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• Research article
• Open access
• Published: 30 January 2013

Health communication in primary health care -A case study of ICT development for health promotion

• Amina Jama Mahmud 1 ,
• Ewy Olander 1 ,
• Sara Eriksén 2 &
• Bo JA Haglund 3  

BMC Medical Informatics and Decision Making volume  13 , Article number:  17 ( 2013 ) Cite this article

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Developing Information and Communication Technology (ICT) supported health communication in PHC could contribute to increased health literacy and empowerment, which are foundations for enabling people to increase control over their health, as a way to reduce increasing lifestyle related ill health. However, to increase the likelihood of success of implementing ICT supported health communication, it is essential to conduct a detailed analysis of the setting and context prior to the intervention. The aim of this study was to gain a better understanding of health communication for health promotion in PHC with emphasis on the implications for a planned ICT supported interactive health channel.

A qualitative case study, with a multi-methods approach was applied. Field notes, document study and focus groups were used for data collection. Data was then analyzed using qualitative content analysis.

Health communication is an integral part of health promotion practice in PHC in this case study. However, there was a lack of consensus among health professionals on what a health promotion approach was, causing discrepancy in approaches and practices of health communication. Two themes emerged from the data analysis: Communicating health and environment for health communication. The themes represented individual and organizational factors that affected health communication practice in PHC and thus need to be taken into consideration in the development of the planned health channel.

Conclusions

Health communication practiced in PHC is individual based, preventive and reactive in nature, as opposed to population based, promotive and proactive in line with a health promotion approach. The most significant challenge in developing an ICT supported health communication channel for health promotion identified in this study, is profiling a health promotion approach in PHC. Addressing health promotion values and principles in the design of ICT supported health communication channel could facilitate health communication for promoting health, i.e. ‘health promoting communication’.

Peer Review reports

Primary Health Care (PHC) has been singled out as the most suitable health care setting to meet the increasing need for health promotion interventions and to curb the rising number of chronic diseases [ 1 – 3 ]. A majority of people depend on health care services for health information, yet PHC is poorly equipped to provide this service [ 4 ]. Developing Information Communication Technology (ICT) supported health communication in PHC could contribute to increased health literacy and empowerment, which are foundations of health promotion and the notion of enabling people to increase control over their health and its determinants, and thereby improve their health [ 5 , 6 ]. It is however essential to conduct a detailed analysis of the setting and context prior to implementing an intervention in order to “avoid murky water and increase the likelihood of success” [ 7 ] (pg 506). The aim of this study was to gain a better understanding of health communication for health promotion and factors affecting such communication in a PHC setting, as a first phase in the development of an ICT supported health channel.

• Health communication

The development of health communication for promoting health has mainly taken place outside the health care services [ 1 ]. When health communication does occur within the health care services, it lacks a broad socio-ecological health promotion approach, needed to tackle lifestyle related ill health and health inequalities [ 8 , 9 ]. An ecological health promotion approach addresses socioeconomic and cultural factors that determine health as well as providing information and life skills to make appropriate health decisions. Such an approach includes both promoting health and preventing diseases [ 10 ], and is referred to as a health promotion approach in this paper.

Consistent with this health promotion approach, health communication in this article is defined as ‘the art and technique of informing, influencing and motivating individuals, institutional and public audiences about important health issues’ [ 11 ]. The communication adopts a participatory approach whose main aim is empowerment through dialogue and mutual learning; the process is as important as the outcome [ 12 ].

Participatory communication could facilitate collaborative learning for both provider and receiver of health communication [ 13 ]. Health communication providers can learn about receiver’s needs and preference for health communication through collaboration process; an insight that could enable them to construct health communication resources that is relevant and accessible to intended receivers. Likewise, receivers may gain more knowledge on health and health management as well as relationship between health and lifestyle through the same dialogue process. Raising health literacy of both parties is important for sustainable health care services [ 14 ].

Improving health literacy is critical to empowerment [ 15 ]. As a concept, health literacy encompasses more than transmitting health information and developing skills. It entails improving people’s access to health information and support capacity to use it effectively; in order for them to make informed choices, reduce health risks and increase quality of life [ 14 , 16 ]. In this light, health literacy is an important public health goal to reduce inequity [ 6 ]. The Ottawa Charter identified creation of supportive environment, developing of personal skills and reorienting health services as important action areas [ 17 ]. These action areas are incorporated in the Swedish Public Health policy [ 18 ], whose overarching goal is ‘to create societal conditions to ensure good health, on equal terms, for the entire population’. To achieve this, eleven goal areas have been identified, two of which are; to enable citizen participation in social and health care services; and to re-orient health care services into a more health promoting health services [ 18 ].

ICT- mediated health communication

ICT mediated health communication media, with internet at the forefront, are increasingly becoming an accepted strategy for communicating health. Internet’s flexibility and accessibility through different channels makes it an ideal platform for communicating health [ 19 , 20 ]. Health channel in this paper is defined as a mode of transmission that enables messages to be exchanged between “senders” and “receivers.” In the context of internet, senders of the communication may have to contend with participants who engage, contest, reframe and deepen the messages in the communication process. This may take place either in an on-going dialogue in real-time or via other feedback avenue [ 21 ]. Implementation of ICT for health communication or aspects of ICT in health communication, as in eHealth applications, is essential to meet growing demands for cost-effective, appropriate and individually tailored health care as well as to increase accessibility to health services [ 22 ], improve population health outcomes and to achieve health equity [ 19 ]. Yet the implementation of ICT supported health communication for health promotion within health care services has been slow in uptake [ 8 , 19 ]. Criticism has been leveled at the existing ICT mediated health communication in health care as it is perceived to be predominantly individual based and pro-medicine in its approach [ 4 , 23 ], lacking a holistic approach and ability to address determinants of health [ 22 ]. Thus there is a need to rethink health promotion in planning for ICT mediated health communication [ 8 , 22 ] for a holistic approach in conceptualization and design of ICT systems in health care [ 24 ]. Innovative ways to design ICT systems in health care can contribute to individual wellbeing and quality of life, and achieve improved public health and sustainable e-services in general [ 25 ].

In the light of the challenges facing PHCs and opportunities presented by ICT in health care services outlined in the background, there is need to conduct a feasibility study prior to implementation of a new ICT supported health communication tool; in order to situate practice in its context and increase the likelihood of success [ 7 ]. Implementation of ICT is expensive, time consuming and often quickly outdated [ 8 , 26 ]. In order to develop sustainable ICT systems that fulfill health promotion goals in PHC, there is a need for both the system developers and health personnel to understand what functions the system is supposed to fulfill and the contexts in which it is to function [ 27 ]. This need informs the aim of this study which is to gain a better understanding of health communication for health promotion and factors affecting such communication in a PHC setting. This study has the potential to guide researchers and PHC managers in future feasibility studies and/or the implementation of ICT systems.

Study setting

The study was conducted within a county council owned PHC and its health promotion center ‘ Hälsotorg ’ in the southeast of Sweden which provides health services to approximately 10,500 inhabitants. The PHC center houses several units: General Practitioner (GP) and District Nurse (DN) consultations services, Child Health Services (CHS), Hälsotorg, Pharmacy, Dental and Psychiatric Clinic.

The Hälsotorg was partly owned and managed by the PHC. Hälsotorg emerged in several county councils in the 1990’s as a collaboration between the then, state owned, pharmaceutical company and PHC in a bid to increase health promotion within the PHC services [ 28 ]. According to local evaluation reports, the concept and ambitions of Hälsotorg were appreciated by health personnel as well as visitors [ 29 ]. As it contributed to the alliance building with other actors working in the field of health, opened up PHC to the non patient segment of the society and thereby increasing citizens’ accessibility to and participation in health care as stipulated by the national public health policy [ 18 ]. This makes PHC a natural entry point for reorientation of health care towards a more health-promoting health services as proposed by the World Health Organization (WHO) [ 17 , 30 ] and the Swedish National Public Health Policy [ 18 ].

To improve accessibility to health promotion initiatives for the local community, a research and development project entitled ‘Virtual Hälsotorg ’ (VHT) was initiated to make Hälsotorg activities more accessible to the local community through an internet supported interactive health channel. The main objective of the VHT project was to develop an interactive digital health channel for health promotion, a virtual “meeting place” for health issues between community members and health care personnel in PHC. According to the project goals, VHT channel was to be specifically adapted to the socio-cultural context of PHC and the local community. The VHT project was part of an EU funded research and development project exploring how ICT can be used to increase citizens’ accessibility to and participation in health care, and development of health care services.

Study design

The Virtual Hälsotorg (VHT) research project adopted a Participatory Action Research (PAR) approach [ 31 ]. A model, entitled Spiral Technology Action Research (STAR) [ 27 ], was used to guide the design process. The STAR model combines health promotion and social theories, PAR approach, critical pedagogy and ICT systems design approaches using rapid cycle of change strategies [ 27 ]. The iterative nature of the STAR model allowed continuous feedback and dialogue between partners in the research project which resulted in action/improvement of the product thereby making it a tangible method for realize the PAR approach of the project. The STAR model consists of five developmental cycles entitled; Listen, Plan, Do, Study and Act . For the VHT project, these cycles were combined to form three developmental phases; phase 1; Listen, phase 2; Plan and Do, phase 3; Study and Act. This article covers the first phase Listen ; which entails ‘scanning the setting’. This article had a dual purpose. First, to familiarize with the setting for the intervention. Second, to assess health communication needs and identify subject’s interaction with technology. The goal of this phase in the VHT project was to ensure that the development of the system was guided by the users, both health professionals and the local population, needs as expressed by them [ 27 ].

A qualitative exploratory case study [ 32 ] methodology with multiple data collection methods; field study with participatory observations, document studies and focus groups were applied in the study to facilitate a holistic view of health communication practiced at Hälsotorg and PHC (Table 1 ). PAR approach, provided possibilities to understand individual and organizational factors as well as the relationships between these factors [ 32 , 33 ]. Since the boundary between Hälsotorg and its context (PHC) were not clearly evident, the whole context was treated as a single case study [ 32 ]. The case and unit of analysis was the phenomenon ‘health communication’ in the context of PHC in general and Hälsotorg in particular. According to Yin, use of multiple sources of evidence allows the investigator to address a broader range of issues comprehensively thereby contributing to convincing and accurate findings or conclusions [ 32 ] hence increasing credibility and trustworthiness of the results [ 33 ].

Case description

Hälsotorg in this study was managed by health professionals from the PHC and the Pharmacy. It offered a range of health promotion activities including health information in print and electronic media, individual health counseling on life style related health problems like stress, physical inactivity, overweight and chronic diseases such as hypertension and diabetes. It also offered group activities such as: open public lectures, ‘power walking’ and aerobics for people with physical disabilities. A customer computer placed at the Hälsotorg; provided access to free, trustworthy internet-based health information sites and self-administered lifestyle tests. All activities were open to all citizens free of charge.

The term ‘visitor’ was used to describe all who visited Hälsotorg, regardless of how or why they came, in contrast to ‘patients’ in other PHC units. Hälsotorg personnel did not have an obligation to document visitors in the electronic patient record, thus all visitors had the right to be anonymous. Hälsotorg had two types of clientele; visitors, who visited of their own accord and visitors who came on referral from GP, DN or CHS.

The case was expanded to include experiences of personnel from the other three Hälsotorg in the region to get a broader perspective of health promotion services offered and to solicit input on the content and development of a VHT model usable in all county council owned PHC in the region. The GP and DN consultations services, CHS and Hälsotorg belong to the same organization and will henceforth be referred to collectively as ‘PHC’ in this paper, likewise, personnel from respective units will be referred to as ‘health personnel’, unless the need to separate them arises.

Fields study

To familiarize with the setting for the intervention, find and assess needs, and identify how subjects interacted with technology, a field study was conducted under a period of three months, twice a week, in 2008–2009. AJM took part in Hälsotorg activities and staff meetings in the PHC, collecting data using participatory observations [ 33 ]. A total of 251 people visited the Hälsotorg during the period of the field study, some of whom took part in the informal interviews which formed part of the field notes.

Participatory observation as a method contributed to a better understanding of the context, its actors and their interrelations. Thereby a nuanced understanding of the context as a basis for understanding data collected through other methods such as focus groups and document studies [ 33 ]. Furthermore, findings from the participatory observations were used to identify key actors (study sample) and to design questions for the focus group. Participatory observation was useful as expression of needs, especially for technology based resources, is often tacit and hard to deduce for the majority of the people [ 31 , 34 ].

A field study manual covering; activities conducted at Hälsotorg , participants and reason for participation. The manual also focused on how health communication was framed and communicated as well as tools and strategies used to communicate health. The interaction between health personnel and between health personnel and Hälsotorg visitors were also covered. The manual observations notes, impromptu conversations and personal reflections were recorded in field notes. The notes were then expanded when the situation allowed or at the end of the day to identify assumptions, make sense of the data, and record personal insights that might have affected the data [ 34 ] and discussed with the DN at Hälsotorg .

When Hälsotorg visitors allowed it, AJM actively participated in the activities which gave the opportunity to closely observe the activity and ask questions in an unobtrusive way [ 34 , 35 ]. Similarly, AJM, helped in the planning of two public lectures during the field study, thus giving insights on how health communication via mass-media was articulated and executed. Field notes were read repeatedly to make sense of the collected data and get a sense of whole. The data was later coded and categorized using qualitative data analysis [ 34 ].

Document studies

Purposive sampling was used to identify documents, printed materials and records [ 34 ] that were of importance to health communication and health promotion in PHC. A total of 13 documents and other printed materials used at Hälsotorg were identified as crucial to understand how health promotion in PHC was articulated in text and how it is interpreted in praxis as basis to understand the what, how and why of health communication for health promotion practiced in PHC and factors influencing it (Table 1 ).

The national documents; the public health policy 2007/8:110 and pharmacy (Apoteket AB) Action plan 2002, were identified through an earlier study of Hälsotorg implementation analysis [ 28 ]. The county council documents were identified during field studies data collection period and obtained through internet searches on the county council website. The rest of the documents included; an evaluation report of Hälsotorg in the region, meeting protocols, monthly reports (mainly activities offered and statistics of visitors) kept by all Hälsotorg during the field study. All the documents related to the development, visions and goals for health promotion in PHC. Qualitative content analyses were conducted whereby phrases describing health promotion, health communication in PHC as well as PHC’s missions, role and responsibility in health promotion were highlighted and coded [ 34 ].

Focus groups

To explore the knowledge and experiences [ 34 , 36 , 37 ] of the different actors in the PHC, focus groups were conducted with actors involved in health promotion in PHC (Table 1 ). Purposive sampling was used to identify potential information rich sources and main actors [ 37 ] among health care personnel in PHC and local community members. To gain a better understanding of health communication for health promotion in PHC and capture perspectives and experiences of the different actors who affect or are affected by it, effort was made to include providers, receivers and decision makers of health communication in PHC.

Focus group participants were recruited using snowball methods [ 38 ] where PHC manager and DN in Hälsotorg played a key role in identifying and recruiting of informants. A letter containing project information and a request for participation was sent out to prospective informants in PHC and to a Swedish language class for immigrants. Respondents to the letter, were later contacted to decide on dates and places for focus groups. Five focus group interviews were conducted. Group 1 and 2 consisted of DNs in PHC (n=9). Group 3, was Hälsotorg’s network (n=10) consisting of PHC managers, a pharmacy manager, dental clinic manager, psychiatric clinic manager, Hälsotorgs personnel across the region, and a public health strategist. Group 4 consisted of immigrants from a Swedish language school while group 5 was made up of Hälsotorgs’ personnel in the PHC of this case study. The total number participants in focus groups was 30 (Table 1 ).

The immigrant group was a strategic choice as Hälsotorg personnel recounted that from their experience, immigrant groups had low health literacy and were hard to reach. During the period of this study, Hälsotorg had contact with immigrants in the Swedish language instruction school (SFI). The immigrants were informed about the study and requested to participate.

Data was collected using semi-structured, open ended interview guide [ 34 , 39 ] divided in two parts. The first part pertained informants’ personal experiences of designing, delivering / receiving health information/ health communication in or from PHC. The second part concerned informants’ knowledge and experience of ICT supported tools for health information and suggestions for improvements of health communications for health promotion. The interview guide was modified to adapt to the different groups of informants in order to capture the varying perspectives, experiences, roles and needs. Focus groups with health personnel were conducted in private rooms within the PHC, while focus group with the immigrant group was conducted in their classroom which was a familiar environment [ 31 ]. AJM functioned as the principle moderator in all the focus groups assisted by EO who took notes. A post meeting analysis of the session was held by the researchers at the end of every session to compare notes and identify new ideas (if any) that needed to be explored in the next focus group [ 37 ]. Focus groups discussions were audio taped and transcribed per verbatim [ 34 ]. Data was read repeatedly to achieve immersion and obtain a sense of whole, then coded and categorized using inductive qualitative content analysis [ 34 ].

Data analysis

Data from focus groups, participatory observations and document analysis were analyzed, coded and categorized separately using inductive qualitative content analysis [ 34 ]. Emerging categories from the different data sets were constantly compared to each other and integrated into themes (Table 2 ) to form a rich description of the case [ 32 ]. Coding was initially done by AJM and thereafter negotiated and checked for comprehension with the other co-authors. The derived results were then presented to the DN in Hälsotorg for validation. Two main themes emerged from the data analysis namely; communicating health and environment for health communication.

Ethical considerations

The informants were informed on the nature of the study, in accordance with the Swedish Ethical Review Act (SFS 2008:192) and informed consent was obtained from participants. Permission to a conduct field study was granted by the PHC manager. One of the main aims of PAR is to create equality between the researcher and research subjects [ 31 ] as well as making explicit the researcher’s assumptions, values and motives [ 40 ]. To achieve this kind of transparency, AJM kept the participants informed of the project through; talking to the personnel, taking part in workplace meetings and holding debriefing sessions with the other research members to ensure that personal values and motives did not affect the outcome of the study. Debriefing sessions provided useful arena to discuss difficulties caused by AJM’s dual role of a researcher and health worker when actively taking part in the activities in Hälsotorg . However, since the participatory element of enquiry was limited to participatory observation, few problems were encountered as the researcher was sensitive to the participants’ wishes [ 31 ]. AJM would always seek their permission prior to engaging in any activity. The study was approved by ‘The regional ethical committee for Lund/Malmö region’, at Lund University in Sweden. Diary number 2009/120.

