUDY DESIGN

Case-control survey.

OBJECTIVES

To explore intrapersonal factors associated with decision of patients with degenerative back pain for surgery.

METHODS

From September 2018 to May 2019 patients were invited to complete a questionnaire. Patients who decided on (case) and declined surgery (control) were later confirmed from medical records.

RESULTS

Seventy-five patients were recruited. Male patients (75.0%, p = 0.019), those who were married (78.7%, p = 0.0045), and had spousal care-givers (89.2%, p < 0.0001) were more likely to decide for surgery. All patients who decided on surgery expressed need for information on "the severity of their spine conditions" (p = 0.039). Those who decided on surgery did not have as the high expectation on "to sleep more comfortably" as those who declined (4.71 vs. 4.91, p = 0.022). The predictive factors for surgery decision by logistic regression analysis were: male gender (OR = 3.23, 95% CI: 1.19-8.77, p = 0.021); married (OR = 5.231, 95% CI: 1.87-14.61, p = 0.002); with available spousal care-giver (OR = 1.85, 95% CI: 0.198-3.89, p = 0.031); and those who preferred to treat/cure the spine disorder by pharmacological treatment (OR = 2.77, 95% CI: 1.02-7.50, p = 0.045).

CONCLUSION

Patients who decided on surgery were likely to indicate need of medical information related to their condition. Patients were in hope of better relief of physical symptoms, especially related to sleep comfort. Patients would escalate their treatment from conservative to surgery when conservative treatments were no longer effective.

The information needs of internet users and their requirements for online health information-A scoping review of qualitative and quantitative studies

OBJECTIVE

This scoping review has been conducted to summarise the information needs of internet users and their requirements for online health information.

METHODS

We searched MEDLINE, Web of Science and Scopus up to July 2019. Qualitative, quantitative and mixed-method studies were included and a thematic synthesis with category formation and exact description of the items was carried out.

RESULTS

118 studies were included. To address all users' needs mentioned in the included studies, we grouped them into nine main categories: authority, comprehension, currency, evidence-based information, exchange with others, independence, purpose, services, user experience. The evaluation showed that website users wanted qualifications of authors to be cited. Users preferred health information that offered interactive elements and resources for relatives, whilst also providing an opportunity for online contact with others. The ease with which information was accessed and the intelligibility of texts were regarded as being very important to users.

CONCLUSION

Given the rapid evolvement and changes of online health information, it is crucial to provide up to date insights and a comprehensive overview of the range of criteria.

PRACTICE IMPLICATIONS

With the results obtained through this scoping review, the creators of online health information could be assisted in providing user-specific resources.

Patient Information Leaflets for Lumbar Spine Surgery: A Missed Opportunity

BACKGROUND

High-quality patient information is recommended to help reduce procedure-related anxiety and encourage patients to become active participants in their recovery. The objective of this study was to analyze the quality of patient information leaflets (PILs) given to National Health Service (NHS) patients ahead of lumbar spine surgery.

METHODS

The DISCERN tool was used to evaluate the quality of PILs, sourced from NHS websites.

RESULTS

Thirty-two PILs on lumbar surgery were included. Two (6%) leaflets were considered poor, 13 (41%) were marked as fair, 14 (44%) were of good quality, and 3 (9%) were scored as excellent. The total mean score was 55 (30-74), which corresponds to good quality. The lowest scoring questions were sources of information (Q4), balanced/unbiased content (Q6), and explanation of no treatment (Q12).

CONCLUSIONS

There is considerable variation in the quality of PILs provided ahead of lumbar spine surgery. The scope for improvement is clear, and as the move toward patient-centered, evidence-based care continues, it is important that hospital resources provide recommendations based upon evidence of clinical effectiveness.

Development of a checklist for people communicating evidence-based information about the effects of healthcare interventions: a mixed methods study

OBJECTIVES

To make informed decisions about healthcare, patients and the public, health professionals and policymakers need information about the effects of interventions. People need information that is based on the best available evidence; that is presented in a complete and unbiased way; and that is relevant, trustworthy and easy to use and to understand. The aim of this paper is to provide guidance and a checklist to those producing and communicating evidence-based information about the effects of interventions intended to inform decisions about healthcare.

DESIGN

To inform the development of this checklist, we identified research relevant to communicating evidence-based information about the effects of interventions. We used an iterative, informal consensus process to synthesise our recommendations. We began by discussing and agreeing on some initial recommendations, based on our own experience and research over the past 20-30 years. Subsequent revisions were informed by the literature we examined and feedback. We also compared our recommendations to those made by others. We sought structured feedback from people with relevant expertise, including people who prepare and use information about the effects of interventions for the public, health professionals or policymakers.

RESULTS

We produced a checklist with 10 recommendations. Three recommendations focus on making it easy to quickly determine the relevance of the information and find the key messages. Five recommendations are about helping the reader understand the size of effects and how sure we are about those estimates. Two recommendations are about helping the reader put information about intervention effects in context and understand if and why the information is trustworthy.

CONCLUSIONS

These 10 recommendations summarise lessons we have learnt developing and evaluating ways of helping people to make well-informed decisions by making research evidence more understandable and useful for them. We welcome feedback for how to improve our advice.

