Do English healthcare settings use 'Choice Architecture' principles in promoting healthy lifestyles for people with psoriasis? An observational study

How do opt-in versus opt-out settings nudge patients toward electronic health record adoption? An exploratory study of facilitators and barriers in Austria and France

BACKGROUND

Electronic health records (EHR) are becoming an integral part of the health system in many developed countries, though implementations and settings vary across countries. Some countries have adopted an opt-out policy, in which patients are enrolled in the EHR system following a default nudge, while others have applied an opt-in policy, where patients have to take action to opt into the system. While opt-in systems may exhibit lower levels of active user requests for access, this contrasts with opt-out systems where a notable percentage of users may passively retain access. Thus, our research endeavor aims to explore facilitators and barriers that contribute to explaining EHR usage (i.e., actively accessing the EHR system) in two countries with either an opt-in or opt-out setting, exemplified by France and Austria.

METHODS

A qualitative exploratory approach using a semi-structured interview guideline was undertaken in both countries: 1) In Austria, with four homogenously composed group discussions, and 2) in France, with 19 single patient interviews. The data were collected from October 2020 to January 2021.

RESULTS

Influencing factors were categorized into twelve subcategories. Patients have similar experiences in both countries with regard to all facilitating categories, for instance, the role of health providers, awareness of EHR and social norms. However, we highlighted important differences between the two systems regarding hurdles impeding EHR usage, namely, a lack of communication as well as transparency or information security about EHR.

CONCLUSION

Implementing additional safeguards to enhance privacy protection and supporting patients to improve their digital ability may help to diminish the perception of EHR-induced barriers and improve patients' health and commitment in the long term.

PRACTICAL IMPLICATIONS

Understanding the differences and similarities will help to develop practical implications to tackle the problem of low EHR usage rates in the long run. This problem is prevalent in countries with both types of EHR default settings.

Non-pharmacological interventions for patients with psoriasis: a scoping review

OBJECTIVES

Healthcare ultimately aims to eradicate diseases and restore normality to people's lives. However, until this is achieved for every person, there is a need to support and assist patients with psoriasis using non-pharmacological interventions. These 'adjuvant' approaches have received little attention, whereas dermatologists and researchers strive for better pharmacological therapy. Here, we aimed to perform a scoping review to identify and catalogue non-pharmacological interventions for patients with psoriasis.

DESIGN

A scoping review.

SETTING

All healthcare settings.

SEARCH STRATEGY

EMBASE, PubMed, CINAHL, PsycINFO and Scopus databases were searched from their inception to June 2022. Irrespective of the study type, the studies included non-pharmacological interventions for patients with psoriasis. This theme was extracted from the included articles. Two reviewers independently screened and analysed the data.

RESULTS

From 1322 initial records, 71 studies were identified and analysed. Non-pharmacological interventions for patients with psoriasis include two levels: organisational and individual. The organisational non-pharmacological interventions included the nationwide healthcare model (PsPSP, ProvenCare, German PsoHealth and Psoriasis Network, IMPROVE model and PsoWell clinic), innovative teledermatology models (mHealth app, electronic Targeted Intervention for Psoriasis study and therapist-guided internet-based cognitive and behavioural treatments) and multidisciplinary interventions. The individual non-pharmacological interventions included educational interventions (therapeutic patient education, psychoeducational intervention and self-management education), psychosocial interventions (cognitive and behavioural treatments, self-help and peer-to-peer support programmes) and others (happify and motivational interviewing-based training).

CONCLUSIONS

Based on previous literature, a nationwide healthcare model protocol was constructed for patients with psoriasis. This provided the direction for developing a new psoriasis healthcare model and a basis for summarising the non-pharmacological interventions for patients with psoriasis, which helps them adjust to changes in the skin disease.

Do health service waiting areas contribute to the health literacy of consumers? A scoping review

Health service waiting areas commonly provide health information, resources and supports for consumers; however, the effect on health literacy and related outcomes remains unclear. This scoping review of the literature aimed to explore the use of waiting areas as a place to contribute to the health literacy and related outcomes of consumers attending health appointments. Articles were included if they focussed on health literacy or health literacy responsiveness (concept) in outpatient or primary care health service waiting areas (context) for adult consumers (population) and were published after 2010. Ten bibliographic databases, one full-text archive, dissertation repositories and web sources were searched. The search yielded 5095 records. After duplicate removal, 3942 title/abstract records were screened and 360 full-text records assessed. Data were charted into a standardized data extraction tool. A total of 116 unique articles (published empirical and grey literature) were included. Most articles were set in primary and community care (49%) waiting areas. A diverse range of health topics and resource types were available, but results demonstrated they were not always used by consumers. Outcomes measured in intervention studies were health knowledge, intentions and other psychological factors, self-reported and observed behaviours, clinical outcomes and health service utilization. Intervention studies overall demonstrated positive trends in health literacy-related outcomes, although the benefit declined after 3-6 months. Research on using waiting areas for health literacy purposes is increasing globally. Future research investigating the needs of consumers to inform optimal intervention design is needed.