The overall analysis shows that health communication is an integral part of health promotion practice in Hälsotorg and PHC but there was a dearth of consensus among health professionals on what a health promotion approach is, causing discordance in approaches and practices of health communication. Two main themes emerged from the analyzed data: Communicating health and Environment for health communication (Table 2 ). The results are presented in these themes with their categories and sub-categories. Quotations are included to illustrate how the interpretation is grounded in the data.

Communicating health

Communicating health was identified as a major function for PHC by all informants. This theme captures how health was communicated, understood and practiced. Health personnel identified a number of strategies and tools used for health communication as well as types of health communication carried out in PHC.

Strategies for health communication

This category mirrored two different approaches used by health personnel to accomplish objectives for health communication; empowerment and behavior change strategies . Empowerment was indicated in the policy documents, and acknowledged by health personnel, as the ultimate goal for health communication in PHC. Field studies and focus groups indicated however that the empowerment strategy was more evident in Hälsotorg and in CHS compared to the rest of the PHC units.

In the empowerment strategy, health personnel assumed the role of a dialogue partner and facilitator for the learning process of patients and visitors. Decision were made based on the receiver's understanding of the information. This approach was commonly referred to by DNs as ‘m eeting the clients where they are, in order to guide them to where they want to go in terms of better health ’. In most Hälsotorg this empowerment strategy mostly focused on building capacity and providing tools for visitors to make informed decisions or creating solutions to health problems or lifestyle changes through a dialogue, while in CHS, it focused on facilitating empowerment of parents and creating a supportive environment for families. As one Hälsotorg visitor expressed:

“ Here (in Hälsotorg ) I can discuss different things at the same time, I was referred here by my Doctor because of my high cholesterol but then, I ended up discussing my sleep patterns that is more disturbing to me really more than high cholesterol (laughter)…You can’t do that at the PHC ” ( Hälsotorg visitor 1)."

Or as another informant expressed;

"“That’s how we work all the time, promoting health and preventing ill health in the home now we focus a lot on unhealthy drinking and we routinely ask both mothers and fathers about their drinking habit not just mothers. It is important that children are safe and parents who need help, feel they can get it” (FG 1)."

In contrast to the empowerment strategy, the behavior change strategy focused on disease and risk prevention. Health personnel were more or less authoritative and ‘instructed’ the patient/visitor, assuming the role of expert, who ultimately informed the patient /visitor, what was best for them. One of the (health) personnel explained the health communication process as follows:

"“We normally go through their (patients’) eating habits and daily exercises together if any and then I show them what they are doing wrong. Then I “teach them” the right diet and tell them that they have to exercise at least half an hour per day. Some do not follow our advice but that’s their own responsibility” (FG 2)."

Comparison of data from interviews and field studies showed that the different strategies could be traced to health personnel’s understanding of the health promotion concept and the exhibited discrepancy between their intentions to promote health and the existing praxis for health communication in their respective units.

Tools for health communication

This category included tools as channels, tools as methods, and tools as competencies.

Tools as channels for health communication included telephones, printed and electronic materials, and Internet-based resources. These were used for health communication with patients/clients/visitors separately or in combination, depending on the nature or purpose of the activity and the desired outcome. According to informants and observations, telephone, printed and electronic materials were common channels for health personnel’s communication with patients and visitors. Health personnel used Internet mostly to search for health information for the purpose of updating their knowledge or to retrieve health information materials for their clients/visitors. Patients and visitors used telephones mostly for health communication with health personnel, while Internet was used to seek knowledge in an area of interest or concern;-mainly chronic diseases and self care.

Tools as methods included questionnaires, brochures, and electronic or printed health tests . Almost all individual counseling sessions were initiated using a printed or electronic health questionnaire followed by a dialogue. Health personnel were positive towards these tools, as they gave structure to health communication activities. However, according to health personnel and visitors these methods could potentially encourage an expert-laymen driven approach, reducing health communication to filling of questionnaires instead of having a dialogue between partners. Health personnel acknowledged the shortcomings of the questionnaires as an effective tool for promoting health as follows:

"“…yaaa (hesitating) …we don’t produce them (questionnaires) ourselves…they are standardized and most people have more than one health concern, there is a risk that you focus too much on the questionnaire instead of listening to the patient” (FG 2)."

Tools as competencies for health communication encompassed knowledge, abilities and pedagogical skills for health communication, which were perceived as necessary tools for imparting or working with health promotion. Knowledge and abilities refer to skills necessary for health personnel to impart health related knowledge that influences individual health choices and self-care. Pedagogical skills refer to health personnel’s ability to apply those skills appropriately and in a way that fosters empowerment in their clients/patients. DNs, in particular, expressed a desire for internal courses to improve their pedagogical skills and capacity to act as health promotion agents. As expressed in one of the focus groups:

"“…of course we can be better at communicating when it comes to health promotion and disease prevention…but it is not always easy. For instance, when you get a patient with hypertension who is a bit fat, you can talk about diet…but to apply it generally in the day to day activities is hard..that needs a different kind of structure, skills and knowledge …pedagogical skills that unfortunately are not there in us…” (FG 1)."

Types of health communication

Three types of health communication were identified from the data: interpersonal, group and ICT mediated health communication. Interpersonal communication was the most common type of communication used in PHC and at Hälsotorg as the majority of activities/services targeted individuals. Motivation Interview (MI) was the recommended method for individual health counseling in the county council policy document and also acknowledged and used by the DN’s. Face-face verbal communication between patients/visitors and health personnel in either planned individual counseling or during ‘drop in’ sessions. The patient/visitor’s needs and abilities were the main focus of interpersonal communications. According to health personnel, it is important to identify patient’s source of motivation as opposed to health personnel’s. As exemplified in the following quotation by health personnel:

"“… it is hard for people to change their habits…but we try to help them identify things that would make them want to change, for example if a visitor is diabetic and overweight…to us it is natural to say diabetes is the problem, but maybe the person wants to lose weight because they want to look beautiful…(all informants nod in agreement)…then beauty is that person’s motivation but in the end the results (of losing weight) would be good for their diabetes too” (FG5)."

Group communication was mostly used at Hälsotorgs during group activities such as physical training and open lectures on different lifestyle related ill health. Different kinds of physical training sessions were offered for example; aerobics for physically challenged persons (including wheelchair- bound persons) and power walking. Open lectures also varied in content, from stress to cardiovascular diseases. These activities paved way for group communication and facilitated dialogue on varied health issues between health personnel and community members.

Findings show that group activities were appreciated by both Hälsotorg personnel and visitors. Hälsotorg personnel saw these sessions with group discussions, as opportunities to communicate health to a larger population, something that is not always easy to accomplish in the day to day work. For visitors, these sessions were more than just an opportunity to exercise or get health information; they presented an opportunity for collaborative learning and opportunity to act on the knowledge acquired for health gains. This would not have been possible if Hälsotorg had not created supportive and inclusive environment for all citizens, regardless of health condition. As expressed by a Hälsotorg visitor:

"“ Hälsotorg has saved my life…I come every Tuesday and walk with this group…it is nice…I made some friends…and the DN can see when somebody is having difficulties…I have a bad heart and I would never dare go on long walks like this if I didn’t know there was somebody to help me if I collapse…she sometimes tells me and the whole group to reduce our pace…because she “sees” when I am struggling…” ( Hälsotorg visitor 6)."

ICT mediated health communication , especially the Internet, was regarded as an important media for health communication by all informants. Younger Hälsotorg visitors and immigrant informants were more positive to the use of internet as a source of health communication; they reported using Internet for health information needs more extensively than health personnel and older Hälsotorg visitors. Younger Hälsotorg visitors and immigrants reported using internet to search information on lifestyle related ill health. Mainly information on weight loss, diet, smoking cessation and stress as well as cardio-vascular diseases. Information on how to contact the local PHC clinics and hospitals was also reported. Immigrant informants used both Internet and digital television, as these channels offered health information in their native languages. Hälsotorg personnel frequently used web based-lifestyle questionnaire on the Pharmacy’s website apoteket.se to tests the visitors’ diet, sleep, exercise, smoking and drinking habits.

Results from the web based-lifestyle questionnaire was used as a basis for individual counseling sessions regardless of what health problem the visitors came in for. A clear irritation was noted among some of the visitors who did not see the connection in for example the hypertension control they came in for and answering the long questionnaire while others appreciated the questionnaire, noting that it has helped them realize that they need to eat better balanced diet or stop smoking for example.

A common phenomenon noted during the field studies was the number of Hälsotorg visitors coming in with health information acquired from the Internet, wanting to discuss the content and validity with the personnel. A DN expressed criticism of the Internet as a source for health information as follows:

"“…patients come with all kinds of information, sometimes wrong information and it’s hard to counter that kind of misinformation…the new health channel would be good because we will be able to give them access to health information that we know is correct” (FG 3)."

Environment for health communication

The environment for health communication was seen as both a facilitator and barrier to health promoting communication efforts in PHC. Two important factors affecting the environment of health communication were identified: Strategic positioning and Collaborating for health communication . Positioning of Hälsotorg within a PHC center affected health communication at the PHC units and Hälsotorg , as well as the collaboration efforts between the different actors.

Strategic positioning

According to the analyzed policy documents, Hälsotorg were strategically placed both organizational and physically within the PHC context to provide local citizens with health promotion and disease prevention services; and to help them navigate the health care system using health information and health communication as strategies. Provision of these services was aimed at increasing health literacy and capacity for self-care among the population, which was supposed to reduce pressure on the PHC medical services.

Organizational and physical positioning were identified as important factors shaping health communication practice in PHC. Organizational positioning referred to the placement of Hälsotorg within the PHCadministrative organization. According to the National Pharmacy Action plan, placing Hälsotorg within the PHC and the pharmacy organizations was a strategy to profile health promotion and disease prevention services in order to involve local citizens in a health dialogue, help people manage their health problems and stay healthy. The Pharmacy, which already had counseling services and a large flow of mainly healthy customers, could play an important role in promoting health at population level in collaboration with PHC. The county council plans also highlighted the importance of adopting a health promotion approach and the creation of a supportive environment for health within the health care services. Hälsotorg was pinpointed as an important setting for realization of these esteemed goals in the first plan (2007–2009) but was not mentioned in the second plan (2008–2010).

PHC was associated with being sick in most people’s minds, according to DNs. ‘Healthy people’ rarely visited PHC, a statement that was echoed by immigrant informants and Hälsotorg visitors. They only contacted or visited PHC when they were ill, prior to their knowledge of Hälsotorg’s existence. The most frequent visitor was a middle-aged woman or an elderly male pensioner with multi-health problems. Some of the health personnel perceived the clientele as being the ‘wrong type’ for health promotion interventions. They expressed a wish to relocate Hälsotorg in order to attract a ‘younger’ and healthier clientele. As expressed below

"“ It is perhaps about the kind of people who walk through our walls (referring to the PHC building)… am I being mean? It is the wrong target group. I feel like…maybe we ought to go to schools, year 7, 8 9, those are the ones we should be aiming at” (FG 2)."

However, not all health personnel held the same view. Some regarded the placement of Hälsotorg within PHC context as perfect as related by other health personnel

"“ …we cannot only target the healthy, we have an obligation to help those who already experience ill health like those with diabetes, they really consume a lot of resources and the best place to “capture” them is in PHC where they come for regular controls. If we can help them prevent further health deterioration like kidney failure, then it is worth the effort” (FG2)."

In ambition to reach out to a larger and ‘different’ audience with health communication, Hälsotorg personnel conducted ‘ Hälsotorg on wheels week’ where they set up camps in the town centre and offered their services to the general public, a move that was much appreciated by both the personnel and the public, according to Hälsotorg personnel’s own documentation. The DNs’ opinion about the positioning of Hälsotorg was not shared by informants in FG 3, who regarded Hälsotorg’s positioning to be the best location to intercept people suffering from minor health problems with services geared towards primary and tertiary disease prevention.

DNs in the focus groups (FG1 and 2), indicated that the organization leadership promoted the image of PHC as a setting for ‘sick care’ through policies on the physical environment of the clinics. An example given by informants was a policy where no posters or information leaflets with health information were allowed in the GP waiting rooms while it was allowed in the CHS and Hälsotorg. This differentiation caused frustration among the personnel, as one of them expressed:

"“Sometimes, I feel like we could be more proactive and put up information pamphlets and posters on HEALTH! But no, we are not allowed, no reasons or discussions! ”(FG2)."

Another informant suggested that the PHC management thwarted their efforts to use health communication proactively, expressing disappointment as follows:

"“.we don’t have notice boards here, I tried to put up some notices on health promotion activities but was summoned and told that I cannot do that by the management!…I don’t understand how they reason” (FG 5)."

Physical positioning refers to the placement of Hälsotorg in the entrance hall of a PHC and/or a Pharmacy or a hospital. Field study observations revealed that Hälsotorg’s physical position made it easy for people to stop by and discuss health concerns, obtain help to navigate the health system e.g. to find the appropriate health clinic at which to seek help. On arrival at the Hälsotorg , curious passersby and referral patients from PHC were introduced to a variety of free services offered. These included universal health information, individual health counseling and access to trustworthy Internet-based health information sites for health promotion .

For visitors with a high risk for lifestyle-related diseases like diabetes and cardiovascular diseases, disease prevention services such as hypertension control, lifestyle tests and group physical activities were offered. The most popular group activity was aerobics for people with physical disabilities.

A disadvantage of the openness of Hälsotorg , was the surrounding noise and lack of privacy during consultations and individual counseling. This was observed during field studies and later acknowledged by the informants. The noise often led to irritation and disgruntlement, thereby affecting the quality and outcome of the sessions. Hälsotorg personnel expressed that the planned Hälsotorg channel would partly solve this problem:

"“This virtual Hälsotorg channel can be good for us; it presents a totally new way of planning individual counseling we can offer a quieter, individual based counseling in the comfort of their homes” (FG 3)."

Adding that the privacy presented by the VHT would enable them to increase the range of services offered to their clients as follows:

"“We can even put up programs (in VHT) where clients can work at their own pace and convenience, without stress or worrying about being disturbed” (FG 3)."

Collaborating for health communication

Collaboration within and outside the health care services such as NGO’s, churches, local communities and municipalities was highlighted as very important for promoting health and providing a supportive environment for health (County Council plan 2007–2009). Hälsotorg was specifically pointed out as a significant converging arena for the different actors to collaborate in creating a supportive environment to achieve health services’ health promotion goals, a setting for communicating health with both patients and local citizens (ibid).

Locating Hälsotorg within the organizational and physical boundaries of health care services resulted in successful collaboration between different professionals and health care organizations for many years, according to the informants and document analysis. Informants acknowledged that making use of the available resources within the different sections of the PHC organization would benefit patients/visitors especially, in health services where lack of resources and time constraints was the norm. However, different structural and organizational factors served as facilitators or obstacles to collaboration efforts. Three categories; interests , resources and trust were identified as factors affecting collaboration efforts and thereby health communication for health promotion purposes.

Collaboration between organizations/professions depended on shared common interest in terms of either the same target group and / or similar organizational demands. PHC organization in this study was made up of specialized units; CHS, GP and DN consultation. Each unit was allocated resources to work with specific or prioritized target groups. Hälsotorg personnel expressed a feeling of marginalization, which they attributed to the fact that they targeted ‘healthy clients’ as opposed to sick/ill patients targeted by the other PHC units. During the field study it was noted that Hälsotorg personnel unsuccessfully tried to enlist the help of DNs with special competencies such as diabetes or incontinence, to give a public lecture at Hälsotorg . Promoting health was conceived as ‘non-urgent’ and was not prioritized, which explained the difficulty of establishing collaboration with Hälsotorg .

Organizational demands of “need-based” prioritization resulted in prioritization of curative and risk-disease prevention in most PHC units. External organizational demands such as national directives and policies were also cited by health personnel as factors affecting interests and, thereby collaboration. For example prioritization of child and geriatric health in the policy years 2008–2010, led to PHC units prioritizing collaboration around these two target groups. Since Hälsotorg did not have a specified ‘target group,’ it experienced difficulties finding collaborating partners in PHC. In an effort to bridge the gap between Hälsotorg and the other PHC units, all the hypertension controls were relocated to Hälsotorg . This was a decision that was not popular among Hälsotorg personnel as it was seen as ‘medicalization’, of their services, as expressed below:

"“…it undermines the whole purpose of my work…I don’t mind them coming but I have to document in their medical journal…I have to talk about their medical history, diseases…that becomes the focus!…Hälsotorg becomes the extended arm of their medical clinic..” (FG5)."

Availability of resources was identified as pre-requisite for communicating health to the public. However, resources were scarce in PHC according to the health personnel. Thus lack of or poor collaboration between different professions and organizations was attributed by the DNs to the scarce resources. Two types of resources were identified from the data: time and economy. Lack of time was attributed to a high workload and little time allocated to each patient, often ageing and multi-morbid patients. However, some DNs suggested that unwillingness to think ‘outside the box’ and negative attitudes towards collaboration more than workload contributed to poor collaboration. Lack of economic resources was also cited by health personnel as a hindrance towards engaging in activities outside the prioritized areas. Health personnel pointed out that they operated on a tight budget, with constant cutbacks which forced them to focus on ‘their’ areas of responsibility.

Trust was identified as an important collaboration factor in and for health communication between health personnel and visitors; and between health personnel in different PHC units. Hälsotorg visitors related that they came to Hälsotorg and took part in the activities because they had confidence in the professionals who worked there. The information they received was perceived as trustworthy, correct and evidence based as it came from a health care authority. DNs in other PHC units also expressed that it was easier to collaborate with Hälsotorg when it was managed by ‘one of them’, meaning a DN

"“…We try to refer our patients to Hälsotorg they are not used to it but we explain that it is one of our own that will help them and the only difference is that there are no medical records. Once they hear they’ll meet a District Nurse, they go willingly…” (DN 8)."

The planned VHT was regarded as an opportunity to overcome some of the collaboration obstacles faced by health personnel. According to health personnel, VHT could be a converging “virtual space” where PHC units could work together but at the same time profile their specific services and communicate with respective target groups.