An Internet-Based Consumer Resource for People with Low Back Pain (MyBackPain): Development and Evaluation

People increasingly use the internet to obtain information about health complaints, including low back pain (LBP). LBP is the leading cause of disability internationally, and outcomes are worsening. There is an urgent need for resources that aid improvement of outcomes. There have been calls to engage consumers in the development of resources, but this has rarely been implemented. MyBackPain is a website that was developed with extensive involvement of consumers to ensure that the resource meets their needs for content and presentation. This paper aimed to describe the multistep process undertaken to develop the MyBackPain website and provide an extensive evaluation of its impact. Development of MyBackPain involved 10 steps, many of which have been published in the academic literature. These steps included consultation regarding consumer needs, evaluation of existing internet resources, identification of key messages to be reinforced, identification of frequently asked questions, consensus for content, content development (including development of algorithms to guide tailoring of the user experience), development of consumer-focused evidence-based treatment summaries, development of descriptions of health care providers, and testing. Evaluation included qualitative examination of people's interactions with the website and its effects on their daily lives and an ongoing randomized controlled trial of impact of use of the site on people's LBP-related health literacy, clinical outcomes, and treatment choices. It is hoped that the website can aid in the reduction of the massive burden of LBP and provide a template for the development of resources for other conditions.

MyBackPain-evaluation of an innovative consumer-focused website for low back pain: study protocol for a randomised controlled trial

INTRODUCTION

Despite the prevalence of low back pain (LBP) worldwide, many people with the condition do not receive evidence-based care or achieve the best possible outcomes. There is a gap in the dissemination of evidence-based information across the globe. The advent of the internet has changed the way people obtain health information. As such, trustworthy, tailored and validated LBP resources may help bridge the gap. This study aims to measure the effectiveness of a new website (MyBackPain) in improving spinal health literacy, treatment preferences and clinical outcomes for people with LBP, in comparison with other online resources.

METHODS AND ANALYSIS

This online, pragmatic, randomised controlled trial will comprise 440 people with non-specific LBP of any duration. In addition to access to publicly available online information (control group), the intervention group will be given access to the MyBackPain.org.au website. Participants and research staff, including the biostatistician, will be blinded to treatment allocation. Data will be collected at baseline, 1, 3 (primary end-point), 6 and 12 months via online surveys and questionnaires. The primary outcome is spinal health literacy. Secondary outcomes include quality of treatment preferences (stated and observed) and LBP clinical outcomes (pain, disability and quality of life). Analyses will be by intention-to-treat and include outcome data on all randomised participants. Descriptive statistics will be presented for demographic and clinical characteristics.

ETHICS AND DISSEMINATION

This trial has been prospectively registered with the Australian New Zealand Clinical Trials Registry and has ethical approval from the University of Queensland Human Research Ethics Committee (2017000995). Trial outcomes will be shared via national and international conference presentations and peer-reviewed journal publications.

TRIAL REGISTRATION NUMBER

ACTRN12617001292369; Pre-results.

Who can you trust? A review of free online sources of "trustworthy" information about treatment effects for patients and the public

BACKGROUND

Information about effects of treatments based on unsystematic reviews of research evidence may be misleading. However, finding trustworthy information about the effects of treatments based on systematic reviews, which is accessible to patients and the public can be difficult. The objectives of this study were to identify and evaluate free sources of health information for patients and the public that provide information about effects of treatments based on systematic reviews.

METHODS

We reviewed websites that we and our colleagues knew of, searched for government sponsored health information websites, and searched for online sources of health information that provide evidence-based information. To be included in our review, a website had to be available in English, freely accessible, and intended for patients and the public. In addition, it had to have a broad scope, not limited to specific conditions or types of treatments. It had to include a description of how the information is prepared and the description had to include a statement about using systematic reviews. We compared the included websites by searching for information about the effects of eight treatments.

RESULTS

Three websites met our inclusion criteria: Cochrane Evidence, Informed Health, and PubMed Health. The first two websites produce content, whereas PubMed Health aggregated content. A fourth website that met our inclusion criteria, CureFacts, was under development. Cochrane Evidence provides plain language summaries of Cochrane Reviews (i.e. summaries that are intended for patients and the public). They are translated to several other languages. No information besides treatment effects is provided. Informed Health provides information about treatment effects together with other information for a wide range of topics. PubMed Health was discontinued in October 2018. It included a large number of systematic reviews of treatment effects with plain language summaries for Cochrane Reviews and some other reviews. None of the three websites included links to ongoing trials, and information about treatment effects was not reported consistently on any of the websites.

CONCLUSION

It is possible for patients and the public to access trustworthy information about the effects of treatments using the two of the websites included in this review.