Perceptions of receiving behaviour change interventions from GPs during routine consultations: A qualitative study

General Practitioners (GPs) are expected to provide patients with health behaviour change interventions, yet little is known about the views of patients themselves. We aimed to understand recent patients': (1) general expectations about GPs delivering health behaviour change interventions during routine consultations (including perceptions of appropriateness and helpfulness for receiving interventions), (2) perceptions of responsibility for GPs to talk about health behaviours, and (3) experiences of receiving behaviour change interventions. Twenty-four semi-structured interviews were conducted with people who had recently attended a routine GP consultation. Data were analysed thematically. Three major themes were identified: (1) acceptability of discussions about behaviour change, (2) establishing clinician-patient rapport, and (3) healthcare professionals as a credible source and well placed to offer behaviour change interventions. Most patients were positive about, and were willing to accept behaviour change interventions from their GP during a routine consultation. Although behaviour change was perceived as a sensitive topic for patients, the doctor-patient relationship was perceived to provide an effective platform to discuss behaviour change, with the GP perceived as an appropriate and important healthcare professional from whom to receive advice. Contrary to the views of GPs, behaviour change interventions were perceived by patients as appropriate and helpful during routine medical consultations, particularly where behaviour change could have a positive effect on long-term condition management. Behaviour change interventions delivered by GPs during routine consultations could be used effectively in time-restricted consultations.

Does message framing affect changes in behavioural intentions in people with psoriasis? A randomized exploratory study examining health risk communication

Message framing is important in health communication research to encourage behaviour change. Psoriasis, a long-term inflammatory skin condition, has additional comorbidities including high levels of anxiety and cardiovascular disease (CVD), making message framing particularly important. This experimental study aimed to: (1) identify whether health messages about psoriasis presented as either gain- or loss-framed were more effective for prompting changes in behavioural intentions (BI), (2) examine whether BI were driven by a desire to improve psoriasis or reduce CVD risk; (3) examine emotional reactions to message frame; and (4) examine predictors of BI. A two by two experiment examined the effects on BI of message frame (loss vs. gain) and message focus (psoriasis symptom reduction vs. CVD risk reduction). Participants with psoriasis (n = 217) were randomly allocated to one of four evidence-based health messages related to either smoking, alcohol, diet or physical activity, using an online questionnaire. BI was the primary outcome. Analysis of variance tests and hierarchical multiple regression analyses were conducted. A significant frame by focus interaction was found for BI to reduce alcohol intake (p = .023); loss-framed messages were more effective for CVD risk reduction information, whilst gain-framed messages were more effective for psoriasis symptom reduction information. Message framing effects were not found for BI for increased physical activity and improving diet. High CVD risk was a significant predictor  of increased BI for both alcohol reduction (β = .290, p < .01) and increased physical activity (β = -.231, p < .001). Message framing may be an important factor to consider depending on the health benefit emphasised (disease symptom reduction or CVD risk reduction) and patient-stated priorities. Condition-specific health messages in psoriasis populations may increase the likelihood of message effectiveness for alcohol reduction.

'New to me': changing patient understanding of psoriasis and identifying mechanisms of change. The Pso Well® patient materials mixed-methods feasibility study

Background

Psoriasis is an inflammatory long‐term condition involving comorbidities, unhealthy lifestyle and significant life impact. Patients’ understanding of psoriasis is limited and support lacking. The Common‐Sense Model of Self‐Regulation of Health and Illness emphasizes the role of illness and treatment beliefs on coping and self‐management. New ‘Pso Well^®’ patient materials informed by the model, addressed psoriasis as a long‐term condition, medication management and lifestyle behaviours.

Objectives

To investigate whether Pso Well^® materials (i) broaden understanding of psoriasis without increasing anxiety; (ii) are acceptable; and (iii) comprise features that appear to effect change.

Methods

The Revised Illness Perceptions Questionnaire (IPQ‐R modified) and the Hospital Anxiety and Depression Scale (HADS) were administered in patients before and after intervention. Numerical rating scales assessed perceptions of change in understanding and anxiety resulting from engagement with the materials. Qualitative interviews explored acceptability and perceived ‘active ingredients’.

Results

Fifty‐five patients completed pre‐ and postintervention questionnaires (56% female; median age 59 years). Postintervention, a large effect size was indicated in two IPQ‐R domains – illness coherence [t(55) = −3·48, P = 0·001 (two‐tailed), η² = 0·19] and personal control [t(55) = −2·98, P = 0·004 (two‐tailed), η² = 0·14] – and a medium effect in one, treatment control [t(55) = −2·08, P = 0·042 (two‐tailed), η² = 0·08]. HADS scores did not change. For numerical rating scales, 80% of participants reported increased understanding of psoriasis and none reported increased anxiety. Interviews with 19 patients indicated the materials were acceptable and usable. Factors reported to broaden understanding and promote engagement with self‐management included linking of related disease aspects, personally relevant content and high‐quality design.

Conclusions

High‐quality, theory‐based psoriasis materials are acceptable to patients and can improve understanding and sense of control without increasing anxiety.

What's already known about this topic?

Psoriasis is associated with comorbidities, unhealthy lifestyle and significant life impact.

Patients’ understanding of psoriasis is limited, self‐management support is lacking and disengagement from healthcare services is common.

What does this study add?

The new, theory‐informed Pso Well^® patient materials address psoriasis as a long‐term condition; medications management and lifestyle behaviour.

The Pso Well^® patient materials can increase understanding of psoriasis, promote feelings of self‐worth and encourage a desire to engage in self‐management and behaviour change, without increasing anxiety or depression.

What are the clinical implications of this work?

The Pso Well^® patient materials could support clinical consultations by helping patients recognize the remitting–relapsing nature of psoriasis.

This will help to improve understanding of the disease, as well as providing a clearer rationale for treatment adherence and lifestyle behaviour change.

Linked Comment: Prinsen. Br J Dermatol 2017; 177:616–617