The aim of this study was to gain a better understanding of health communication for health promotion and factors affecting such communication in a PHC setting, as a first phase for developing the ‘Virtual Hälsotorg’ (VHT), an interactive health channel. According to Kreps [ 8 ], understanding the context is central to planning of health communication interventions, especially within the health care services, where a myriad of individual, organizational and societal factors influence health related decisions and practice. Findings from this study highlight the interrelation between individual and organizational factors, tools and strategies that affect framing of health communication and, how health communication is communicated, received and understood. These factors need to be addressed by researchers and PHC actors in the planning and designing an ICT mediated health channel for health promotion [ 8 , 24 ], to achieve its goal of improving health literacy [ 4 , 14 ], and to realize the national public health goal of re-orienting health care services into a more health promoting services [ 18 ].

PHC in this study is expected to act as a single organization; working towards the same goal of preventing diseases and promoting health for individuals and the community, according to the health policy documents. However, analyses show that the studied PHC faces challenges of catering for a clientele of different ages and health status, as well as serving both individuals and the community as a group. Furthermore, the PHC units were assigned different target groups and adopted different strategies for health communication, making it difficult to achieve the cohesive organization and stated goals. This study therefore highlights a discrepancy between what is stated in policy documents and expressed intentions by health personnel, from the health communication in practice at the PHC.

Collaboration between different actors within and outside the health care settings is an important principle in health promotion. to increase effectiveness and validity of programs [ 41 ]. Division of the PHC into specialized units, each with a given target group, ear marked resources for the target group and prioritization were important factors in contributing to the poor adaptation of a health promotion approach in PHC. This demarcation affected content of, and approaches to health communication as well as collaboration between the different PHC units and other partners. Similar results were reported in Johansson et al. [ 42 ], where health personnel exhibited both the will and skills for promoting health but lacked the chance to implement them due to perceived lack of opportunity or support from the organization. Thus, organizational structures play an important role in creating a supportive environment to enable integration of health promotion [ 43 ]. Health promotion in the PHC studied was regarded as a non-urgent service and as such was not prioritized, which confirms findings from earlier studies showing that health promotion in PHC is sidelined from the rest of PHC activities [ 42 – 44 ].

Health personnel in PHC possess competencies of working with a range of strategies, tools and types of health communication; competencies that could contribute to better ICT based health communication channels such as the planned VHT. DNs in this study have experience of, and skill for working with individual counseling, knowledge and experience that can be used to inform the design of interactive services of the VHT channel; such as tailoring of health information to better suit the intended end users. Tailoring of health information is believed to be one of the most effective strategies for health promotion and lifestyle-changing interventions [ 23 , 45 , 46 ].

The results also revealed a need for skills development in health promotion approach among health personnel in this study. Majority of informants equated health promotion to primary prevention, disease prevention and/or prevention of risk for diseases. Prevention was the dominant approach in health communication strategies and health professionals’ repertoire. This despite policy documents clearly stated the need for a health promotion approach in PHC and Hälsotorg even when working with primary, secondary and tertiary disease prevention. Similarly, health promotion was understood as activities to promote health as opposed to an approach to health promotion . According to Irvine [ 47 ], health professionals in primary care settings, including nurses, lack adequate knowledge to integrate health promotion in their daily work in an effective and planned manner. Thus there is a need to prioritize education and training of health personnel in health promotion knowledge and skills. By involving them directly in the development process of the planned health communication channel, collaborative learning could be facilitated through dialogue between different professionals and lay people.

Allocating Hälsotorg within the PHC context resulted in a symbiotic relationship between Hälsotorg and PHC. Hälsotorg contributed to a more health promoting PHC services through its health promotion activities while PHC’s narrow and “reactive” prevention approach were forced upon Hälsotorg despite protests from Hälsotorg personnel , like the hypertension controls. However, results also show that Hälsotorg and PHC collaborated in the planning and hosting of theme weeks and public lectures despite their differences. Establishment of VHT could benefit from this existing mutual relationship as it aims to promote health by providing accessible and empowering health communication, and creating a supportive environment for health for individuals and the community. VHT could be a potential and ideal converging point for PHC and Hälsotorgs’ health promotion and prevention approaches. This collaboration could further strengthen the PHC’s health promotion ambitions as stated in the policy documents.

DN’s in this study blamed the poor adaptation of health promotion approach in PHC to the lack of support and interest from the management. Similar results were displayed in Johansson et al. study [ 42 ], where health personnel had both the will and skills but lacked the chance to show them due to perceived lack of opportunity or of support from the organization. In this study however, there seems to be contradictions, as participatory observations and meetings with the PHC leadership revealed a willingness among PHC leaders to create infrastructures to improve health communication for the purpose of promoting health. These different perceptions could be the result of the lack of dialogue between PHC leadership and DNs.

According to previous studies [ 19 , 45 , 48 ], trust can be a defining factor for health information seekers ’ use or rejection of the content of health information on the internet. Trust in content and professions were also cited as two most important factors for choosing health communication resources by local citizens in this study. Pilemalm et al. [ 45 ] suggest that involving end users in the design process increases trust among them and thereby probability of their using the system. There is therefore a need to involve all the actors; from PHC managers to DNs in a dialogue during the process of developing VHT; in order to create trust between PHC actors, facilitate sense of shared ownership and sustainability [ 45 , 49 ].

Communicating health is given as an important function in PHC however; results show that there was a lack of synthesis in approaches, strategies and tools to achieve this common goal of promoting health and preventing diseases at individual and community levels. Similarly, empowerment was stated as the ultimate goal of health communication initiatives in PHC but results show that behavior change was the most common approach. Earlier studies have shown that health communication for the purpose of promoting health within health care services, lack a broad socio-ecological health promotion approach [ 8 ]. An approach that is necessary to increase individual and population health literacy in order to tackle the determinants of health and the growing burden of chronic diseases [ 4 , 6 , 8 ]. In order to identify a common health promoting approach and strategies based on health promotion values and principles, a participatory design involving both end users and providers throughout the design process will be used. Participatory design is attributed to contribute to capacity building as participants learn with and from each other while working towards the same goal, making it an appropriate method for development of VHT [ 24 , 45 ].

Data analysis revealed that PHC personnel face a growing challenge of addressing health queries from informed patients and visitors who are more versed with internet use than themselves. In order to meet this, and other future health communication challenges, health personnel need to improve their capacity for using internet-based information [ 19 , 50 ]. Lack of health information in other languages, besides Swedish, is another aspect that needs to be taken into consideration as studies indicate that immigrants generally experience poorer health than native Swedes [ 43 ]. According to the Swedish board of statistics, immigrant communities in Sweden increased from 95750 in 2006, to 96467 in 2011. Prognoses indicate that this trend will continue [ 51 ]. An accessible Internet-based health communication could be a strong motivation for immigrants to seek health information frequently and manage their own health. One of the major challenges to introducing a new technology in PHC is the need to increase the capacity of health personnel’s ability to use ICT resources effectively while paying attention to the eminent risk for contributing to communication inequalities and digital divide [ 19 ]. Equity and inclusion of the needs of non- Swedish speakers will need to be considered by enabling participation of these groups in the design process of health promoting services.

Study strengths and limitations

Use of triangulation of methods and involving other researchers and informants in the data analysis process provided a rich description of the case and context. Furthermore, this study revealed that a multi-method approach unearths more details that are difficult to identify using a single method, for instance, the discrepancy between policy and what is practiced. This provides readers with information to make their own judgments on the study’s applicability in similar contexts, thereby increasing the study’s transferability [ 52 ].

Prolonged participatory observation of three months increased the study’s credibility [ 53 ] and enabled the researcher to study not only what was present but also what was ‘missing’. Two important observations made were; the lack of communication between PHC and Hälsotorg personnel and absence of pharmacy personnel at Hälsotorg [ 34 ]. Participatory observations also gave a detailed documentation of the methodology used for health communication and transparency of decisions, which increases the dependability of this study [ 52 ].

By familiarizing with the target groups, the researcher also gained ‘access’ to the field as well as an opportunity to recruit participants for the continued VHT project. According to Smith et al. [ 40 ], the success of a PAR research project, like the VHT, depends upon the establishment of an environment for trust between the researcher and the subjects of the study. Furthermore, this phase resonated well with the ‘listen’ phase of the STAR model [ 27 ] which entails interacting with the target groups, familiarizing with the context, identifying how target groups interact with technology and carrying out a needs assessment.

A limitation of the study is that it is built on one Hälsotorg and one PHC, and as such, based on a small number of informants. This may have had an impact on the results, as the experiences of the other Hälsotorg have not been explored fully.

Confining the field study to only one Hälsotorg may have narrowed the results as a previous study [ 28 ] showed that Hälsotor g offer different services and some had existed longer than others. However, expanding the case to include workers from the other Hälsotorg , was an effort made in order to compensate for the above mentioned limitations.

Exclusion of GP’s and other health professionals, like dieticians and physiotherapists, from the study is a shortcoming as they could have contributed with valuable information to the study. However DNs, included in this study, was the professional group in PHC who were responsible for health promotion services. Including GP’s was considered, but was not feasible as a majority of the GP’s working at the PHC, at the time of the study, were hired on temporary assignment basis.

This study identified challenges facing the development of health communication for health promotion in PHC. Understanding the opportunities and obstacles for health promotion and health communication in PHC makes it possible to start a dialogue with the different actors identified in the study i.e. health care personnel, PHC managers and local citizens. Engaging the actors in a dialogue could facilitate a consensus on common strategies to overcome the hindering factors and capitalize on the opportunities.

The most significant challenge in developing an ICT supported health communication channel for health promotion identified in this study is profiling a health promotion approach in PHC. To achieve VHT’s health promotion intentions, the development of VHT channel will have to be based on health promotion values and principles of empowerment, participation, holistic and intersectoral approach, equity, sustainability and multi-strategy. There is a need for a shift of focus from individual to a more population- based orientation, placing emphasis not only on people at risk but also directed at health determinants [ 22 , 23 , 25 ]. Furthermore, there is a need for a combination of different strategies, aiming at effective participation of all stakeholders on equal terms, and on professionals taking an enabling role instead of an expert role when communicating with patients/PHC visitors [ 8 , 23 , 45 ]. Finally equity issues need to be addressed through the creation of accessible health communication to improve health literacy [ 14 ], even for non- Swedish speakers as well as those with low literacy [ 53 ]. By addressing these factors in the design of e-Health services, health communication via an ICT supported channel could be health communication for promoting health, i.e. ‘health promoting communication’.

Although this study provides valuable insights to factors that need to be taken into consideration prior to development of an ICT supported health channel, there is a need for further research to better understand the needs for health communication among non-Swedish speakers and to further explore the relationship between the different organizational and social factors affecting health communication.

Abbreviations

Information Communication Technology

Primary Health Care

Virtuellt Hälsotorg’ (Virtual Health Channel)

World Health Organization

Spiral Technology Action Research

Participatory Action Research

General Practitioner

District Nurse

Children Health Services.

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Acknowledgements

This study was part of the ‘Syster Gudrun Fullskalelabb I Blekinge för IT i vård och omsorg’ research and development project (Nurse Gudrun’s full-scale lab in Blekinge for IT in nursing and caring). We would like to thank all the participants who have contributed to this study. We would also like to thank the Blekinge Research Board for generously funding the VHT project. Last but not least, we thank the School of Health Sciences, Blekinge Institute of Technology, for the support and opportunity to work in research.

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AJM, EO and BH contributed to the conceptualization and design of the study. AJM conducted data collection, analysis and drafting of the manuscript. AJM, EO, SE and BH contributed to interpretation of the results and critical revision of the manuscript. All authors have read and approved the final manuscript.

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Mahmud, A.J., Olander, E., Eriksén, S. et al. Health communication in primary health care -A case study of ICT development for health promotion. BMC Med Inform Decis Mak 13 , 17 (2013). https://doi.org/10.1186/1472-6947-13-17

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Aware that high blood pressure was an issue, state and local health planners approached the HCRC about launching a strategic communication campaign to raise awareness about the dangers of hypertension among African American populations living in six zip codes in Greater Kansas City.

Livable Streets

What zip code you live in can determine more about your health outcomes than your income or race. More Missourians have to manage multiple chronic diseases with limited access to easy ways to get active. The Missouri Livable Streets project set out to change that fact among rural audiences by increasing awareness of Complete or Livable Streets design concepts in the Heartland.

Photovoice for Mental Health/Substance Abuse Awareness

Individuals and families who experience mental illness and substance abuse report that getting help can be difficult. Moreover, they also report that staying well is just as hard. Clinical evidence and other research has shown that trauma histories are often at the root of the problem and until these trauma histories are addressed, mental illness and substance abuse are rarely successfully treated. To raise awareness and support an effective treatment, the Mental Health Board of St. Louis and NAMI St. Louis approached the HCRC about using photovoice with clients who have gone through  TREM  or  M-TREM . TREM or M-TREM stands for Trauma Recovery Empowerment Model or Men’s Trauma Recovery and Empowerment Model and has been recognized as an effective treatment modality for adults across ages, genders, races and ethnicities.

Photovoice Missouri

We wanted to see if by working with middle and high school teachers, especially in rural areas, and their students we could give teens a platform to their unique perspecitve to the individuals in their communities and advocate for change.

We thought by giving them cameras and telling them to take photographs and write about the health of their communities, we could provide the tools they would need to accomplish that goal.

Health Literacy Missouri

Understanding insurance forms, doctor’s instructions and government health programs can be difficult regardless of a person’s education. The ability, or lack thereof, to understand this sort of information is what health literacy is about. Back in 2006, when the HCRC began working in health literacy, this concept was unknown by most and misunderstood by many. Our challenge was to raise awareness about health literacy and help turn Health Literacy Missouri (HLM) into a recognized leader in the field in Missouri.

The dangers and risks of cancer to minority populations has been well documented by the national media, federal health agencies and advocacy groups. All too often, however, these stories are about the chances of getting the disease and risk of death without any mention of how to prevent cancer.

Through a collaboration with researchers at the Health Communication Research Lab at Washington University in St. Louis and funding from the National Cancer Institute, the HCRC embarked on the creation of the Ozioma News Service to send positive messages about cancer prevention out to African American newspapers around the country.

C3/SciXchange

Those who work in the sciences have their own language. Whether it is biochemistry, botany, or physics, this language is often specific to that field. Through the C3/SciXchange program, we are teaching undergraduate science students how to be bilingual. That is, teaching them how to communicate those in other fields of science as well as with the public

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• Published: 13 December 2022

What did the pandemic teach us about effective health communication? Unpacking the COVID-19 infodemic

• Eric J. Cooks   ORCID: orcid.org/0000-0003-2310-1237 1 ,
• Melissa J. Vilaro 2 ,
• Brenda W. Dyal 3 ,
• Shu Wang 4 ,
• Gillian Mertens 1 ,
• Aantaki Raisa 1 ,
• Bumsoo Kim 5 ,
• Gemme Campbell-Salome 6 ,
• Diana J. Wilkie 3 ,
• Folake Odedina 7 ,
• Versie Johnson-Mallard 8 ,
• Yingwei Yao 3 &
• Janice L. Krieger 1  

BMC Public Health volume  22 , Article number:  2339 ( 2022 ) Cite this article

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The spread of unvetted scientific information about COVID-19 presents a significant challenge to public health, adding to the urgency for increased understanding of COVID-19 information-seeking preferences that will allow for the delivery of evidence-based health communication. This study examined factors associated with COVID-19 information-seeking behavior.

An online survey was conducted with US adults ( N  = 1800) to identify key interpersonal (e.g., friends, health care providers) and mediated (e.g., TV, social media) sources of COVID-19 information. Logistic regression models were fitted to explore correlates of information-seeking.

Study findings show that the first sought and most trusted sources of COVID-19 information had different relationships with sociodemographic characteristics, perceived discrimination, and self-efficacy. Older adults had greater odds of seeking information from print materials (e.g., newspapers and magazines) and TV first. Participants with less educational attainment and greater self-efficacy preferred interpersonal sources first, with notably less preference for mass media compared to health care providers. Those with more experiences with discrimination were more likely to seek information from friends, relatives, and co-workers. Additionally, greater self-efficacy was related to increased trust in interpersonal sources.

Study results have implications for tailoring health communication strategies to reach specific subgroups, including those more vulnerable to severe illness from COVID-19. A set of recommendations are provided to assist in campaign development.

Peer Review reports

Since first identified in December 2019, the novel SARS-CoV-2 (COVID-19) virus has left a trail of death and economic disruption in its wake. In the United States (US) alone, the COVID-19 pandemic has caused more than 1 million deaths, with many more likely due to reporting errors [ 1 , 2 ]. The spread of COVID-19 can be mitigated through strategies such as mask-wearing and social distancing in public settings, and while the development of vaccines and therapeutics offer effective options for prevention and care, hesitancy and non-compliance with these treatments and strategies remains a considerable problem [ 3 ]. While new and more contagious variants continue to emerge, we have also witnessed the spread of conspiracy theories on virus origin, racist threats, and suspicion towards public health institutions that present significant challenges to public health measures [ 4 , 5 , 6 ].

This rise in COVID-related incivility, skepticism, and conspiracy beliefs can partly be attributed to high levels of dis/misinformation and distrust in media that has been described as a “hidden epidemic” [ 7 , 8 ]. As efforts to control virus spread in the US reduced opportunities for face-to-face communication, individuals turned instead to social media, TV news, and other mass media platforms often littered with inaccuracies in search of COVID-19 information. As this information went viral and became widely spread many of these “fake news” stories became ubiquitous in American culture. The spread of unvetted scientific information presents a significant challenge to public health efforts, adding to the urgency for increased understanding of information-seeking preferences during the COVID-19 pandemic that will ultimately allow for the tailored delivery of evidence-based health communication through these preferred sources and channels.

Information-seeking

According to the Protective Action Decision Model (PADM) [ 9 ], behavioral response to health risks depends partly on information exposure. By receiving timely and accurate information about COVID-19, individuals are better equipped to formulate accurate risk perceptions and engage in preventive steps [ 10 , 11 , 12 , 13 ]. Following this logic, it is essential that evidence-based COVID-19 information be translated in a manner that meets the needs of diverse stakeholder groups by understanding the factors associated with health information-seeking behavior (HISB). One strategy for understanding HISBs during the pandemic is to explore preferences for the first sought information source as an indicator of persuasiveness [ 14 ], and for sources deemed most trustworthy as a proxy for credibility [ 15 ].