Information and communication technologies and access to maternal and child health information: Implications for sustainable development

Maternal and child mortality pose a great challenge in developing nations notwithstanding the robust initiatives instituted at both the global and national levels to ameliorate it. This study is aimed at ascertaining women’s perception of the impact of information and communication technologies on access to maternal and child health information and its implication on sustainable development. The descriptive research design was adopted for the study. Purposive sampling technique was used in selecting University of Lagos Teaching Hospital and subsequently, the three clinics (Obstetrics and Gynaecology, Paediatrics Outpatient, and Antenatal clinics) where the needed groups could be seen. Questionnaire was the instrument used for data collection while SPSS statistical package was used for data analysis. The study revealed that the women perceive information and communication technologies to have a positive impact on their access to maternal and child health information while the key technological facilities used by the respondents in accessing maternal and child health information were mobile phones and social media tools such as Facebook, YouTube, blogs and Twitter. It was also found that irregular power supply, poor Internet access, and ignorance of the media that transmit maternal and child health information were the key factors that militate against effective access to maternal and child health information using communication technologies. The implication of this result on sustainable development is discussed and recommendations made.

Designing an online resource for people with low back pain: health-care provider perspectives

People with low back pain (LBP) seek education and information from the Internet. Existing LBP websites are often of poor quality, and disparities have been identified between patient and health-care provider evaluations of LBP websites. This study aimed to identify health-care provider perspectives on desirable content for a proposed LBP website and how this information should be presented. It complements an earlier study of LBP patient (consumer) perspectives. A qualitative descriptive study, encompassing focus groups and telephone interviews, was conducted with 42 health-care professionals practising in the LBP field. Four categories of information were identified: explaining LBP; treatment and management options; myth-busting information; and communication with health-care professionals. Presentation preferences included: use of visual media; interactivity; and useability and readability. Comparison with the consumer study identified differences with regard to: depth and breadth of diagnostic and treatment information; provision of lay person experiences and stories; and capacity for consumer-to-consumer interaction online. Views of both consumers and health-care providers are critical when developing an online LBP resource. Failure to address the needs of both stakeholder groups diminishes the potential of the resource to improve consumer outcomes.

Examining the role of patients’ experiences as a resource for choice and decision-making in health care: a creative, interdisciplinary mixed-method study in digital health

Background

Traditional health information has been based on facts and figures and not on patient experience (PEx). Websites featuring people’s accounts of their experiences of health and illness are popular as a source of information, support and much else. However, there are concerns that experiential information on the internet might have adverse effects on health.

Aims

To find out whether, when and how the NHS should incorporate PEx into online health information and elucidate the mechanisms through which PEx might influence health, develop a tool to measure the effects of online PEx, explore how PEx is used, and investigate the feasibility and acceptability of a randomised controlled trial of online PEx.

Methods

Mixed methods, including a conceptual literature review, qualitative secondary data analysis, the development of a new questionnaire, online ethnography, observational and experimental studies in an internet café environment, and finally feasibility trials to compare new websites based on PEx with those based on facts and figures.

Results

The review concluded that online PEx could affect health outcomes through seven domains (information, support, affecting relationships, providing ideas on how to use health services, influencing behaviour change, learning to tell the story and visualising illness). We developed the e-Health Impact Questionnaire, which demonstrates good psychometric properties and is suitable for use across different health groups and various styles of online information. Online ethnographic studies found three types of PEx on multiple sclerosis (MS) platforms: accounts of ‘living with MS’, self-expression and creativity, and experiences of health care and treatment. Observational and laboratory-based methods included studies of how people find and use PEx to inform health choices. We developed a three-stage model (gating, the engagement loop and outcomes) which guided the development of six prototype multimedia websites featuring either experiential information (intervention) or factual information (comparator) for three exemplar health issues. We evaluated the feasibility and acceptability of a trial of the prototype PEx websites, comparing self-report and process measures with a comparator. In the three conditions we randomised 87 (smoking cessation), 148 (asthma), and 42 (caring for someone with MS) participants. At final (2-week) follow-up, retention rates were 75%, 82% and 86%, for smoking cessation, asthma and MS carers, respectively. Usage of the allocated websites was low. The median number of logins to the websites over the 2-week period was two, two and four; the median number of page views was 10, 15 and 27.5, respectively, with a median total duration on site of 9 minutes, 17 minutes and 31.5 minutes respectively. There were no reported adverse events or harms. The qualitative interviews with 30 trial participants found that the trial methods were acceptable and not burdensome and that preferences for combinations of different types of information were both idiosyncratic and dependent on timing and need.

Limitations

This programme used a pragmatic, mixed-methods approach, in which we adapted some standard approaches (e.g. realist review). The conceptual review provided a framework for the whole programme but did not draw on a single overarching theoretically informed approach. Instead, we used relevant theory and methods from the work package leads, who represented a range of disciplines.

Conclusions

Online PEx is not seen as an alternative to facts, or to care from a health professional, but is used in addition to other sources of information, support and expression. This programme of work indicates how the sharing of online PEx may benefit people, and how this can be measured. A randomised controlled trial is feasible but an allocated ‘exposure’ to a ‘dose of information’ is far from from how online experiences are shared in everyday life. Future work evaluating online health interventions which incorporate personal experiences should aim to reflect ‘natural’ use of the internet and might include online ethnography and offline interviews. Studies might explore how and why people use online sources of experience-based health information, and the effects on subsequent behaviour and health and social outcomes in different conditions. Future intervention research evaluating online health interventions should examine and explain issues of engagement and use, and seek to identify how to increase engagement.

Trial registration

Current Controlled Trials ISRCTN29549695.

Funding

This project was funded by the Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 4, No. 17. See the NIHR Journals Library website for further project information.

Design and development of a decision support package for low back pain

OBJECTIVE

To develop a decision support package for people with low back pain (LBP) referred for physiotherapy.

METHODS

We used a program of exploratory work, including literature reviews, a Delphi study, a nominal group with physiotherapists, focus groups with patients, and secondary analysis of existing interview data.

RESULTS

We developed an information booklet describing the evidence-based treatment modalities available in a physiotherapy department. This includes data on likely benefits and risks and how the intervention is delivered. The booklet specifically addresses questions identified as important in our exploratory work. Space is provided for patients to note down the pros and cons of each treatment and what matters to them when choosing treatments. The patient is subsequently directed to a section that explores any gaps in knowledge, values, support, and choice before finally clarifying if a treatment decision is possible. At this stage they are encouraged to note down any questions or concerns they have to be discussed at the first physiotherapy consultation. This overall package includes patient material in the form of a booklet posted prior to their consultation, plus the enhanced consultation with the specially trained physiotherapist. Patients then receive their chosen treatment. In addition we developed a training package for physiotherapists that explains the content of the booklet and supports them in using informed, shared decision making in their consultation.

CONCLUSION

This package has the potential to improve effectiveness of treatments and patient satisfaction for LBP by facilitating patient choice and therefore matching patients more effectively to different treatments.

A meta-ethnography of patients’ experience of chronic non-malignant musculoskeletal pain

Background

The alleviation of pain is a key aim of health care yet pain can often remain a puzzle as it is not always explained by a specific pathology. Musculoskeletal (MSK) pain is one of the most predominant kinds of chronic pain and its prevalence is increasing. One of the aims of qualitative research in health care is to understand the experience of illness, and make sense of the complex processes involved. However, the proliferation of qualitative studies can make it difficult to use this knowledge. There has been no attempt to systematically review and integrate the findings of qualitative research in order to increase our understanding of chronic MSK pain. A synthesis of qualitative research would help us to understand what it is like to have chronic MSK pain. Specifically, it would help us understand peoples' experience of health care with the aim of improving it.

Aim

The aim of this study was to increase our understanding of patients’ experience of chronic non-malignant MSK pain; utilise existing research knowledge to improve understanding and, thus, best practice in patient care; and contribute to the development of methods for qualitative research synthesis.

Methods

We used the methods of meta-ethnography, which aim to develop concepts that help us to understand a particular experience, by synthesising research findings. We searched six electronic bibliographic databases (including MEDLINE, EMBASE and PsycINFO) and included studies up until the final search in February 2012. We also hand-searched particular journals known to report qualitative studies and searched reference lists of all relevant qualitative studies for further potential studies. We appraised each study to decide whether or not to include it. The full texts of 321 potentially relevant studies were screened, of which 77 qualitative studies that explored adults’ experience of chronic non-malignant MSK pain were included. Twenty-eight of these studies explored the experience of fibromyalgia.

Results

Our findings revealed the new concept of an adversarial struggle that explains the experience of people with chronic MSK pain. This included the struggle to affirm self and construct self over time; find an explanation for pain; negotiate the health-care system while feeling compelled to stay in it; be valued and believed; and find the right balance between sick/well and hiding/showing pain. In spite of this struggle, our model showed that some people were able to move forward alongside their pain by listening to their body rather than fighting it; letting go of the old self and finding a new self; becoming part of a community and not feeling like the only one; telling others about pain and redefining relationships; realising that pain is here to stay rather than focusing on diagnosis and cure; and becoming the expert and making choices. We offer unique methodological innovations for meta-ethnography, which allowed us to develop a conceptual model that is grounded in 77 original studies. In particular, we describe a collaborative approach to interpreting the primary studies.

Conclusion

Our model helps us to understand the experience of people with chronic MSK pain as a constant adversarial struggle. This may distinguish it from other types of pain. This study opens up possibilities for therapies that aim to help a person to move forward alongside pain. Our findings call on us to challenge some of the cultural notions about illness, in particular the expectation of achieving a diagnosis and cure. Cultural expectations are deep-rooted and can deeply affect the experience of pain. We therefore should incorporate cultural categories into our understanding of pain. Not feeling believed can have an impact on a person’s participation in everyday life. The qualitative studies in this meta-ethnography revealed that people with chronic MSK pain still do not feel believed. This has clear implications for clinical practice. Our model suggests that central to the relationship between patient and practitioner is the recognition of the patient as a person whose life has been deeply changed by pain. Listening to a person’s narratives can help us to understand the impact of pain. Our model suggests that feeling valued is not simply an adjunct to the therapy, but central to it. Further conceptual syntheses would help us make qualitative research accessible to a wider relevant audience. Further primary qualitative research focusing on reconciling acceptance with moving forward with pain might help us to further understand the experience of pain. Our study highlights the need for research to explore educational strategies aimed at improving patients’ and clinicians’ experience of care.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Information needs of people with low back pain for an online resource: a qualitative study of consumer views

PURPOSE

To identify the information needs of people with low back pain (LBP) in Australia, and the preferred methods to present this information online, as a basis for development of a patient-centred website. Available online LBP resources are limited in quality and content and it is not clear if they are meeting the needs of sufferers.

METHOD

Focus groups and semi-structured telephone interviews, involving 28 people with LBP.