The concept of uncertainty is important to HISB. The novelty of COVID-19 and lack of societal preparedness increased uncertainty in how to respond [ 16 ], increasing the likelihood that individuals will seek to manage this uncertainty by searching for relevant information [ 17 , 18 , 19 ]. Related to this idea of HISB as a tool to manage uncertainty is self-efficacy, which refers to the extent to which one believes in their ability to successfully perform a behavior [ 20 ]. Prior to engaging in a HISB, individuals have a tendency to first develop outcome expectations and evaluate whether they possess the ability to enact this search [ 21 ].

HISB during the pandemic operates within the context of advances in mass media technology, with increased use of digital media platforms (e.g., Internet search engines, social media) and the associated concerns regarding false information [ 22 , 23 ]. In addition to information received from interpersonal sources (e.g., friends, family, health care providers), information consumers now have diverse opportunities to seek and obtain health-related information with platforms such as Facebook, YouTube, and Google providing 24/7 access to information of varying quality [ 12 ]. The affordances of these platforms (e.g., sharing, liking, commenting) allow for an enhanced ability to create, receive, and disseminate health information. This increased media choice also allows for selective exposure to like-minded voices, which can lead to increased perceptions of bias within the general media [ 24 ]. Further, media slant towards a specific political ideology or issue position can be extreme within these mediated settings, with exposure having an influence on COVID-19 incidence [ 25 ]. All told, preferences for health information in the current media landscape warrant exploration to assess how audience factors are related to HISB.

While technological advancements have placed a wealth of information at our fingertips, there are disparities in who utilizes and benefits from these technologies based in part on longstanding social and digital inequalities [ 26 , 27 ]. While it has been argued that groups often marginalized by society (e.g., inequality based on age, gender, educational attainment, etc.) are simply lagging behind the curve in uptake of these technologies and will eventually bridge the gap, many of these groups often require government intervention to stimulate use and are more likely to discontinue use once begun [ 28 ]. Also, for these marginalized groups, self-efficacy in the use of technology is likely to be lower compared to those with more capital [ 29 ]. Therefore, while mass media technology provides wide reach and convenience to many, the associated inequities in use suggest that health communication campaigns seeking to tailor dissemination strategies should attend to audience features that may point to source preferences.

The COVID-19 pandemic illuminated how racial and ethnic discrimination can be amplified via the media, making HISB difficult for some groups. Anti-Asian sentiment, fueled in part by social media, has seen a dramatic increase during the pandemic, and politicians have used this crisis to propagate stereotyping and discriminatory policies against racial and ethnic minorities [ 30 , 31 , 32 ]. Black Americans who have historically been confronted with significant racism and discrimination in the US also report that their experiences with discrimination have increased during COVID-19 [ 33 ]. This lived discrimination can act as a biological stressor for which individuals must develop coping strategies, such as information-seeking [ 34 , 35 ].

Given that uncertainty about COVID-19 has increased HISB [ 36 , 37 ], focused effort is needed to deliver evidence-based health information through preferred sources in order to combat mis/disinformation and improve population health. Prior work has demonstrated that self-efficacy is positively associated with the frequency of HISB during the pandemic [ 38 , 39 ]. However additional work is needed to explore the sources people seek out first and which ones they trust the most, particularly in relation to confidence in information-seeking ability. In some cases, first sought and most trusted sources may be the same. In other cases, the sources that are most readily available to an individual may not be the most trusted. For example, some individuals may find health care providers to be highly trustworthy, but they are unavailable 24/7 to meet information needs.

Digital inequalities have also likely been exacerbated during the pandemic as marginalized groups are unable to offset the loss of in-person communication [ 40 ]; these factors may contribute to differences in HISB [ 41 ]. Further, increases in perceived discrimination may be associated with information-seeking strategies during the pandemic [ 42 ]. Building on previous work related to HISB during COVID-19 [ 41 , 43 ], the aim of this study was to investigate individual preferences for the first sought out and most trusted sources of COVID-19 information to guide tailored campaign development.

Research questions

RQ1: Are sociodemographic characteristics associated with preferences for (a) first sought and (b) most trusted source of COVID-19 information?

RQ2: Are discrimination and self-efficacy associated with preferences for (a) first sought and (b) most trusted source of COVID-19 information?

Study design and participant recruitment

Using a cross-sectional study design, between September and November 2020, a period that saw approximately 94,000 deaths from COVID-19 in the US (Johns Hopkins COVID-19 Tracker https://coronavirus.jhu.edu/us-map ), US adults aged ≥ 18 years ( N  = 1800) recruited through a panel owned by a cloud-based survey platform completed the online Florida Health Ancestry Study survey (FHAS). The sampling framework was specified so that quotas would represent the general US adult population (see Table  1 ).

Participants meeting these inclusion criteria received an electronic link to the survey. Partial responses were not recorded, but all participants were given one week to complete the survey. The “Forced Response” validation was used for all items, although participants could select “prefer not to answer.“ A $15.00 incentive was mailed to participants who completed the survey. The University of Florida Institutional Review Board (IRB201901264) approved this study with a waiver of documentation of informed consent.

Participants completed the 48-item FHAS survey developed using the behavioral core measures from NCI-designated cancer center catchment area supplements [ 44 ]. The FHAS includes investigator-derived measures related to COVID-19, perceived discrimination, and self-efficacy in obtaining health information (see supplement “additional_file_ 1 ” for more information on items used in this analysis). For all items, responses of “Don’t know” and “Prefer not to answer” were treated as missing.

COVID-19 information-seeking

To measure the first sought and most trusted sources of information about COVID-19, participants responded to two items (the COVID-19 questions in this study were adapted from a Palliative Care & Supportive Oncology Workgroup Survey and the eHealth Literacy Scale [ 45 ]), (“When you had a strong need to get information about COVID-19, where did you FIRST go to get information?“; “When you had a strong need to get information about COVID-19, which of the following did you find to be the MOST trusted as a source of information about coronavirus or COVID-19?“). For the univariable and multivariable analyses, response options for both items were dichotomized into the following sources: “Mass media” (Internet: Google or another search engine/WebMD or another medical website; Printed materials: newspapers, magazines; Social media: Facebook, Instagram, Twitter; Television) and “Interpersonal” (Conversations with people you trust: friends, relatives, or co-workers; Health care provider: doctor, nurse, social worker). Responses of “Other (Please specify:)” were treated as missing.

Self-efficacy

On a 5-point scale where 1 = “Not confident at all” and 5 = “Completely confident,“ self-efficacy was measured as confidence in obtaining general health information using a single item [ 46 ], “Overall, how confident are you that you could get advice or information about health or medical topics if you needed it?“ (M = 4.1, SD = 1.0).

Perceived discrimination

Experiences with everyday discrimination were assessed with a five-item measure on a four-point scale [ 47 ] where 0 = “Never,“ 1 = “Rarely,“ and 2 = “Sometimes”; responses of Often,“ “At least once a week,“ and “Almost every day” were categorized as 3. Participants were asked how often they are treated with less courtesy or respect than others, how often they receive poorer services at restaurants or stores, how often people act as if they are afraid of them, how often people act as if they are not smart, and how often they are threatened or harassed. Perceived discrimination was calculated as the mean score of these items (α = 0.91, M = 1.3, SD = 1.0).

Sociodemographic characteristics

Participant information about age, gender, race, education, marital status, living situation (live alone/live with someone), income, and overall health status was also obtained.

COVID-19 mitigation beliefs

On a 5-point scale where 1 = “Strongly disagree” and 5 = “Strongly agree,“ participants responded to two items asking how important they thought it was to wear a mask and maintain social distance when going out in public. These two items were combined for a mean score (α = 0.81, M = 4.5, SD = 1.0).

Analysis plan

Multivariable logistic regression models were fitted for the first source of COVID-19 information (mass media vs. interpersonal) and the most trusted source (mass media vs. interpersonal), respectively. Specifically, an odds ratio (OR) larger than 1 indicated higher odds of choosing a mass media source, and an OR smaller than 1 showed higher odds of selecting an interpersonal information source. Univariable logistic regressions were fitted first with factors identified as potentially relevant to COVID-19 information-seeking based on previous research (e.g., [ 12 , 29 , 42 , 48 , 49 ]), and factors with p -values less than 0.15 were then considered for multivariable logistic regressions. Backward selection was used to build final multivariable models. Age, race, gender, education, marital status, and overall health status were kept in the multivariable model of the first source of COVID-19 information, while living situation, income, and marital status were kept in the multivariable model of most trusted source of COVID-19 information regardless of their p -values.

Multivariable multinomial logistic regression models were also fitted for the first sought and most trusted source of COVID-19 information to look at specific associations between source types, but in a non-aggregated fashion: comparing trusted individuals vs. Internet vs. printed materials vs. social media vs. Television vs. health care providers.

Participant characteristics are presented in Table  2 . Average age was about 47 years (M = 46.6, SD = 17.5) with slightly more females (51.1%) than males (48.3%). Participants were primarily White (75.5%), followed by Black (14.8%) and Asian (5.8%). Most participants were college-educated (72.4%). In addition, a majority of participants were non-Hispanic (82.4%). Over half of the participants reported an income of $50,000 or greater (56%). Most participants were married (56.7%), living with someone else (77.6%), and did not live in a rural area (69.2%). Among the overall sample, 61.4% of participants preferred mass media as the first source of COVID-19 information, while the most trusted source was evenly split.

RQ1: How are sociodemographic characteristics associated with information seeking about COVID-19?

Table  3 presents univariable and multivariable logistic regression estimates for the association between individual characteristics and COVID-19 information-seeking behavior (See Additional file 2 : Appendix for boxplots and bar graphs of significant predictors). Tables  4 and 5 present multivariable multinomial logistic regression estimates that provide a more granulated analysis of information-seeking across source category.

Tables  3 , 4 and 5 also present univariable and multivariable logistic regression estimates along with findings from the multinomial analysis to evaluate the association between individual characteristics and COVID-19 information-seeking behavior.

Univariable/multivariable logistic model

On univariable analysis, characteristics associated with a preference for mass media as the first source of information rather than interpersonal connections were older age (OR: 1.02, p  < .01), poor health status (OR: 1.99, p  = .05), and stronger beliefs in the importance of masking and social distancing (OR: 1.27, p  < .01). Conversely, factors related to a preference for interpersonal communication as an initial source were self-identifying as Black or African American (OR: 0.63, p  = < 0.01), self-identifying as male (OR: 0.73, p  = < 0.01), and high school education or less (OR: 0.79, p  = .04). Further, related to trustworthiness, living with someone else (OR: 0.74, p  = .02). Having a higher income level (see Table  3 ) was associated with greater trust in interpersonal sources of COVID-19 information in the univariable model.

In the multivariable model, older age and stronger beliefs in the importance of masking and social distancing were independently associated with a preference for mass media as the first source of COVID-19 information. Self-identifying as male and less educational attainment were independently related to increased odds of seeking COVID-19 information first from interpersonal sources. Living with someone else was independently associated with trust in interpersonal rather than mass media sources.

Multivariable multinomial logistic model

Findings from the multivariable multinomial analysis suggest the preference of older adults for mass media as a first source of information was only significant for printed materials (e.g., newspapers, magazines) (OR: 1.02, p  = .04) and television (OR: 1.04, p  < .01) when compared to health care providers. There was no specific preference for mass media type based on mitigation beliefs. Also, while there was not a reported preference for interpersonal source based on educational attainment, the Internet (e.g., Google, WebMD) was less preferred as an initial source of COVID-19 information by participants with less formal educational attainment when compared to health care providers (OR: 0.50, p  < .01). Similarly, while males were inclined towards interpersonal sources first, there was not a meaningful difference in the preferred interpersonal source type based on gender. However, male participants did report less preference for Internet (OR: 0.70, p  = .02) and television (OR: 0.69, p  = .04) sources when compared to their health care providers.

Regarding the sources most trusted for COVID-19 information, living with someone else was not found to have a significant relationship with a preferred interpersonal source, but printed materials were considered a less trustworthy source of information compared to health care providers for individuals living with another person (OR: 0.47, p  = .02).

RQ2: How are discrimination and self-efficacy associated with information-seeking about COVID-19?

Tables  3 , 4 and 5 also present univariable and multivariable logistic regression estimates for the relationship between self-efficacy, perceived discrimination, and COVID-19 information-seeking behavior.

On univariable analysis, experiences with discrimination (OR: 0.73, p  < .01) were related to a preference for interpersonal sources of COVID-19 information. Further, greater confidence in personal health information-seeking ability (self-efficacy) was associated with seeking out interpersonal sources first (OR: 0.87, p  = .01) and regarding these sources as more trustworthy (OR: 0.79, p  < .001) compared to mass media sources.

In the multivariable model, having more experiences with discrimination was independently related to an increased odds of seeking COVID-19 information first from interpersonal sources. Increased self-efficacy was also an independent correlate of both increased preference and trust in interpersonal sources for COVID-19 information compared to mass media.

Results of the multivariable multinomial analysis suggest that individuals with stronger experiences with discrimination preferred to seek out COVID-19 information first from trusted family, relatives, or coworkers (OR: 1.30, p  = .05) and printed materials (OR: 1.5, p  < .01), but were less likely to seek information first from the Internet (OR: 0.70, p  < .01) and television (OR: 0.63, p  < .01) compared to their health care provider. There was not a meaningful difference in which interpersonal source participants preferred based on self-efficacy; however, greater efficacy was associated with less preference for the Internet (OR: 0.71, p  < .01), social media (OR: 0.66, p  = .02), and television (OR: 0.73, p  < .01) compared to health care providers.

Regarding the most trusted source of COVID-19 information, individuals with greater efficacy had smaller odds of viewing their family, relatives, or coworkers (OR: 0.76, p  = .01), Internet (OR: 0.72, p  < .01), and social media (OR:0.67, p  < .01) as a trustworthy source of information compared to health care providers. Table  6 provides a summary of the study findings.

The purpose of this study was to explore factors associated with audience preferences (first sought, most trusted) for COVID-19 information to inform the development of tailored health communication strategies. The current work adds to literature on HISB during the COVID-19 pandemic by providing evidence for the relationship between sociodemographics and source trust first proposed by Ali et al. [ 41 ], and extends by demonstrating how information sources, notably those first sought, are related to discrimination and information efficacy.

Sociodemographics driving COVID-19 information-seeking

One key finding is that mass media outlets, specifically print materials (e.g., newspapers, magazines) and TV, were preferred as initial sources for COVID-19 information for older participants. The elderly are particularly vulnerable to becoming severely ill from COVID-19, increasing the urgency for tailored communication strategies [ 50 ]. This preference for mass media as initial sources of information conflicts with previous findings suggesting that older adults rely on interpersonal sources such as health care providers and family members, not only for information but also to satisfy emotional needs stemming from social isolation during the pandemic [ 51 , 52 ].

One rationale for this inconsistency might be that the COVID-19 pandemic morphed into a political wedge issue in which risk perceptions, conspiracy beliefs, and responses to government recommendations were demarcated along partisan lines [ 6 , 53 , 54 ]. As a result, older adults might have sought information from their political echo chambers (e.g., cable news networks) rather than other sources such as government websites or health care providers [ 41 , 55 , 56 ].

Another explanation is that the novelty of the SARS-CoV-2 virus and the associated uncertainty, fear, and confusion limited the value of interpersonal discussions, prompting information to be sought elsewhere. It is worth noting that a large portion of this sample was college-educated, and other factors including health status may have contributed to this finding; individuals with chronic conditions may access COVID-19 information more often through the mass media but have less trust in these sources [ 57 ]. The interaction of age and health status on COVID-19 information-seeking is an area of future study.

Another key finding was that communication with interpersonal sources was preferred as a primary resource for information by those with lower levels of educational attainment. Further analysis revealed that there was not a significant difference in preference of first information source for participants with less formal education between preferring friends/relatives/co-workers or health care providers. However, the Internet was a less preferred source compared to health care providers for these participants, suggesting that providers can be targeted for campaigns aimed at this group. Studies of education level and COVID-19 misinformation have reported relationships with a multitude of factors, including lower confidence in government and scientific institutions as well as lower perceived infection risk [ 58 , 59 ]. However, previous research suggests that those with less formal education may perceive a greater risk of dying from COVID-19 and experience greater economic consequences because of the pandemic [ 58 ]; it is possible that this increased risk prompts information-seeking from professional sources. Further, individuals with lower levels of educational attainment are more likely to have reduced health literacy, and these individuals may instead turn to their doctors for information [ 60 ]. Educational attainment has been found to positively correlate with a diversity of sources [ 43 ], furthering the argument that education level is a barrier to information-seeking through mass media.

Mitigation beliefs

Participants with weaker beliefs in the importance of masking and social distancing when in public were more likely to seek out COVID-19 information through their interpersonal contacts first, regardless of the source. Individuals with strong doubts about the effectiveness of masking and social distancing are less prone to seek knowledge through external mass media channels, particularly when there is evolving information [ 61 ]. This finding offers confirming evidence for previous research demonstrating a significant relationship between COVID-19 information-seeking and adherence to mitigation strategies [ 62 ].

Given the politicization and polarization of the pandemic, those more skeptical of mitigation strategies would be more likely to look for information within their interpersonal networks rather than a media system that is viewed as biased [ 26 , 63 , 64 ]. These individuals may be challenging to target with health communication campaigns. However, given the demonstrated direct relationship between COVID-19 information seeking and preventive behavior [ 65 , 66 ], there is a pressing need for evidence-based efforts.

Discrimination and self-efficacy driving COVID-19 information-seeking

Discrimination.

Individuals reporting more common experiences with discrimination also described a greater preference for interpersonal contacts as an initial source for COVID-19 information, specifically friends, relatives, and co-workers. Discrimination can cause a delay in seeking medical care, including cancer screenings [ 67 ], and significantly increases stress response [ 68 ]. One speculation for this finding is that while mass media may be used as a means of coping with the stress that comes along with mistreatment, information exposure during a health crisis such as COVID-19 can intensify feelings of stress, leading to avoidance [ 69 , 70 ]. Given the high levels of discrimination reported during the pandemic [ 71 , 72 ], these groups may find it less distressing to receive information from trusted interpersonal sources, particularly those that share similar demographic backgrounds [ 69 ]. Additional research is needed to disentangle the effect of different sources of discrimination (e.g., gender, race, ethnicity) on information-seeking about COVID-19 [ 73 ].