RESULTS

Seven categories of information were identified: reasons for LBP, treatment and management options, self-help information, psychological and social dimensions, lay stories, quality assurance of information and roles of different healthcare professionals and locally available services. Identified preferences for online presentation included: multimodality, emphasis on visual media, readability and interactivity. Participants had been unable to obtain desired LBP information using existing resources.

CONCLUSIONS

This study provides important guidance for development of a patient-centred website grounded in the expressed needs and preferences of people with LBP. Understanding the breadth of patients' questions and concerns is essential for provision of patient-centred information and interventions. Incorporating these with the current evidence base would provide an accessible and relevant LBP patient education referral point, which is currently lacking. Implications for Rehabilitation Use of the internet to obtain health information is increasing, although there is little evidence that existing low back pain websites are meeting the expressed needs of health consumers. Our research suggests that people with low back pain have difficulty finding relevant and trustworthy information about the condition on the internet. Taking patient information needs and presentation preferences into account when designing online information material will provide people with low back pain an accessible and relevant educational resource that is currently lacking.

How do general practitioners assess low back pain Web sites?

STUDY DESIGN

Cross-sectional study of teaching general practitioners (TGPs) in the South of France.

OBJECTIVE

To determine what TGPs think about francophone Internet sites dedicated to chronic low back pain (CLBP).

SUMMARY OF BACKGROUND DATA

Patients with CLBP often seek medical information about their symptoms on the Internet. The quality of the information is usually poor. To date, the opinion of TGPs concerning the quality of CLBP Web sites remains unknown.

METHODS

We invited the 112 TGPs in the Southern region to participate. The participants used an assessment scale to evaluate 7 Web sites about CLBP in semicontrolled conditions. The quality and the importance of the different types of information (medical, nonmedical) and the design were measured on a visual analog scale (0-100) and with the point-sharing method (scale of 0-10).

RESULTS

In total, 47 TGPs responded. The median quality score for the 7 Web sites was 50 (range 30-79). The score for medical information was 52.5 (10-80), for nonmedical information it was 60.4 (20-90), and for design it was 56.4 (30-85). For nonmedical information, the median relative weight was 4, and for both medical information and design it was 3.

CONCLUSION

French TGPs believe that CLBP Web sites should focus on nonmedical, practical advice; they consider the design at least as important as the medical information. This viewpoint seems to conflict in part with patients' expectations. Good-quality and interactive Web sites could reduce this discordance. A list of approved sites should be available for general practitioners to recommend to their patients, to supplement information given during the consultation.

The Internet and the therapeutic education of patients: A systematic review of the literature

OBJECTIVES

To evaluate from a review of the literature the interest of using the Internet as a tool for the therapeutic education of patients.

METHOD

A systematic review of Pubmed was carried out using the key words: the Internet, or World Wide Web and patient education, or patient preference, or self-care. The search was restricted to articles in English published between 1990 and 2009. References to the selected articles were also analyzed. Only randomized controlled studies were retained.

RESULTS

Thirty-nine articles concerning 20 different diseases met the inclusion criteria and were analyzed. Different types of programs were proposed: informative, interactive, cognitive-behavioral and programs concerning self-management of the disease and the treatment. These different approaches were sometimes compared. The use of quality Internet sites made it possible to induce beneficial changes in lifestyle habits, and to diminish subjective and/or objective symptom severity in chronic invalidating diseases when used as a complement to traditional management. By using the Internet, patients were also able to improve decision-making skills to a degree that was at least as good as that obtained using traditional paper documents.

CONCLUSION

The Internet is an effective complementary tool that can contribute to improving therapeutic education. Nonetheless, healthcare professionals should work with patients to create quality sites that correspond more closely to their expectations. It is also essential for learned societies such as the SOFMER to invest in therapeutic education on the Internet to make quality therapeutic education modules based on factual medical data and complying with good practices available on line.

Presenting the results of Cochrane Systematic Reviews to a consumer audience: a qualitative study

OBJECTIVE

To develop and obtain feedback about a summary format for Cochrane reviews that is accessible to a consumer audience, without oversimplification or incorrect presentation.

METHODS

We developed 3 versions of a Plain Language Summary (PLS) format of a Cochrane Systematic Review. Using a semi-structured interview guide we tested these versions among 34 members of the public in Norway, Argentina, Canada, and Australia. The authors analyzed feedback, identified problems, and generated new solutions before retesting to produce a final version of a Plain Language Summary format.

RESULTS

Participants preferred results presented as words, supplemented by numbers in a table. There was a lack of understanding regarding the difference between a review and an individual study, that the effect is rarely an exact number, that evidence can be of low or high quality, and that level of quality is a separate issue from intervention effect. Participants also found it difficult to move between presentations of dichotomous and continuous outcomes. Rephrasing the introduction helped participants grasp the concept of a review. Confidence intervals were largely ignored or misunderstood. Our attempts to explain them were only partially successful. Text modifiers (''probably,'' ''may'') to convey different levels of quality were only partially understood, whereas symbols with explanations were more helpful. Participants often understood individual information elements about effect size and quality of these results, but did not always actively merge these elements.

CONCLUSION

Through testing and iteration the authors identified and addressed several problems, using explanations, rephrasing, and symbols to present scientific concepts. Other problems remain, including how best to present confidence intervals and continuous outcomes. Future research should also test information elements in combination rather than in isolation. The new Plain Language Summary format is being evaluated in a randomized controlled trial.

Divided by a lack of common language? A qualitative study exploring the use of language by health professionals treating back pain

BACKGROUND

The importance of using a common language when communicating to others about back pain is acknowledged in the literature. There are broadly three areas where difficulties in communication about back pain arise. Firstly, patients seeking information from health care professionals can experience difficulties understanding them and the medical literature; secondly, misunderstandings among health professionals concerning terminology can arise. Thirdly, the lack of standardised definitions for back pain terms can make comparison of research studies problematic. This study aims to explore the meanings and issues surrounding the use of existing medical terms for back pain from the perspective of health care professionals, lay people who have consulted health care practitioners for back pain and lay people who have not seen a health care professional regarding back pain.

METHODS

A series of focus groups were used to explore participants' understanding. A purposive sampling approach was used to achieve a sample which included general practitioners, chiropractors, osteopaths, physiotherapists, and lay people. Focus groups were facilitated by an independent professional qualitative researcher. They were audio taped and full transcripts of each focus group underwent line by line analysis, identifying concepts and coded. Constant comparison was used to allow each item to be checked or compared against the rest of the data

RESULTS

Lay participants understood the majority of the terms explored in the group differently to the health professionals. The terms, as understood by the lay participants, can be split into three broad categories. Firstly, terms which were not understood or were misconstrued and which had inadvertent negative connotations or implications. Secondly, terms which were not understood or were misconstrued, but without this leading to negative emotional responses. Thirdly, terms which were understood by lay participants as the health professionals stated they intended them to be understood.

CONCLUSION

Few of the existing medical terms were understood and accepted by lay participants in the way discussed and expected by health professionals. Misunderstandings, unintended meanings and negative emotional responses to terms were common within the study focus groups.

Qualitative evaluation of the expectations of low back pain patients with regard to information gained through semi-directed navigation on the Internet

OBJECTIVES

To make a qualitative analysis of the expectations of chronic low back pain (LBP) sufferers with regard to information gained using semi-directed Internet navigation on a sample of French LBP-related websites, and to compare the results with those of physical medicine and rehabilitation (PMR) medical doctors (MD).

MATERIAL AND METHODS

Twenty-seven hospitalised chronic LBP sufferers assessed in ecological conditions a sample of seven LBP-related websites. The sites were assessed using a simplified version of a rating scale of patients' expectations. Analysis of the relative importance of the different kinds of information delivered was done using a point sharing method.

RESULTS

In a comfortable environment, patients gave high scores for medical and extra-medical information, but low scores for website design. Overall quality assessment was similar for patients and MDs. The relative importance of medical and extra-medical information, and design quality, was similar for Chronic LBP patients and MDs.

CONCLUSION

PMR MD seemed able to correctly evaluate the overall expectations of chronic LBP patients with regard to information, but their opinions on the different qualities of websites were different. Doctors and patients should collaborate in order to create or validate high quality websites concerned with LBP.

[Does the quality of Web sites related to low back pain meet patients expectations? A systematic review]

INTRODUCTION

An assessment of 36 back-pain-related French-language Web sites, miming a patient search strategy, was previously done by use of evidence-based items. Medical information quality was poor, as already noted about English-language Web sites. Thus, patients' expectations may exceed that provided by Web sites with simple medical information.

OBJECTIVES

To study whether French-language Web sites related to low back pain meet patients expectations and to valid a rating scale including patients' expectations.

MATERIALS AND METHOD

First we reviewed French-language Web sites with new keywords and medical gateways. Second, we systematically double assessed back pain-related Web sites with a health care professional and patient-centered scale.

RESULTS

We found 30 additional Web sites not found with the previous search, 7 focusing on patient information. The rating scale is valid, and its use on a Web site sample leads to results different from those generated by an evidence-based medicine rating scale but close to a more global assessment.

DISCUSSION

French-language Web sites related to low back pain do not meet patients' expectations. Patients participation in Web site assessment or construction could help to close the gap between the expectations of people with low back pain and information delivered by doctors.

Information in mental health: qualitative study of mental health service users

BACKGROUND

Despite the widespread proliferation of consumer health information provision, little is known about information needs or information-seeking behaviour in mental health. A qualitative study was therefore undertaken to explore these issues for mental health service users.

DESIGN

In-depth interview study with purposive sample of 36 men and women with experience of mental health problems.

RESULTS

Four main themes were identified. A general lack of information was equated with a lack of respect. People undertook their own research into their condition, and recognized the challenge to professionals. Stigma was widespread and inhibited information seeking. There was a desire for an explanation of mental health problems in physical terms. People particularly valued hearing other people's experience of mental health problems, for reasons of universality, instillation of hope, and understanding and empathy.

CONCLUSIONS

The findings provide support for a more equal partnership between patients and professionals. Information providers and health practitioners should take account of the value of other people's experience as an information source.