Finally, this work also found that individuals with greater confidence in their ability to obtain health information preferred to seek out interpersonal sources first, with a particularly lower preference for the Internet, social media, and TV compared to their health care provider. Participants with greater efficacy also found interpersonal sources to be more trustworthy, yet maintained a lower perception of trustworthiness for friends, relatives, and family compared to health care providers. Individuals tend to make determinations on whether to engage in information-seeking by evaluating three types of efficacies: communication efficacy (whether the individual has the skill to seek information), target efficacy (whether their interpersonal source has the knowledge and is willing to share it), and coping efficacy (whether the individual can emotionally deal with the information) [ 21 ]. Thus, individuals with greater efficacy may feel more confidence in their ability to seek information from interpersonal sources based on their communication skills, beliefs that their interpersonal sources have reliable information, and beliefs that they can cope with the information potentially shared.

Interpersonal sources may also help calm the often overwhelming “noise” of competing and emerging information shared by media channels. Individuals who are confident in obtaining health information are also more likely to experience feelings such as fatalism when they experience challenges and frustrations in seeking this information [ 74 ]. Therefore, individuals with increased self-efficacy in their HISB may prefer to engage with interpersonal sources rather than mass media to attenuate the uncertainty associated with this massive influx of information.

Practical implications

Audience segmentation refers to the process of dividing an audience into definable, measurable groups to create messaging that is responsive to specific population needs [ 75 ]. This approach to message design can significantly impact engagement, as well as attitude and behavior change [ 76 ] and is thus considered an essential piece of tailored communication strategies already applied to COVID-19 messaging [ 69 ].

Findings from this study have meaningful implications for future practice through the identified audience variations regarding information-seeking preferences. These results can be leveraged to enhance the capability of specific target audiences to engage with evidence-based COVID-19 information. The politicization of COVID-19 and its influence on health inequalities, along with the rapid and uneven pace of information dissemination on COVID-19 guidelines, has been a challenge for effective health communication [ 77 ]. Thus, health communication campaigns that can efficiently identify strategies to reach various audiences in a targeted manner will have increased effectiveness. The following guidelines should be priority considerations when developing audience-focused COVID-19 information campaigns:

Understand the unique contexts of the intended audience, including the influence of societal inequalities on information-seeking behavior. Taking a user-centered approach to campaign design that actively seeks out and incorporates feedback will ensure that the preferences, needs, and values of the target audience are fully understood. This approach will also enhance campaign acceptability while reducing the effort required to engage with its components, all of which will increase efficacy. We offer the following specific recommendations for campaign tailoring based on the findings of this study:

Campaigns targeting older adults should develop materials for dissemination through television and print.

When developing campaigns targeting individuals with less formal educational attainment, include medical professionals.

Incorporating close social ties (i.e., friends, relatives, and co-workers) may increase the effectiveness of campaigns targeting groups experiencing discrimination.

Audiences with greater efficacy can be effectively targeted through their health care provider, whereas those with weaker beliefs in their ability to obtain health information can be better reached through the Internet (e.g., WebMD) and social media.

In addition to examining the “what” and “how” of message dissemination, the “where” and “who” should also be carefully considered. Theoretical frameworks such as diffusion of innovations [ 78 ] and social influence [ 79 ] can serve as starting points to further understand the influence of social networks and source credibility in information-seeking. Building capacity to bring these campaigns to scale will also be required and can be facilitated through the development of diverse collaborations that include community members and other stakeholders.

Lastly, consider the context of the topic and understand that source preferences for information may vary when the topics change, particularly given the political climate (e.g., COVID-19 information seeking may be very different than cancer screening). Campaign development should be iterative and agile in order to adapt to the fluidity inherent to these politically charged health topics, with systems in place for ongoing evaluation.

Strengths and limitations

This study adds to the literature on information-seeking about COVID-19 through the examination of sources of COVID-19 information most likely to be sought first and the exploration of the role of discrimination and self-efficacy on source preference (i.e., first sought and most trusted). The findings also offer support for previous research on the influence of sociodemographic factors in HISB.

This study is not without limitations. The measures of information sources may contain within-group differences (e.g., different social media platforms such as Facebook and Twitter are often used in different ways). Yet, this study provides compelling evidence for HISB during the pandemic and how individuals can be targeted with persuasive messaging. Also, while this online survey asked only for the FIRST preferred source or the MOST trusted, communication does not occur in a vacuum. Mass and interpersonal methods of communication are becoming increasingly intermingled [ 77 ], and factors such as authority (e.g., government websites and health care providers) might play a role [ 41 ]. Additional research is needed to build information-seeking models of increasing complexity surrounding the interplay of these factors.

The COVID-19 pandemic has weakened the US economy and led to tremendous life loss, and the uptake of protective measures is lacking due in part to false information being circulated within the media and personal networks. The findings of this study contribute to our understanding of how people are seeking out information about COVID-19 during the pandemic, which will allow for the development of evidence-based dissemination strategies. As information-seeking increases during the pandemic, exposure to risk information can have a direct tie to behavior, and the results of this study suggest that even with such a wide diversity of digital information sources and the capacity for scalable health communication campaigns that maximizing efforts to involve interpersonal connections may be preferable for some individuals. This idea is even more relevant during the current infodemic, where mass media channels have, in many ways, been corrupted by misinformation. By considering the audience factors illuminated in this study, researchers and practitioners become better equipped to deliver messaging through the sources and channels that are highly sought and trusted.

Availability of data and materials

Data are available upon request from the corresponding author.

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Research reported in this publication was supported by the State of Florida, the Florida Academic Cancer Center Alliance (FACCA), and the University of Florida Health Cancer Center (UFHCC), Cancer Population Sciences research program, and Biostatistics & Quantitative Sciences Shared Resource (BQS-SR). This research was also supported by the Team-based Interdisciplinary Cancer Research Training Program (T32 CA257923) at the University of Florida Health Cancer Center. And Grant Number U54CA233444 from the National Institutes of Health (NIH), National Cancer Institute (NCI). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the State of Florida, FACCA, NIH, or NCI.

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Contributions. EJC: Conceptualization, Writing – Original Draft, Writing – Review & Editing; MJV: Conceptualization, Writing—Original Draft, Writing-Review & Editing; BWD: Conceptualization, Methodology, Investigation, Writing – Original Draft, Writing-Review & Editing; SW: Formal analysis, Methodology, Writing-Original Draft, Writing-Review & Editing; GM: Writing-Original Draft, Writing-Review & Editing; AR: Conceptualization; Writing-Original Draft; BK: Conceptualization, Writing – Original Draft; Writing-Review & Editing; GCS: Conceptualization, Writing—Original Draft, Writing-Review & Editing; DJW: Funding Acquisition, Methodology, Investigation, Writing-Review & Editing; FO: Funding Acquisition, Methodology, Investigation, Writing-Review & Editing; VJM: Investigation, Writing-Review & Editing; YY: Methodology, Investigation, Writing-Review & Editing; JLK: Funding Acquisition, Conceptualization, Methodology, Investigation, Writing—Original Draft, Writing-Review & Editing. *All authors have read and approved the final manuscript. *

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Supplementary Information

Additional file 1..

 Study questionnaire. 

Additional file 2: Appendix 1.

Boxplots and bar graphs for predictors of COVID-19 information-seeking. 

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Cooks, E.J., Vilaro, M.J., Dyal, B.W. et al. What did the pandemic teach us about effective health communication? Unpacking the COVID-19 infodemic. BMC Public Health 22 , 2339 (2022). https://doi.org/10.1186/s12889-022-14707-3

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Communication Case Studies for Health Care Professionals: An Applied Approach, by Pagano, M

2017, Health Communication

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Elaine Hsieh (MA, Monterey Institute of International Studies; Ph.D., University of Illinois at Urbana-Champaign; J.D., University of Oklahoma) is an internationally accomplished researcher. She is a Professor and Chair in the Department of Communication Studies at the University of Minnesota. Before coming to the University of Minnesota, she was a Professor and Presidential Professor at the University of Oklahoma. She has worked professionally as a translator and an interpreter in the US and Taiwan. As an NIH-funded researcher and a Fulbright Scholar, she examines the universal and culturally-specific experiences of minority and marginalized populations.

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Health Case Studies

(29 reviews)

Glynda Rees, British Columbia Institute of Technology

Rob Kruger, British Columbia Institute of Technology

Janet Morrison, British Columbia Institute of Technology

Copyright Year: 2017

Publisher: BCcampus

Language: English

Formats Available

Conditions of use.

Learn more about reviews.

Reviewed by Jessica Sellars, Medical assistant office instructor, Blue Mountain Community College on 10/11/23

This is a book of compiled and very well organized patient case studies. The author has broken it up by disease patient was experiencing and even the healthcare roles that took place in this patients care. There is a well thought out direction and... read more

Comprehensiveness rating: 5 see less

This is a book of compiled and very well organized patient case studies. The author has broken it up by disease patient was experiencing and even the healthcare roles that took place in this patients care. There is a well thought out direction and plan. There is an appendix to refer to as well if you are needing to find something specific quickly. I have been looking for something like this to help my students have a base to do their project on. This is the most comprehensive version I have found on the subject.

Content Accuracy rating: 5

This is a book compiled of medical case studies. It is very accurate and can be used to learn from great care and mistakes.

Relevance/Longevity rating: 5

This material is very relevant in this context. It also has plenty of individual case studies to utilize in many ways in all sorts of medical courses. This is a very useful textbook and it will continue to be useful for a very long time as you can still learn from each study even if medicine changes through out the years.

Clarity rating: 5

The author put a lot of thought into the ease of accessibility and reading level of the target audience. There is even a "how to use this resource" section which could be extremely useful to students.

Consistency rating: 5

The text follows a very consistent format throughout the book.

Modularity rating: 5

Each case study is individual broken up and in a group of similar case studies. This makes it extremely easy to utilize.

Organization/Structure/Flow rating: 5

The book is very organized and the appendix is through. It flows seamlessly through each case study.

Interface rating: 5

I had no issues navigating this book, It was clearly labeled and very easy to move around in.

Grammatical Errors rating: 5

I did not catch any grammar errors as I was going through the book

Cultural Relevance rating: 5

This is a challenging question for any medical textbook. It is very culturally relevant to those in medical or medical office degrees.

I have been looking for something like this for years. I am so happy to have finally found it.

Reviewed by Cindy Sun, Assistant Professor, Marshall University on 1/7/23

Interestingly, this is not a case of ‘you get what you pay for’. Instead, not only are the case studies organized in a fashion for ease of use through a detailed table of contents, the authors have included more support for both faculty and... read more

Interestingly, this is not a case of ‘you get what you pay for’. Instead, not only are the case studies organized in a fashion for ease of use through a detailed table of contents, the authors have included more support for both faculty and students. For faculty, the introduction section titled ‘How to use this resource’ and individual notes to educators before each case study contain application tips. An appendix overview lists key elements as issues / concepts, scenario context, and healthcare roles for each case study. For students, learning objectives are presented at the beginning of each case study to provide a framework of expectations.

The content is presented accurately and realistic.

The case studies read similar to ‘A Day In the Life of…’ with detailed intraprofessional communications similar to what would be overheard in patient care areas. The authors present not only the view of the patient care nurse, but also weave interprofessional vantage points through each case study by including patient interaction with individual professionals such as radiology, physician, etc.

In addition to objective assessment findings, the authors integrate standard orders for each diagnosis including medications, treatments, and tests allowing the student to incorporate pathophysiology components to their assessments.

Each case study is arranged in the same framework for consistency and ease of use.

This compilation of eight healthcare case studies focusing on new onset and exacerbation of prevalent diagnoses, such as heart failure, deep vein thrombosis, cancer, and chronic obstructive pulmonary disease advancing to pneumonia.

Each case study has a photo of the ‘patient’. Simple as this may seem, it gives an immediate mental image for the student to focus.

Interface rating: 4

As noted by previous reviewers, most of the links do not connect active web pages. This may be due to the multiple options for accessing this resource (pdf download, pdf electronic, web view, etc.).

Grammatical Errors rating: 4

A minor weakness that faculty will probably need to address prior to use is regarding specific term usages differences between Commonwealth countries and United States, such as lung sound descriptors as ‘quiet’ in place of ‘diminished’ and ‘puffers’ in place of ‘inhalers’.

The authors have provided a multicultural, multigenerational approach in selection of patient characteristics representing a snapshot of today’s patient population. Additionally, one case study focusing on heart failure is about a middle-aged adult, contrasting to the average aged patient the students would normally see during clinical rotations. This option provides opportunities for students to expand their knowledge on risk factors extending beyond age.

This resource is applicable to nursing students learning to care for patients with the specific disease processes presented in each case study or for the leadership students focusing on intraprofessional communication. Educators can assign as a supplement to clinical experiences or as an in-class application of knowledge.

Reviewed by Stephanie Sideras, Assistant Professor, University of Portland on 8/15/22

The eight case studies included in this text addressed high frequency health alterations that all nurses need to be able to manage competently. While diabetes was not highlighted directly, it was included as a potential comorbidity. The five... read more

The eight case studies included in this text addressed high frequency health alterations that all nurses need to be able to manage competently. While diabetes was not highlighted directly, it was included as a potential comorbidity. The five overarching learning objectives pulled from the Institute of Medicine core competencies will clearly resonate with any faculty familiar with Quality and Safety Education for Nurses curriculum.

The presentation of symptoms, treatments and management of the health alterations was accurate. Dialogue between the the interprofessional team was realistic. At times the formatting of lab results was confusing as they reflected reference ranges specific to the Canadian healthcare system but these occurrences were minimal and could be easily adapted.

The focus for learning from these case studies was communication - patient centered communication and interprofessional team communication. Specific details, such as drug dosing, was minimized, which increases longevity and allows for easy individualization of the case data.

While some vocabulary was specific to the Canadian healthcare system, overall the narrative was extremely engaging and easy to follow. Subjective case data from patient or provider were formatted in italics and identified as 'thoughts'. Objective and behavioral case data were smoothly integrated into the narrative.

The consistency of formatting across the eight cases was remarkable. Specific learning objectives are identified for each case and these remain consistent across the range of cases, varying only in the focus for the goals for each different health alterations. Each case begins with presentation of essential patient background and the progress across the trajectory of illness as the patient moves from location to location encountering different healthcare professionals. Many of the characters (the triage nurse in the Emergency Department, the phlebotomist) are consistent across the case situations. These consistencies facilitate both application of a variety of teaching methods and student engagement with the situated learning approach.

Case data is presented by location and begins with the patient's first encounter with the healthcare system. This allows for an examination of how specific trajectories of illness are manifested and how care management needs to be prioritized at different stages. This approach supports discussions of care transitions and the complexity of the associated interprofessional communication.

The text is well organized. The case that has two levels of complexity is clearly identified

The internal links between the table of contents and case specific locations work consistently. In the EPUB and the Digital PDF the external hyperlinks are inconsistently valid.

The grammatical errors were minimal and did not detract from readability

Cultural diversity is present across the cases in factors including race, ethnicity, socioeconomic status, family dynamics and sexual orientation.

The level of detail included in these cases supports a teaching approach to address all three spectrums of learning - knowledge, skills and attitudes - necessary for the development of competent practice. I also appreciate the inclusion of specific assessment instruments that would facilitate a discussion of evidence based practice. I will enjoy using these case to promote clinical reasoning discussions of data that is noticed and interpreted with the resulting prioritizes that are set followed by reflections that result from learner choices.

Reviewed by Chris Roman, Associate Professor, Butler University on 5/19/22

It would be extremely difficult for a book of clinical cases to comprehensively cover all of medicine, and this text does not try. Rather, it provides cases related to common medical problems and introduces them in a way that allows for various... read more

Comprehensiveness rating: 4 see less

It would be extremely difficult for a book of clinical cases to comprehensively cover all of medicine, and this text does not try. Rather, it provides cases related to common medical problems and introduces them in a way that allows for various learning strategies to be employed to leverage the cases for deeper student learning and application.

The narrative form of the cases is less subject to issues of accuracy than a more content-based book would be. That said, the cases are realistic and reasonable, avoiding being too mundane or too extreme.

These cases are narrative and do not include many specific mentions of drugs, dosages, or other aspects of clinical care that may grow/evolve as guidelines change. For this reason, the cases should be “evergreen” and can be modified to suit different types of learners.

Clarity rating: 4

The text is written in very accessible language and avoids heavy use of technical language. Depending on the level of learner, this might even be too simplistic and omit some details that would be needed for physicians, pharmacists, and others to make nuanced care decisions.

The format is very consistent with clear labeling at transition points.

The authors point out in the introductory materials that this text is designed to be used in a modular fashion. Further, they have built in opportunities to customize each cases, such as giving dates of birth at “19xx” to allow for adjustments based on instructional objectives, etc.

The organization is very easy to follow.

I did not identify any issues in navigating the text.

The text contains no grammatical errors, though the language is a little stiff/unrealistic in some cases.

Cases involve patients and members of the care team that are of varying ages, genders, and racial/ethnic backgrounds

Reviewed by Trina Larery, Assistant Professor, Pittsburg State University on 4/5/22

The book covers common scenarios, providing allied health students insight into common health issues. The information in the book is thorough and easily modified if needed to include other scenarios not listed. The material was easy to understand... read more

The book covers common scenarios, providing allied health students insight into common health issues. The information in the book is thorough and easily modified if needed to include other scenarios not listed. The material was easy to understand and apply to the classroom. The E-reader format included hyperlinks that bring the students to subsequent clinical studies.

Content Accuracy rating: 4

The treatments were explained and rationales were given, which can be very helpful to facilitate effective learning for a nursing student or novice nurse. The case studies were accurate in explanation. The DVT case study incorrectly identifies the location of the clot in the popliteal artery instead of in the vein.

The content is relevant to a variety of different types of health care providers and due to the general nature of the cases, will remain relevant over time. Updates should be made annually to the hyperlinks and to assure current standard of practice is still being met.

Clear, simple and easy to read.

Consistent with healthcare terminology and framework throughout all eight case studies.

The text is modular. Cases can be used individually within a unit on the given disease process or relevant sections of a case could be used to illustrate a specific point providing great flexibility. The appendix is helpful in locating content specific to a certain diagnosis or a certain type of health care provider.

The book is well organized, presenting in a logical clear fashion. The appendix allows the student to move about the case study without difficulty.

The interface is easy and simple to navigate. Some links to external sources might need to be updated regularly since those links are subject to change based on current guidelines. A few hyperlinks had "page not found".

Few grammatical errors were noted in text.

The case studies include people of different ethnicities, socioeconomic status, ages, and genders to make this a very useful book.

I enjoyed reading the text. It was interesting and relevant to today's nursing student. There are roughly 25 broken online links or "pages not found", care needs to be taken to update at least annually and assure links are valid and utilizing the most up to date information.

Reviewed by Benjamin Silverberg, Associate Professor/Clinician, West Virginia University on 3/24/22

The appendix reviews the "key roles" and medical venues found in all 8 cases, but is fairly spartan on medical content. The table of contents at the beginning only lists the cases and locations of care. It can be a little tricky to figure out what... read more

Comprehensiveness rating: 3 see less

The appendix reviews the "key roles" and medical venues found in all 8 cases, but is fairly spartan on medical content. The table of contents at the beginning only lists the cases and locations of care. It can be a little tricky to figure out what is going on where, especially since each case is largely conversation-based. Since this presents 8 cases (really 7 with one being expanded upon), there are many medical topics (and venues) that are not included. It's impossible to include every kind of situation, but I'd love to see inclusion of sexual health, renal pathology, substance abuse, etc.

Though there are differences in how care can be delivered based on personal style, changing guidelines, available supplies, etc, the medical accuracy seems to be high. I did not detect bias or industry influence.

Relevance/Longevity rating: 4

Medications are generally listed as generics, with at least current dosing recommendations. The text gives a picture of what care looks like currently, but will be a little challenging to update based on new guidelines (ie, it can be hard to find the exact page in which a medication is dosed/prescribed). Even if the text were to be a little out of date, an instructor can use that to point out what has changed (and why).

Clear text, usually with definitions of medical slang or higher-tier vocabulary. Minimal jargon and there are instances where the "characters" are sorting out the meaning as well, making it accessible for new learners, too.

Overall, the style is consistent between cases - largely broken up into scenes and driven by conversation rather than descriptions of what is happening.

There are 8 (well, again, 7) cases which can be reviewed in any order. Case #2 builds upon #1, which is intentional and a good idea, though personally I would have preferred one case to have different possible outcomes or even a recurrence of illness. Each scene within a case is reasonably short.

Organization/Structure/Flow rating: 4

These cases are modular and don't really build on concepts throughout. As previously stated, case #2 builds upon #1, but beyond that, there is no progression. (To be sure, the authors suggest using case #1 for newer learners and #2 for more advanced ones.) The text would benefit from thematic grouping, a longer introduction and debriefing for each case (there are learning objectives but no real context in medical education nor questions to reflect on what was just read), and progressively-increasing difficulty in medical complexity, ethics, etc.

I used the PDF version and had no interface issues. There are minimal photographs and charts. Some words are marked in blue but those did not seem to be hyperlinked anywhere.

No noticeable errors in grammar, spelling, or formatting were noted.

I appreciate that some diversity of age and ethnicity were offered, but this could be improved. There were Canadian Indian and First Nations patients, for example, as well as other characters with implied diversity, but there didn't seem to be any mention of gender diverse or non-heterosexual people, or disabilities. The cases tried to paint family scenes (the first patient's dog was fairly prominently mentioned) to humanize them. Including more cases would allow for more opportunities to include sex/gender minorities, (hidden) disabilities, etc.

The text (originally from 2017) could use an update. It could be used in conjunction with other Open Texts, as a compliment to other coursework, or purely by itself. The focus is meant to be on improving communication, but there are only 3 short pages at the beginning of the text considering those issues (which are really just learning objectives). In addition to adding more cases and further diversity, I personally would love to see more discussion before and after the case to guide readers (and/or instructors). I also wonder if some of the ambiguity could be improved by suggesting possible health outcomes - this kind of counterfactual comparison isn't possible in real life and could be really interesting in a text. Addition of comprehension/discussion questions would also be worthwhile.

Reviewed by Danielle Peterson, Assistant Professor, University of Saint Francis on 12/31/21

This text provides readers with 8 case studies which include both chronic and acute healthcare issues. Although not comprehensive in regard to types of healthcare conditions, it provides a thorough look at the communication between healthcare... read more

This text provides readers with 8 case studies which include both chronic and acute healthcare issues. Although not comprehensive in regard to types of healthcare conditions, it provides a thorough look at the communication between healthcare workers in acute hospital settings. The cases are primarily set in the inpatient hospital setting, so the bulk of the clinical information is basic emergency care and inpatient protocol: vitals, breathing, medication management, etc. The text provides a table of contents at opening of the text and a handy appendix at the conclusion of the text that outlines each case’s issue(s), scenario, and healthcare roles. No index or glossary present.

Although easy to update, it should be noted that the cases are taking place in a Canadian healthcare system. Terms may be unfamiliar to some students including “province,” “operating theatre,” “physio/physiotherapy,” and “porter.” Units of measurement used include Celsius and meters. Also, the issue of managed care, health insurance coverage, and length of stay is missing for American students. These are primary issues that dictate much of the healthcare system in the US and a primary job function of social workers, nurse case managers, and medical professionals in general. However, instructors that wish to add this to the case studies could do so easily.

The focus of this text is on healthcare communication which makes it less likely to become obsolete. Much of the clinical information is stable healthcare practice that has been standard of care for quite some time. Nevertheless, given the nature of text, updates would be easy to make. Hyperlinks should be updated to the most relevant and trustworthy sources and checked frequently for effectiveness.

The spacing that was used to note change of speaker made for ease of reading. Although unembellished and plain, I expect students to find this format easy to digest and interesting, especially since the script is appropriately balanced with ‘human’ qualities like the current TV shows and songs, the use of humor, and nonverbal cues.

A welcome characteristic of this text is its consistency. Each case is presented in a similar fashion and the roles of the healthcare team are ‘played’ by the same character in each of the scenarios. This allows students to see how healthcare providers prioritize cases and juggle the needs of multiple patients at once. Across scenarios, there was inconsistency in when clinical terms were hyperlinked.

The text is easily divisible into smaller reading sections. However, since the nature of the text is script-narrative format, if significant reorganization occurs, one will need to make sure that the communication of the script still makes sense.

The text is straightforward and presented in a consistent fashion: learning objectives, case history, a script of what happened before the patient enters the healthcare setting, and a script of what happens once the patient arrives at the healthcare setting. The authors use the term, “ideal interactions,” and I would agree that these cases are in large part, ‘best case scenarios.’ Due to this, the case studies are well organized, clear, logical, and predictable. However, depending on the level of student, instructors may want to introduce complications that are typical in the hospital setting.

The interface is pleasing and straightforward. With exception to the case summary and learning objectives, the cases are in narrative, script format. Each case study supplies a photo of the ‘patient’ and one of the case studies includes a link to a 3-minute video that introduces the reader to the patient/case. One of the highlights of this text is the use of hyperlinks to various clinical practices (ABG, vital signs, transfer of patient). Unfortunately, a majority of the links are broken. However, since this is an open text, instructors can update the links to their preference.

Although not free from grammatical errors, those that were noticed were minimal and did not detract from reading.

Cultural Relevance rating: 4

Cultural diversity is visible throughout the patients used in the case studies and includes factors such as age, race, socioeconomic status, family dynamics, and sexual orientation. A moderate level of diversity is noted in the healthcare team with some stereotypes: social workers being female, doctors primarily male.

As a social work instructor, I was grateful to find a text that incorporates this important healthcare role. I would have liked to have seen more content related to advance directives, mediating decision making between the patient and care team, emotional and practical support related to initial diagnosis and discharge planning, and provision of support to colleagues, all typical roles of a medical social worker. I also found it interesting that even though social work was included in multiple scenarios, the role was only introduced on the learning objectives page for the oncology case.

Reviewed by Crystal Wynn, Associate Professor, Virginia State University on 7/21/21

The text covers a variety of chronic diseases within the cases; however, not all of the common disease states were included within the text. More chronic diseases need to be included such as diabetes, cancer, and renal failure. Not all allied... read more

The text covers a variety of chronic diseases within the cases; however, not all of the common disease states were included within the text. More chronic diseases need to be included such as diabetes, cancer, and renal failure. Not all allied health care team members are represented within the case study. Key terms appear throughout the case study textbook and readers are able to click on a hyperlink which directs them to the definition and an explanation of the key term.

Content is accurate, error-free and unbiased.

The content is up-to-date, but not in a way that will quickly make the text obsolete within a short period of time. The text is written and/or arranged in such a way that necessary updates will be relatively easy and straightforward to implement.

The text is written in lucid, accessible prose, and provides adequate context for any jargon/technical terminology used

The text is internally consistent in terms of terminology and framework.

The text is easily and readily divisible into smaller reading sections that can be assigned at different points within the course. Each case can be divided into a chronic disease state unit, which will allow the reader to focus on one section at a time.

Organization/Structure/Flow rating: 3

The topics in the text are presented in a logical manner. Each case provides an excessive amount of language that provides a description of the case. The cases in this text reads more like a novel versus a clinical textbook. The learning objectives listed within each case should be in the form of questions or activities that could be provided as resources for instructors and teachers.

Interface rating: 3

There are several hyperlinks embedded within the textbook that are not functional.

The text contains no grammatical errors.

Cultural Relevance rating: 3

The text is not culturally insensitive or offensive in any way. More examples of cultural inclusiveness is needed throughout the textbook. The cases should be indicative of individuals from a variety of races and ethnicities.

Reviewed by Rebecca Hillary, Biology Instructor, Portland Community College on 6/15/21

This textbook consists of a collection of clinical case studies that can be applicable to a wide range of learning environments from supplementing an undergraduate Anatomy and Physiology Course, to including as part of a Medical or other health... read more

This textbook consists of a collection of clinical case studies that can be applicable to a wide range of learning environments from supplementing an undergraduate Anatomy and Physiology Course, to including as part of a Medical or other health care program. I read the textbook in E-reader format and this includes hyperlinks that bring the students to subsequent clinical study if the book is being used in a clinical classroom. This book is significantly more comprehensive in its approach from other case studies I have read because it provides a bird’s eye view of the many clinicians, technicians, and hospital staff working with one patient. The book also provides real time measurements for patients that change as they travel throughout the hospital until time of discharge.

Each case gave an accurate sense of the chaos that would be present in an emergency situation and show how the conditions affect the practitioners as well as the patients. The reader gets an accurate big picture--a feel for each practitioner’s point of view as well as the point of view of the patient and the patient’s family as the clock ticks down and the patients are subjected to a number of procedures. The clinical information contained in this textbook is all in hyperlinks containing references to clinical skills open text sources or medical websites. I did find one broken link on an external medical resource.

The diseases presented are relevant and will remain so. Some of the links are directly related to the Canadian Medical system so they may not be applicable to those living in other regions. Clinical links may change over time but the text itself will remain relevant.

Each case study clearly presents clinical data as is it recorded in real time.

Each case study provides the point of view of several practitioners and the patient over several days. While each of the case studies covers different pathology they all follow this same format, several points of view and data points, over a number of days.

The case studies are divided by days and this was easy to navigate as a reader. It would be easy to assign one case study per body system in an Anatomy and Physiology course, or to divide them up into small segments for small in class teaching moments.

The topics are presented in an organized way showing clinical data over time and each case presents a large number of view points. For example, in the first case study, the patient is experiencing difficulty breathing. We follow her through several days from her entrance to the emergency room. We meet her X Ray Technicians, Doctor, Nurses, Medical Assistant, Porter, Physiotherapist, Respiratory therapist, and the Lab Technicians running her tests during her stay. Each practitioner paints the overall clinical picture to the reader.

I found the text easy to navigate. There were not any figures included in the text, only clinical data organized in charts. The figures were all accessible via hyperlink. Some figures within the textbook illustrating patient scans could have been helpful but I did not have trouble navigating the links to visualize the scans.

I did not see any grammatical errors in the text.

The patients in the text are a variety of ages and have a variety of family arrangements but there is not much diversity among the patients. Our seven patients in the eight case studies are mostly white and all cis gendered.

Some of the case studies, for example the heart failure study, show clinical data before and after drug treatments so the students can get a feel for mechanism in physiological action. I also liked that the case studies included diet and lifestyle advice for the patients rather than solely emphasizing these pharmacological interventions. Overall, I enjoyed reading through these case studies and I plan to utilize them in my Anatomy and Physiology courses.

Reviewed by Richard Tarpey, Assistant Professor, Middle Tennessee State University on 5/11/21

As a case study book, there is no index or glossary. However, medical and technical terms provide a useful link to definitions and explanations that will prove useful to students unfamiliar with the terms. The information provided is appropriate... read more

As a case study book, there is no index or glossary. However, medical and technical terms provide a useful link to definitions and explanations that will prove useful to students unfamiliar with the terms. The information provided is appropriate for entry-level health care students. The book includes important health problems, but I would like to see coverage of at least one more chronic/lifestyle issue such as diabetes. The book covers adult issues only.

Content is accurate without bias

The content of the book is relevant and up-to-date. It addresses conditions that are prevalent in today's population among adults. There are no pediatric cases, but this does not significantly detract from the usefulness of the text. The format of the book lends to easy updating of data or information.

The book is written with clarity and is easy to read. The writing style is accessible and technical terminology is explained with links to more information.

Consistency is present. Lack of consistency is typically a problem with case study texts, but this book is consistent with presentation, format, and terminology throughout each of the eight cases.

The book has high modularity. Each of the case studies can be used independently from the others providing flexibility. Additionally, each case study can be partitioned for specific learning objectives based on the learning objectives of the course or module.

The book is well organized, presenting students conceptually with differing patient flow patterns through a hospital. The patient information provided at the beginning of each case is a wonderful mechanism for providing personal context for the students as they consider the issues. Many case studies focus on the problem and the organization without students getting a patient's perspective. The patient perspective is well represented in these cases.

The navigation through the cases is good. There are some terminology and procedure hyperlinks within the cases that do not work when accessed. This is troubling if you intend to use the text for entry-level health care students since many of these links are critical for a full understanding of the case.

There are some non-US variants of spelling and a few grammatical errors, but these do not detract from the content of the messages of each case.

The book is inclusive of differing backgrounds and perspectives. No insensitive or offensive references were found.

I like this text for its application flexibility. The book is useful for non-clinical healthcare management students to introduce various healthcare-related concepts and terminology. The content is also helpful for the identification of healthcare administration managerial issues for students to consider. The book has many applications.

Reviewed by Paula Baldwin, Associate Professor/Communication Studies, Western Oregon University on 5/10/21

The different case studies fall on a range, from crisis care to chronic illness care. read more

The different case studies fall on a range, from crisis care to chronic illness care.

The contents seems to be written as they occurred to represent the most complete picture of each medical event's occurence.

These case studies are from the Canadian medical system, but that does not interfere with it's applicability.

It is written for a medical audience, so the terminology is mostly formal and technical.

Some cases are shorter than others and some go in more depth, but it is not problematic.

The eight separate case studies is the perfect size for a class in the quarter system. You could combine this with other texts, videos or learning modalities, or use it alone.

As this is a case studies book, there is not a need for a logical progression in presentation of topics.

No problems in terms of interface.

I have not seen any grammatical errors.

I did not see anything that was culturally insensitive.

I used this in a Health Communication class and it has been extraordinarily successful. My studies are analyzing the messaging for the good, the bad, and the questionable. The case studies are widely varied and it gives the class insights into hospital experiences, both front and back stage, that they would not normally be able to examine. I believe that because it is based real-life medical incidents, my students are finding the material highly engaging.

Reviewed by Marlena Isaac, Instructor, Aiken Technical College on 4/23/21

This text is great to walk through patient care with entry level healthcare students. The students are able to take in the information, digest it, then provide suggestions to how they would facilitate patient healing. Then when they are faced with... read more

This text is great to walk through patient care with entry level healthcare students. The students are able to take in the information, digest it, then provide suggestions to how they would facilitate patient healing. Then when they are faced with a situation in clinical they are not surprised and now how to move through it effectively.

The case studies provided accurate information that relates to the named disease.

It is relevant to health care studies and the development of critical thinking.

Cases are straightforward with great clinical information.

Clinical information is provided concisely.

Appropriate for clinical case study.

Presented to facilitate information gathering.

Takes a while to navigate in the browser.

Cultural Relevance rating: 1

Text lacks adequate representation of minorities.

Reviewed by Kim Garcia, Lecturer III, University of Texas Rio Grande Valley on 11/16/20

The book has 8 case studies, so obviously does not cover the whole of medicine, but the cases provided are descriptive and well developed. Cases are presented at different levels of difficulty, making the cases appropriate for students at... read more

The book has 8 case studies, so obviously does not cover the whole of medicine, but the cases provided are descriptive and well developed. Cases are presented at different levels of difficulty, making the cases appropriate for students at different levels of clinical knowledge. The human element of both patient and health care provider is well captured. The cases are presented with a focus on interprofessional interaction and collaboration, more so than teaching medical content.

Content is accurate and un-biased. No errors noted. Most diagnostic and treatment information is general so it will remain relevant over time. The content of these cases is more appropriate for teaching interprofessional collaboration and less so for teaching the medical care for each diagnosis.

The content is relevant to a variety of different types of health care providers (nurses, radiologic technicians, medical laboratory personnel, etc) and due to the general nature of the cases, will remain relevant over time.

Easy to read. Clear headings are provided for sections of each case study and these section headings clearly tell when time has passed or setting has changed. Enough description is provided to help set the scene for each part of the case. Much of the text is written in the form of dialogue involving patient, family and health care providers, making it easy to adapt for role play. Medical jargon is limited and links for medical terms are provided to other resources that expound on medical terms used.

The text is consistent in structure of each case. Learning objectives are provided. Cases generally start with the patient at home and move with the patient through admission, testing and treatment, using a variety of healthcare services and encountering a variety of personnel.

The text is modular. Cases could be used individually within a unit on the given disease process or relevant sections of a case could be used to illustrate a specific point. The appendix is helpful in locating content specific to a certain diagnosis or a certain type of health care provider.

Each case follows a patient in a logical, chronologic fashion. A clear table of contents and appendix are provided which allows the user to quickly locate desired content. It would be helpful if the items in the table of contents and appendix were linked to the corresponding section of the text.

The hyperlinks to content outside this book work, however using the back arrow on your browser returns you to the front page of the book instead of to the point at which you left the text. I would prefer it if the hyperlinks opened in a new window or tab so closing that window or tab would leave you back where you left the text.