Voice Care Knowledge Among Clinicians and People With Healthy Voices or Dysphonia

An important clinical component in the prevention and treatment of voice disorders is voice care and hygiene. Research in voice care knowledge has mainly focussed on specific groups of professional voice users with limited reporting on the tool and evidence base used. In this study, a questionnaire to measure voice care knowledge was developed based on "best evidence." The questionnaire was validated by measuring specialist voice clinicians' agreement. Preliminary data are then presented using the voice care knowledge questionnaire with 17 subjects with nonorganic dysphonia and 17 with healthy voices. There was high (89%) agreement among the clinicians. There was a highly significant difference between the dysphonic and the healthy group scores (P = 0.00005). Furthermore, the dysphonic subjects (63% agreement) presented with less voice care knowledge than the subjects with healthy voices (72% agreement). The questionnaire provides a useful and valid tool to investigate voice care knowledge. The findings have implications for clinical intervention, voice therapy, and health prevention.

Summaries of findings, descriptions of interventions, and information about adverse effects would make reviews more informative

BACKGROUND AND OBJECTIVE

To describe challenges when extracting and presenting relevant, consistent, and accessible information from systematic reviews.

MATERIALS AND METHODS

We systematically selected comparisons and outcomes from 18 Cochrane reviews, evaluated the quality of evidence for each outcome using the GRADE system, and developed standardized patient information. We evaluated the information using patient, review author, researcher, and clinician feedback.

RESULTS

Challenges included large numbers of comparisons and outcomes; missing information about treatments and adverse effects; and variations in how effect was measured and presented. By selecting comparisons and outcomes based on patient-relevance, quality, and nonredundancy, we halved the number of outcomes. We prepared information about treatments and adverse effects using other sources. We framed outcomes consistently and standardized the presentation of magnitude of effect.

CONCLUSIONS

The incorporation of summary of findings tables in reviews could address these challenges. Problems could also be reduced if review groups agreed upon standard outcomes; excluded less relevant outcomes; incorporated more information about interventions and adverse effects; and implemented clearer guidelines for the presentation of results.

Information and low back pain management: a systematic review

STUDY DESIGN

A systematic search of three electronic databases was done to identify randomized controlled trials on the effect of written or audiovisual information in low back pain.

OBJECTIVES

To determine whether information is an effective preventive action and/or therapy for low back pain and which type of information is most effective.

SUMMARY OF BACKGROUND DATA

Information is commonly used in the primary care of low back pain and mostly delivered by booklets.

METHODS

A systematic computer-aided search of the Medline, PsyclInfo, and Embase database. A rating system was used to assess the strength of the evidence, based on the methodologic quality of the randomized controlled trials, the relevance of the outcome measures, and the consistency of the results.

RESULTS

Eleven randomized controlled trials were selected, including seven trials of high methodologic quality, as well as one parallel group controlled survey and one longitudinal study. Only three of the seven high-quality studies showed favorable results for information. There is strong evidence that a booklet increases knowledge and moderate evidence that physician-related cues increase the confidence in a booklet and adherence to exercises. There is limited evidence that a biopsychosocial booklet is more efficient than a biomedical booklet to shift patient's beliefs about physical activity, pain, and consequences of low back trouble. There is strong evidence that booklets are not efficient on absenteeism and conflicting evidence that they are efficient on healthcare use. There is no evidence that e-mail discussion or video programs alone are effective to reduce low back pain, disability, and healthcare costs.

CONCLUSIONS

Information based on a biopsychosocial model is recommended in primary care to shift patient beliefs on low back pain. Nevertheless, information delivery alone is not sufficient to prevent absenteeism and reduce healthcare costs.

Lay perceptions of evidence-based information--a qualitative evaluation of a website for back pain sufferers

Background

In an evidence-informed patient choice the patient has access to research-based information about the effectiveness of health care options and is encouraged to use this information in treatment decisions. This concept has seen growing popularity in recent years. However, we still know relatively little about users' attitudes to the use of research-based information, possibly because people have been unexposed to this type of information. After developing the BackInfo website where the results of Cochrane systematic reviews on the effects of low back pain were adapted and presented to lay users we evaluated how users responded to this information.

Methods

Focus group meetings were held with 18 chronic back pain sufferers, after they had been sent a link to the website before the meetings.

Results

The focus groups suggest that the most important challenges to the use of BackInfo's research-based information are not primarily tied to the comprehension or presentation of the information, but are mainly associated with participants' attitudes towards the credibility of research and researchers, and the applicability of research results to themselves as individuals. Possible explanations for participants' lack of trust in research and their apparent difficulties in applying this research to their own situations include aspects that may be typical for the general public including the media's presentation of research, and a lack of familiarity with and feelings of distance to research evidence. Other aspects may be typical for patient groups with chronic and unclear medical conditions, such as a lack of trust in the health care establishment in general.

Conclusion

In order to enhance the credibility and applicability of research evidence, providers of research-based information could explore a number of possibilities including the use of including personal stories to illustrate the research outcomes.

Meeting the educational needs of people at risk of diabetes-related amputation: a vignette study with patients and professionals

OBJECTIVE

To investigate how patients and professionals view the role of advice in diabetes foot care, in order to inform educational practice.

DESIGN

A qualitative study based upon one-to-one interviews using a vignette technique with patients and professionals.