No grammatical errors were noted.

The text is culturally inclusive and appropriate. Characters, both patients and care givers are of a variety of races, ethnicities, ages and backgrounds.

I enjoyed reading the cases and reviewing this text. I can think of several ways in which I will use this content.

Reviewed by Raihan Khan, Instructor/Assistant Professor, James Madison University on 11/3/20

The book contains several important health issues, however still missing some chronic health issues that the students should learn before they join the workforce, such as diabetes-related health issues suffered by the patients. read more

The book contains several important health issues, however still missing some chronic health issues that the students should learn before they join the workforce, such as diabetes-related health issues suffered by the patients.

The health information contained in the textbook is mostly accurate.

I think the book is written focusing on the current culture and health issues faced by the patients. To keep the book relevant in the future, the contexts especially the culture/lifestyle/health care modalities, etc. would need to be updated regularly.

The language is pretty simple, clear, and easy to read.

There is no complaint about consistency. One of the main issues of writing a book, consistency was well managed by the authors.

The book is easy to explore based on how easy the setup is. Students can browse to the specific section that they want to read without much hassle of finding the correct information.

The organization is simple but effective. The authors organized the book based on what can happen in a patient's life and what possible scenarios students should learn about the disease. From that perspective, the book does a good job.

The interface is easy and simple to navigate. Some links to external sources might need to be updated regularly since those links are subject to change that is beyond the author's control. It's frustrating for the reader when the external link shows no information.

The book is free of any major language and grammatical errors.

The book might do a little better in cultural competency. e.g. Last name Singh is mainly for Sikh people. In the text Harj and Priya Singh are Muslim. the authors can consult colleagues who are more familiar with those cultures and revise some cultural aspects of the cases mentioned in the book.

The book is a nice addition to the open textbook world. Hope to see more health issues covered by the book.

Reviewed by Ryan Sheryl, Assistant Professor, California State University, Dominguez Hills on 7/16/20

This text contains 8 medical case studies that reflect best practices at the time of publication. The text identifies 5 overarching learning objectives: interprofessional collaboration, client centered care, evidence-based practice, quality... read more

This text contains 8 medical case studies that reflect best practices at the time of publication. The text identifies 5 overarching learning objectives: interprofessional collaboration, client centered care, evidence-based practice, quality improvement, and informatics. While the case studies do not cover all medical conditions or bodily systems, the book is thorough in conveying details of various patients and medical team members in a hospital environment. Rather than an index or glossary at the end of the text, it contains links to outside websites for more information on medical tests and terms referenced in the cases.

The content provided is reflective of best practices in patient care, interdisciplinary collaboration, and communication at the time of publication. It is specifically accurate for the context of hospitals in Canada. The links provided throughout the text have the potential to supplement with up-to-date descriptions and definitions, however, many of them are broken (see notes in Interface section).

The content of the case studies reflects the increasingly complex landscape of healthcare, including a variety of conditions, ages, and personal situations of the clients and care providers. The text will require frequent updating due to the rapidly changing landscape of society and best practices in client care. For example, a future version may include inclusive practices with transgender clients, or address ways medical racism implicitly impacts client care (see notes in Cultural Relevance section).

The text is written clearly and presents thorough, realistic details about working and being treated in an acute hospital context.

The text is very straightforward. It is consistent in its structure and flow. It uses consistent terminology and follows a structured framework throughout.

Being a series of 8 separate case studies, this text is easily and readily divisible into smaller sections. The text was designed to be taken apart and used piece by piece in order to serve various learning contexts. The parts of each case study can also be used independently of each other to facilitate problem solving.

The topics in the case studies are presented clearly. The structure of each of the case studies proceeds in a similar fashion. All of the cases are set within the same hospital so the hospital personnel and service providers reappear across the cases, giving a textured portrayal of the experiences of the various service providers. The cases can be used individually, or one service provider can be studied across the various studies.

The text is very straightforward, without complex charts or images that could become distorted. Many of the embedded links are broken and require updating. The links that do work are a very useful way to define and expand upon medical terms used in the case studies.

Grammatical errors are minimal and do not distract from the flow of the text. In one instance the last name Singh is spelled Sing, and one patient named Fred in the text is referred to as Frank in the appendix.

The cases all show examples of health care personnel providing compassionate, client-centered care, and there is no overt discrimination portrayed. Two of the clients are in same-sex marriages and these are shown positively. It is notable, however, that the two cases presenting people of color contain more negative characteristics than the other six cases portraying Caucasian people. The people of color are the only two examples of clients who smoke regularly. In addition, the Indian client drinks and is overweight, while the First Nations client is the only one in the text to have a terminal diagnosis. The Indian client is identified as being Punjabi and attending a mosque, although there are only 2% Muslims in the Punjab province of India. Also, the last name Singh generally indicates a person who is a Hindu or Sikh, not Muslim.

Reviewed by Monica LeJeune, RN Instructor, LSUE on 4/24/20

Has comprehensive unfolding case studies that guide the reader to recognize and manage the scenario presented. Assists in critical thinking process. read more

Has comprehensive unfolding case studies that guide the reader to recognize and manage the scenario presented. Assists in critical thinking process.

Accurately presents health scenarios with real life assessment techniques and patient outcomes.

Relevant to nursing practice.

Clearly written and easily understood.

Consistent with healthcare terminology and framework

Has a good reading flow.

Topics presented in logical fashion

Easy to read.

No grammatical errors noted.

Text is not culturally insensitive or offensive.

Good book to have to teach nursing students.

Reviewed by april jarrell, associate professor, J. Sargeant Reynolds Community College on 1/7/20

The text is a great case study tool that is appropriate for nursing school instructors to use in aiding students to learn the nursing process. read more

The text is a great case study tool that is appropriate for nursing school instructors to use in aiding students to learn the nursing process.

The content is accurate and evidence based. There is no bias noted

The content in the text is relevant, up to date for nursing students. It will be easy to update content as needed because the framework allows for addition to the content.

The text is clear and easy to understand.

Framework and terminology is consistent throughout the text; the case study is a continual and takes the student on a journey with the patient. Great for learning!

The case studies can be easily divided into smaller sections to allow for discussions, and weekly studies.

The text and content progress in a logical, clear fashion allowing for progression of learning.

No interface issues noted with this text.

No grammatical errors noted in the text.

No racial or culture insensitivity were noted in the text.

I would recommend this text be used in nursing schools. The use of case studies are helpful for students to learn and practice the nursing process.

Reviewed by Lisa Underwood, Practical Nursing Instructor, NTCC on 12/3/19

The text provides eight comprehensive case studies that showcase the different viewpoints of the many roles involved in patient care. It encompasses the most common seen diagnoses seen across healthcare today. Each case study comes with its own... read more

The text provides eight comprehensive case studies that showcase the different viewpoints of the many roles involved in patient care. It encompasses the most common seen diagnoses seen across healthcare today. Each case study comes with its own set of learning objectives that can be tweaked to fit several allied health courses. Although the case studies are designed around the Canadian Healthcare System, they are quite easily adaptable to fit most any modern, developed healthcare system.

Content Accuracy rating: 3

Overall, the text is quite accurate. There is one significant error that needs to be addressed. It is located in the DVT case study. In the study, a popliteal artery clot is mislabeled as a DVT. DVTs are located in veins, not in arteries. That said, the case study on the whole is quite good. This case study could be used as a learning tool in the classroom for discussion purposes or as a way to test student understanding of DVTs, on example might be, "Can they spot the error?"

At this time, all of the case studies within the text are current. Healthcare is an ever evolving field that rests on the best evidence based practice. Keeping that in mind, educators can easily adapt the studies as the newest evidence emerges and changes practice in healthcare.

All of the case studies are well written and easy to understand. The text includes several hyperlinks and it also highlights certain medical terminology to prompt readers as a way to enhance their learning experience.

Across the text, the language, style, and format of the case studies are completely consistent.

The text is divided into eight separate case studies. Each case study may be used independently of the others. All case studies are further broken down as the focus patient passes through each aspect of their healthcare system. The text's modularity makes it possible to use a case study as individual work, group projects, class discussions, homework or in a simulation lab.

The case studies and the diagnoses that they cover are presented in such a way that educators and allied health students can easily follow and comprehend.

The book in itself is free of any image distortion and it prints nicely. The text is offered in a variety of digital formats. As noted in the above reviews, some of the hyperlinks have navigational issues. When the reader attempts to access them, a "page not found" message is received.

There were minimal grammatical errors. Some of which may be traced back to the differences in our spelling.

The text is culturally relevant in that it includes patients from many different backgrounds and ethnicities. This allows educators and students to explore cultural relevance and sensitivity needs across all areas in healthcare. I do not believe that the text was in any way insensitive or offensive to the reader.

By using the case studies, it may be possible to have an open dialogue about the differences noted in healthcare systems. Students will have the ability to compare and contrast the Canadian healthcare system with their own. I also firmly believe that by using these case studies, students can improve their critical thinking skills. These case studies help them to "put it all together".

Reviewed by Melanie McGrath, Associate Professor, TRAILS on 11/29/19

The text covered some of the most common conditions seen by healthcare providers in a hospital setting, which forms a solid general base for the discussions based on each case. read more

The text covered some of the most common conditions seen by healthcare providers in a hospital setting, which forms a solid general base for the discussions based on each case.

I saw no areas of inaccuracy

As in all healthcare texts, treatments and/or tests will change frequently. However, everything is currently up-to-date thus it should be a good reference for several years.

Each case is written so that any level of healthcare student would understand. Hyperlinks in the text is also very helpful.

All of the cases are written in a similar fashion.

Although not structured as a typical text, each case is easily assigned as a stand-alone.

Each case is organized clearly in an appropriate manner.

I did not see any issues.

I did not see any grammatical errors

The text seemed appropriately inclusive. There are no pediatric cases and no cases of intellectually-impaired patients, but those types of cases introduce more advanced problem-solving which perhaps exceed the scope of the text. May be a good addition to the text.

I found this text to be an excellent resource for healthcare students in a variety of fields. It would be best utilized in inter professional courses to help guide discussion.

Reviewed by Lynne Umbarger, Clinical Assistant Professor, Occupational Therapy, Emory and Henry College on 11/26/19

While the book does not cover every scenario, the ones in the book are quite common and troublesome for inexperienced allied health students. The information in the book is thorough enough, and I have found the cases easy to modify for educational... read more

While the book does not cover every scenario, the ones in the book are quite common and troublesome for inexperienced allied health students. The information in the book is thorough enough, and I have found the cases easy to modify for educational purposes. The material was easily understood by the students but challenging enough for classroom discussion. There are no mentions in the book about occupational therapy, but it is easy enough to add a couple words and make inclusion simple.

Very nice lab values are provided in the case study, making it more realistic for students.

These case studies focus on commonly encountered diagnoses for allied health and nursing students. They are comprehensive, realistic, and easily understood. The only difference is that the hospital in one case allows the patient's dog to visit in the room (highly unusual in US hospitals).

The material is easily understood by allied health students. The cases have links to additional learning materials for concepts that may be less familiar or should be explored further in a particular health field.

The language used in the book is consistent between cases. The framework is the same with each case which makes it easier to locate areas that would be of interest to a particular allied health profession.

The case studies are comprehensive but well-organized. They are short enough to be useful for class discussion or a full-blown assignment. The students seem to understand the material and have not expressed that any concepts or details were missing.

Each case is set up like the other cases. There are learning objectives at the beginning of each case to facilitate using the case, and it is easy enough to pull out material to develop useful activities and assignments.

There is a quick chart in the Appendix to allow the reader to determine the professions involved in each case as well as the pertinent settings and diagnoses for each case study. The contents are easy to access even while reading the book.

As a person who attends carefully to grammar, I found no errors in all of the material I read in this book.

There are a greater number of people of different ethnicities, socioeconomic status, ages, and genders to make this a very useful book. With each case, I could easily picture the person in the case. This book appears to be Canadian and more inclusive than most American books.

I was able to use this book the first time I accessed it to develop a classroom activity for first-year occupational therapy students and a more comprehensive activity for second-year students. I really appreciate the links to a multitude of terminology and medical lab values/issues for each case. I will keep using this book.

Reviewed by Cindy Krentz, Assistant Professor, Metropolitan State University of Denver on 6/15/19

The book covers eight case studies of common inpatient or emergency department scenarios. I appreciated that they had written out the learning objectives. I liked that the patient was described before the case was started, giving some... read more

The book covers eight case studies of common inpatient or emergency department scenarios. I appreciated that they had written out the learning objectives. I liked that the patient was described before the case was started, giving some understanding of the patient's background. I think it could benefit from having a glossary. I liked how the authors included the vital signs in an easily readable bar. I would have liked to see the labs also highlighted like this. I also felt that it would have been good written in a 'what would you do next?' type of case study.

The book is very accurate in language, what tests would be prudent to run and in the day in the life of the hospital in all cases. One inaccuracy is that the authors called a popliteal artery clot a DVT. The rest of the DVT case study was great, though, but the one mistake should be changed.

The book is up to date for now, but as tests become obsolete and new equipment is routinely used, the book ( like any other health textbook) will need to be updated. It would be easy to change, however. All that would have to happen is that the authors go in and change out the test to whatever newer, evidence-based test is being utilized.

The text is written clearly and easy to understand from a student's perspective. There is not too much technical jargon, and it is pretty universal when used- for example DVT for Deep Vein Thrombosis.

The book is consistent in language and how it is broken down into case studies. The same format is used for highlighting vital signs throughout the different case studies. It's great that the reader does not have to read the book in a linear fashion. Each case study can be read without needing to read the others.

The text is broken down into eight case studies, and within the case studies is broken down into days. It is consistent and shows how the patient can pass through the different hospital departments (from the ER to the unit, to surgery, to home) in a realistic manner. The instructor could use one or more of the case studies as (s)he sees fit.

The topics are eight different case studies- and are presented very clearly and organized well. Each one is broken down into how the patient goes through the system. The text is easy to follow and logical.

The interface has some problems with the highlighted blue links. Some of them did not work and I got a 'page not found' message. That can be frustrating for the reader. I'm wondering if a glossary could be utilized (instead of the links) to explain what some of these links are supposed to explain.

I found two or three typos, I don't think they were grammatical errors. In one case I think the Canadian spelling and the United States spelling of the word are just different.

This is a very culturally competent book. In today's world, however, one more type of background that would merit delving into is the trans-gender, GLBTQI person. I was glad that there were no stereotypes.

I enjoyed reading the text. It was interesting and relevant to today's nursing student. Since we are becoming more interprofessional, I liked that we saw what the phlebotomist and other ancillary personnel (mostly different technicians) did. I think that it could become even more interdisciplinary so colleges and universities could have more interprofessional education- courses or simulations- with the addition of the nurse using social work, nutrition, or other professional health care majors.

Reviewed by Catherine J. Grott, Interim Director, Health Administration Program, TRAILS on 5/5/19

The book is comprehensive but is specifically written for healthcare workers practicing in Canada. The title of the book should reflect this. read more

The book is comprehensive but is specifically written for healthcare workers practicing in Canada. The title of the book should reflect this.

The book is accurate, however it has numerous broken online links.

Relevance/Longevity rating: 3

The content is very relevant, but some links are out-dated. For example, WHO Guidelines for Safe Surgery 2009 (p. 186) should be updated.

The book is written in clear and concise language. The side stories about the healthcare workers make the text interesting.

The book is consistent in terms of terminology and framework. Some terms that are emphasized in one case study are not emphasized (with online links) in the other case studies. All of the case studies should have the same words linked to online definitions.

Modularity rating: 3

The book can easily be parsed out if necessary. However, the way the case studies have been written, it's evident that different authors contributed singularly to each case study.

The organization and flow are good.

Interface rating: 1

There are numerous broken online links and "pages not found."

The grammar and punctuation are correct. There are two errors detected: p. 120 a space between the word "heart" and the comma; also a period is needed after Dr (p. 113).

I'm not quite sure that the social worker (p. 119) should comment that the patient and partner are "very normal people."

There are roughly 25 broken online links or "pages not found." The BC & Canadian Guidelines (p. 198) could also include a link to US guidelines to make the text more universal . The basilar crackles (p. 166) is very good. Text could be used compare US and Canadian healthcare. Text could be enhanced to teach "soft skills" and interdepartmental communication skills in healthcare.

Reviewed by Lindsey Henry, Practical Nursing Instructor, Fletcher on 5/1/19

I really appreciated how in the introduction, five learning objectives were identified for students. These objectives are paramount in nursing care and they are each spelled out for the learner. Each Case study also has its own learning... read more

I really appreciated how in the introduction, five learning objectives were identified for students. These objectives are paramount in nursing care and they are each spelled out for the learner. Each Case study also has its own learning objectives, which were effectively met in the readings.

As a seasoned nurse, I believe that the content regarding pathophysiology and treatments used in the case studies were accurate. I really appreciated how many of the treatments were also explained and rationales were given, which can be very helpful to facilitate effective learning for a nursing student or novice nurse.

The case studies are up to date and correlate with the current time period. They are easily understood.

I really loved how several important medical terms, including specific treatments were highlighted to alert the reader. Many interventions performed were also explained further, which is great to enhance learning for the nursing student or novice nurse. Also, with each scenario, a background and history of the patient is depicted, as well as the perspectives of the patient, patients family member, and the primary nurse. This really helps to give the reader a full picture of the day in the life of a nurse or a patient, and also better facilitates the learning process of the reader.

These case studies are consistent. They begin with report, the patient background or updates on subsequent days, and follow the patients all the way through discharge. Once again, I really appreciate how this book describes most if not all aspects of patient care on a day to day basis.

Each case study is separated into days. While they can be divided to be assigned at different points within the course, they also build on each other. They show trends in vital signs, what happens when a patient deteriorates, what happens when they get better and go home. Showing the entire process from ER admit to discharge is really helpful to enhance the students learning experience.

The topics are all presented very similarly and very clearly. The way that the scenarios are explained could even be understood by a non-nursing student as well. The case studies are very clear and very thorough.

The book is very easy to navigate, prints well on paper, and is not distorted or confusing.

I did not see any grammatical errors.

Each case study involves a different type of patient. These differences include race, gender, sexual orientation and medical backgrounds. I do not feel the text was offensive to the reader.

I teach practical nursing students and after reading this book, I am looking forward to implementing it in my classroom. Great read for nursing students!