SETTING AND PARTICIPANTS

Interviews with 15 patients with diabetes-related foot complications attending diabetes foot clinics, and 15 health professionals across two hospital sites and two primary care trusts.

RESULTS

There were similarities between issues raised by patients and professionals, with differences in emphasis. An important factor was patient understanding and acceptance of the implications of diabetes from diagnosis. Many patients reported a lack of early understanding that may reflect inadequate provision or acceptance of advice. Development of positive relationships with health professionals was important for patients and encouraged shared understanding. Use of the vignette technique highlighted the gap between patient knowledge and action, with patients and professionals emphasizing their own responsibilities in relation to reduction of risk through education and action. Responses suggest that early positive interactions with appropriately trained professionals are needed to help patients assimilate advice into everyday routines.

CONCLUSIONS

For effective preventive care, patients need to understand how diabetes impacts on their health. Foot care education should begin early, be patient-centred and delivered with empathy by professionals whom the patients trust. The findings reflect patient and professional expectations in educational practice, and therefore have relevance for other chronic conditions for which much education and advice is related to self-care.

Illnesses you have to fight to get: facts as forces in uncertain, emergent illnesses

Chronic fatigue syndrome and multiple chemical sensitivity are two clusters of illnesses that are pervaded by medical, social and political uncertainty. This article examines how facts are talked about and experienced in struggles over these emergent, contested illnesses in the US. Based principally on a large archive of internet newsgroup postings, and also on fieldwork and on published debates, it finds that (1) sufferers describe their experiences of being denied healthcare and legitimacy through bureaucratic categories of exclusion as dependent upon their lack of biological facts; (2) institutions manage these exclusions rhetorically through exploiting the open-endedness of science to deny efficacy to new facts; (3) collective patient action responds by archiving the systematic nature of these exclusions and developing counter-tactics. The result is the maintenance of these very expensive struggles for all involved.

Visual illusions? Beliefs and behaviours of presbyope clients in optometric practice

Many clients in optometry practice have reported that they do not receive sufficient information from practitioners to make informed purchasing decisions for corrective spectacles. The aim of this study was to identify participants' attitudes and beliefs towards visiting an optician and purchasing spectacles, to compare clients' and practitioners' perceptions of purchasing decisions, and to examine clients' preferences for information and decision making. One hundred and fifty-eight presbyopes completed a questionnaire to examine attitudes and behaviours regarding visiting an optician. Thirty-four practitioners completed a questionnaire examining the purchasing recommendations they make to clients, and their perceptions of clients' purchasing decisions and information needs. Participants reported positive attitudes towards visiting an optician but required more information about their eyesight and about purchasing options. A discrepancy was found between client and practitioner perceptions of purchasing decisions and of involvement in the decision making process. Practitioners overestimated the importance of price to clients and underestimated the importance of their own recommendations on purchasing decisions. The findings of this study could be used to guide practitioners in their provision of information to clients.

Évaluation de la qualité de l'information concernant l'incontinence urinaire féminine sur le web francophone

OBJECTIVES

An increasing number of patients look for medical information on Internet, and find hardly accurate answers to their questions. The objective of this study was to assess the quality of information about urinary incontinence on free access Web-sites.

MATERIAL AND METHODS

A search using the most used search engines in French speaking countries and key words given by patients located 24 Web-sites on female urinary incontinence to review. A general description of each site was done. Then a specially designed assessment scale, whose criteria were extracted from a literature review and from practice guidelines for the management of female urinary incontinence, was used by two reviewers to assess each Web-site content.

RESULTS

Three key terms (urinary incontinence, urine loss, urine leak) were used on three search engine (Google, Yahoo, Voila) and the first 10 Web-sites located for each search were analyzed. The mean score was low (7.92 (+/-3.1) range 0-24, maximum 24) and only four sites received the "highly recommended" mention.

CONCLUSIONS

This study using medical evidence-based criteria to assess the quality content of French speaking Web-sites about female urinary incontinence highlights the poor quality of information available for Internet "typical users". Doctors should play a greater role in evaluating these sites and/or developing their quality.

Chronic back pain sufferers—striving for the sick role

The paper draws on data from a Norwegian online discussion list for back pain sufferers and from open, in-depth interviews with Norwegian back pain sufferers. In both sources, back pain sufferers express a fear that the reality of their pain is being questioned. The paper discusses how these experiences of delegitimation can be understood as a result of the back pain sufferers' inability to achieve the sick role. Many of these individuals strive and frequently fail to achieve clinical and social characteristics that make up appropriate sickness behaviour. A lack of proof that they are sick, including a lack of medical diagnosis, appropriate health care treatment, and visible disabilities, can lead to accusations, both felt and enacted, of malingering, hypochondria and/or mental illness. This in turn can lead to problems in the achievement and/or legitimisation of sick role benefits such as sick leave and medication. The sick role concept has been criticised as being inappropriate for describing the experiences of the chronically ill. The paper argues that the sick role concept still appears to reflect the expectations of health professionals, the public and the patient himself. The study does not support the view that chronic illness is related to a decreased dependency on the medical profession. Instead, doctors' inability to offer chronic back pain sufferers a clear diagnosis, explanation, and/or a course of treatment or cure appears not to liberate the patient but rather prolongs his or her dependence on the doctor.