Reviewed by Leah Jolly, Instructor, Clinical Coordinator, Oregon Institute of Technology on 4/10/19

Good variety of cases and pathologies covered. read more

Good variety of cases and pathologies covered.

Content Accuracy rating: 2

Some examples and scenarios are not completely accurate. For example in the DVT case, the sonographer found thrombus in the "popliteal artery", which according to the book indicated presence of DVT. However in DVT, thrombus is located in the vein, not the artery. The patient would also have much different symptoms if located in the artery. Perhaps some of these inaccuracies are just typos, but in real-life situations this simple mistake can make a world of difference in the patient's course of treatment and outcomes.

Good examples of interprofessional collaboration. If only it worked this way on an every day basis!

Clear and easy to read for those with knowledge of medical terminology.

Good consistency overall.

Broken up well.

Topics are clear and logical.

Would be nice to simply click through to the next page, rather than going through the table of contents each time.

Minor typos/grammatical errors.

No offensive or insensitive materials observed.

Reviewed by Alex Sargsyan, Doctor of Nursing Practice/Assistant Professor , East Tennessee State University on 10/8/18

Because of the case study character of the book it does not have index or glossary. However it has summary for each health case study outlining key elements discussed in each case study. read more

Because of the case study character of the book it does not have index or glossary. However it has summary for each health case study outlining key elements discussed in each case study.

Overall the book is accurately depicting the clinical environment. There are numerous references to external sites. While most of them are correct, some of them are not working. For example Homan’s test link is not working "404 error"

Book is relevant in its current version and can be used in undergraduate and graduate classes. That said, the longevity of the book may be limited because of the character of the clinical education. Clinical guidelines change constantly and it may require a major update of the content.

Cases are written very clearly and have realistic description of an inpatient setting.

The book is easy to read and consistent in the language in all eight cases.

The cases are very well written. Each case is subdivided into logical segments. The segments reflect different setting where the patient is being seen. There is a flow and transition between the settings.

Book has eight distinct cases. This is a great format for a book that presents distinct clinical issues. This will allow the students to have immersive experiences and gain better understanding of the healthcare environment.

Book is offered in many different formats. Besides the issues with the links mentioned above, overall navigation of the book content is very smooth.

Book is very well written and has no grammatical errors.

Book is culturally relevant. Patients in the case studies come different cultures and represent diverse ethnicities.

Reviewed by Justin Berry, Physical Therapist Assistant Program Director, Northland Community and Technical College, East Grand Forks, MN on 8/2/18

This text provides eight patient case studies from a variety of diagnoses, which can be utilized by healthcare students from multiple disciplines. The cases are comprehensive and can be helpful for students to determine professional roles,... read more

This text provides eight patient case studies from a variety of diagnoses, which can be utilized by healthcare students from multiple disciplines. The cases are comprehensive and can be helpful for students to determine professional roles, interprofessional roles, when to initiate communication with other healthcare practitioners due to a change in patient status, and treatment ideas. Some additional patient information, such as lab values, would have been beneficial to include.

Case study information is accurate and unbiased.

Content is up to date. The case studies are written in a way so that they will not be obsolete soon, even with changes in healthcare.

The case studies are well written, and can be utilized for a variety of classroom assignments, discussions, and projects. Some additional lab value information for each patient would have been a nice addition.

The case studies are consistently organized to make it easy for the reader to determine the framework.

The text is broken up into eight different case studies for various patient diagnoses. This design makes it highly modular, and would be easy to assign at different points of a course.

The flow of the topics are presented consistently in a logical manner. Each case study follows a patient chronologically, making it easy to determine changes in patient status and treatment options.

The text is free of interface issues, with no distortion of images or charts.

The text is not culturally insensitive or offensive in any way. Patients are represented from a variety of races, ethnicities, and backgrounds

This book would be a good addition for many different health programs.

Reviewed by Ann Bell-Pfeifer, Instructor/Program Director, Minnesota State Community and Technical College on 5/21/18

The book gives a comprehensive overview of many types of cases for patient conditions. Emergency Room patients may arrive with COPD, heart failure, sepsis, pneumonia, or as motor vehicle accident victims. It is directed towards nurses, medical... read more

The book gives a comprehensive overview of many types of cases for patient conditions. Emergency Room patients may arrive with COPD, heart failure, sepsis, pneumonia, or as motor vehicle accident victims. It is directed towards nurses, medical laboratory technologists, medical radiology technologists, and respiratory therapists and their roles in caring for patients. Most of the overview is accurate. One suggestion is to provide an embedded radiologist interpretation of the exams which are performed which lead to the patients diagnosis.

Overall the book is accurate. Would like to see updates related to the addition of direct radiography technology which is commonly used in the hospital setting.

Many aspects of medicine will remain constant. The case studies seem fairly accurate and may be relevant for up to 3 years. Since technology changes so quickly in medicine, the CT and x-ray components may need minor updates within a few years.

The book clarity is excellent.

The case stories are consistent with each scenario. It is easy to follow the structure and learn from the content.

The book is quite modular. It is easy to break it up into cases and utilize them individually and sequentially.

The cases are listed by disease process and follow a logical flow through each condition. They are easy to follow as they have the same format from the beginning to the end of each case.

The interface seems seamless. Hyperlinks are inserted which provide descriptions and references to medical procedures and in depth definitions.

The book is free of most grammatical errors. There is a place where a few words do not fit the sentence structure and could be a typo.

The book included all types of relationships and ethnic backgrounds. One type which could be added is a transgender patient.

I think the book was quite useful for a variety of health care professionals. The authors did an excellent job of integrating patient cases which could be applied to the health care setting. The stories seemed real and relevant. This book could be used to teach health care professionals about integrated care within the emergency department.

Reviewed by Shelley Wolfe, Assistant Professor, Winona State University on 5/21/18

This text is comprised of comprehensive, detailed case studies that provide the reader with multiple character views throughout a patient’s encounter with the health care system. The Table of Contents accurately reflected the content. It should... read more

This text is comprised of comprehensive, detailed case studies that provide the reader with multiple character views throughout a patient’s encounter with the health care system. The Table of Contents accurately reflected the content. It should be noted that the authors include a statement that conveys that this text is not like traditional textbooks and is not meant to be read in a linear fashion. This allows the educator more flexibility to use the text as a supplement to enhance learning opportunities.

The content of the text appears accurate and unbiased. The “five overarching learning objectives” provide a clear aim of the text and the educator is able to glean how these objectives are captured into each of the case studies. While written for the Canadian healthcare system, this text is easily adaptable to the American healthcare system.

Overall, the content is up-to-date and the case studies provide a variety of uses that promote longevity of the text. However, not all of the blue font links (if using the digital PDF version) were still in working order. I encountered links that led to error pages or outdated “page not found” websites. While the links can be helpful, continued maintenance of these links could prove time-consuming.

I found the text easy to read and understand. I enjoyed that the viewpoints of all the different roles (patient, nurse, lab personnel, etc.) were articulated well and allowed the reader to connect and gain appreciation of the entire healthcare team. Medical jargon was noted to be appropriate for the intended audience of this text.

The terminology and organization of this text is consistent.

The text is divided into 8 case studies that follow a similar organizational structure. The case studies can further be divided to focus on individual learning objectives. For example, the case studies could be looked at as a whole for discussing communication or could be broken down into segments to focus on disease risk factors.

The case studies in this text follow a similar organizational structure and are consistent in their presentation. The flow of individual case studies is excellent and sets the reader on a clear path. As noted previously, this text is not meant to be read in a linear fashion.

This text is available in many different forms. I chose to review the text in the digital PDF version in order to use the embedded links. I did not encounter significant interface issues and did not find any images or features that would distract or confuse a reader.

No significant grammatical errors were noted.

The case studies in this text included patients and healthcare workers from a variety of backgrounds. Educators and students will benefit from expanding the case studies to include discussions and other learning opportunities to help develop culturally-sensitive healthcare providers.

I found the case studies to be very detailed, yet written in a way in which they could be used in various manners. The authors note a variety of ways in which the case studies could be employed with students; however, I feel the authors could also include that the case studies could be used as a basis for simulated clinical experiences. The case studies in this text would be an excellent tool for developing interprofessional communication and collaboration skills in a variety healthcare students.

Reviewed by Darline Foltz, Assistant Professor, University of Cincinnati - Clermont College on 3/27/18

This book covers all areas listed in the Table of Contents. In addition to the detailed patient case studies, there is a helpful section of "How to Use this Resource". I would like to note that this resource "aligns with the open textbooks... read more

This book covers all areas listed in the Table of Contents. In addition to the detailed patient case studies, there is a helpful section of "How to Use this Resource". I would like to note that this resource "aligns with the open textbooks Clinical Procedures for Safer Patient Care and Anatomy and Physiology: OpenStax" as noted by the authors.

The book appears to be accurate. Although one of the learning outcomes is as follows: "Demonstrate an understanding of the Canadian healthcare delivery system.", I did not find anything that is ONLY specific to the Canadian healthcare delivery system other than some of the terminology, i.e. "porter" instead of "transporter" and a few french words. I found this to make the book more interesting for students rather than deter from it. These are patient case studies that are relevant in any country.

The content is up-to-date. Changes in medical science may occur, i.e. a different test, to treat a diagnosis that is included in one or more of the case studies, however, it would be easy and straightforward to implement these changes.

This book is written in lucid, accessible prose. The technical/medical terminology that is used is appropriate for medical and allied health professionals. Something that would improve this text would to provide a glossary of terms for the terms in blue font.

This book is consistent with current medical terminology

This text is easily divided into each of the 6 case studies. The case studies can be used singly according to the body system being addressed or studied.

Because this text is a collection of case studies, flow doesn't pertain, however the organization and structure of the case studies are excellent as they are clear and easy to read.

There are no distractions in this text that would distract or confuse the reader.

I did not identify any grammatical errors.

This text is not culturally insensitive or offensive in any way and uses patients and healthcare workers that are of a variety of races, ethnicities and backgrounds.

I believe that this text would not only be useful to students enrolled in healthcare professions involved in direct patient care but would also be useful to students in supporting healthcare disciplines such as health information technology and management, medical billing and coding, etc.

Table of Contents

• Introduction

Case Study #1: Chronic Obstructive Pulmonary Disease (COPD)

• Learning Objectives
• Patient: Erin Johns
• Emergency Room

Case Study #2: Pneumonia

• Day 0: Emergency Room
• Day 1: Emergency Room
• Day 1: Medical Ward
• Day 2: Medical Ward
• Day 3: Medical Ward
• Day 4: Medical Ward

Case Study #3: Unstable Angina (UA)

• Patient: Harj Singh

Case Study #4: Heart Failure (HF)

• Patient: Meryl Smith
• In the Supermarket
• Day 0: Medical Ward

Case Study #5: Motor Vehicle Collision (MVC)

• Patient: Aaron Knoll
• Crash Scene
• Operating Room
• Post Anaesthesia Care Unit (PACU)
• Surgical Ward

Case Study #6: Sepsis

• Patient: George Thomas
• Sleepy Hollow Care Facility

Case Study #7: Colon Cancer

• Patient: Fred Johnson
• Two Months Ago
• Pre-Surgery Admission

Case Study #8: Deep Vein Thrombosis (DVT)

• Patient: Jamie Douglas

Appendix: Overview About the Authors

Ancillary Material

About the book.

Health Case Studies is composed of eight separate health case studies. Each case study includes the patient narrative or story that models the best practice (at the time of publishing) in healthcare settings. Associated with each case is a set of specific learning objectives to support learning and facilitate educational strategies and evaluation.

The case studies can be used online in a learning management system, in a classroom discussion, in a printed course pack or as part of a textbook created by the instructor. This flexibility is intentional and allows the educator to choose how best to convey the concepts presented in each case to the learner.

Because these case studies were primarily developed for an electronic healthcare system, they are based predominantly in an acute healthcare setting. Educators can augment each case study to include primary healthcare settings, outpatient clinics, assisted living environments, and other contexts as relevant.

About the Contributors

Glynda Rees teaches at the British Columbia Institute of Technology (BCIT) in Vancouver, British Columbia. She completed her MSN at the University of British Columbia with a focus on education and health informatics, and her BSN at the University of Cape Town in South Africa. Glynda has many years of national and international clinical experience in critical care units in South Africa, the UK, and the USA. Her teaching background has focused on clinical education, problem-based learning, clinical techniques, and pharmacology.

Glynda‘s interests include the integration of health informatics in undergraduate education, open accessible education, and the impact of educational technologies on nursing students’ clinical judgment and decision making at the point of care to improve patient safety and quality of care.

Faculty member in the critical care nursing program at the British Columbia Institute of Technology (BCIT) since 2003, Rob has been a critical care nurse for over 25 years with 17 years practicing in a quaternary care intensive care unit. Rob is an experienced educator and supports student learning in the classroom, online, and in clinical areas. Rob’s Master of Education from Simon Fraser University is in educational technology and learning design. He is passionate about using technology to support learning for both faculty and students.

Part of Rob’s faculty position is dedicated to providing high fidelity simulation support for BCIT’s nursing specialties program along with championing innovative teaching and best practices for educational technology. He has championed the use of digital publishing and was the tech lead for Critical Care Nursing’s iPad Project which resulted in over 40 multi-touch interactive textbooks being created using Apple and other technologies.

Rob has successfully completed a number of specialist certifications in computer and network technologies. In 2015, he was awarded Apple Distinguished Educator for his innovation and passionate use of technology to support learning. In the past five years, he has presented and published abstracts on virtual simulation, high fidelity simulation, creating engaging classroom environments, and what the future holds for healthcare and education.

Janet Morrison is the Program Head of Occupational Health Nursing at the British Columbia Institute of Technology (BCIT) in Burnaby, British Columbia. She completed a PhD at Simon Fraser University, Faculty of Communication, Art and Technology, with a focus on health information technology. Her dissertation examined the effects of telehealth implementation in an occupational health nursing service. She has an MA in Adult Education from St. Francis Xavier University and an MA in Library and Information Studies from the University of British Columbia.

Janet’s research interests concern the intended and unintended impacts of health information technologies on healthcare students, faculty, and the healthcare workforce.

She is currently working with BCIT colleagues to study how an educational clinical information system can foster healthcare students’ perceptions of interprofessional roles.

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Session 2. Teamwork and Communication in Health Care

Chapter 6. Case-Based Learning

At a glance, instructor’s guide.

Overview for instructors. The purpose of this didactic session is to introduce students to the concepts of interprofessional education and collaborative practice. Instructors will use two case studies to highlight the specific teamwork and communication skills individuals need to work effectively on an interprofessional health care team. Each case study uses little to no medical or dental terminology to embed oral health. As a result, this session is ideal for pre-licensure health sciences students with no clinical training.

Materials provided in this toolkit.

• Pre- and Post-Session Assessment Questionnaire
• Instructor’s Copy, Case Study: Jill
• Instructor’s Copy, Case Study: Mr. Jones
• Case Study: Jill
• Case Study: Mr. Jones

Instructor Preparation.

• Download slides 30–34 and the accompanying speaker notes from Smiles for Life Course 1: The Relationship of Oral to Systemic Health

Note: You must register as an educator before you can download individual slides and speaker notes. Slide numbers viewed through the web interface for Smiles for Life differ from the numbers on the downloaded slides. Slide numbers in this toolkit correspond to slides in the third edition of Smiles for Life in their downloaded format.

• Ask a faculty member from each of the participating programs to locate or draft a short description of the roles and responsibilities for his or her respective profession. Compile these descriptions into one Word document and make it available to your students through email, your preferred learning management system, or your website.
• Pre-Session Assignment: Teamwork and Communication in Health Care

Note : The survey portion of the Pre- and Post-Session Assessment Questionnaire is taken from the TeamSTEPPS ® Teamwork Attitudes Questionnaire , which looks at five core components of teamwork. TeamSTEPPS was developed jointly by the Department of Defense and the Agency for Healthcare Research and Quality to improve the quality and safety of patient care. To learn more about the system, which includes a full curriculum and other resources, visit TeamSTEPPS .

• Complete the Pre- and Post-Session Assignment: Teamwork and Communication in Health Care .
• Review the roles and responsibilities document provided by the instructor.
• Pre-assessment (2–5 minutes)
• Introduction (5 minutes)
• Discussion of the pre-session assignment (10 minutes)
• Smiles for Life Course 1: The Relationship of Oral to Systemic Health PowerPoint slides 30–34 (10 minutes)
• Case study for Jill (10 minutes)
• Case study for Mr. Jones (10 minutes)
• Wrap-up (5 minutes)
• Post-assessment (2–5 minutes)

Instructor’s Notes

This session will take approximately one hour, depending on the number of participants.

Pre-assessment (2–5 minutes). Ask students to complete the pre-session portion of the Pre- and Post-Session Assessment Questionnaire as they arrive.

Introduction (5 minutes). Review the learning objectives and purpose of the session. Ask students to identify themselves by hand as you note the professions represented in class. Then, ask a student volunteer from each profession to read the roles and responsibilities for his or her profession aloud.

Discussion of pre-session assignment (10 minutes). The purpose of this assignment is to provide students with a real-world example of substandard health care delivery.

Ask student volunteers to share their answers to the questions in the Pre-Session Assignment: Teamwork and Communication in Health Care . Use the following notes to enhance discussion for each question.

• The purpose of this question is to prompt students to think about their personal experiences with teamwork. Allow a few students to share their answers.
• The purpose of this question is to prompt students to identify specific examples of effective or ineffective teamwork.
• This question should prompt students to reflect on the consequences of poor health care delivery (i.e., what happens when teamwork, collaboration, and good communication are absent).
• This question asks students to contemplate what went wrong with Deamonte’s health care delivery.

If necessary, guide students toward an understanding of the ways better communication and teamwork could have resulted in the more timely care needed to save Deamonte’s life.

Smiles for Life Course 1: The Relationship of Oral to Systemic Health PowerPoint slides 30–34 (10 minutes). This portion of Smiles for Life Course 1: The Relationship of Oral to Systemic Health introduces the concepts of interprofessional education and collaborative practice. Take time to read the definition of each and point out that the purpose of this didactic session is to prepare students for collaborative practice.

Case study for Jill (10 minutes). Break students into interprofessional teams of five or six. If possible, place one student from each profession on each team.

Instruct students to read Jill’s case study silently, then answer the questions as a team. One student should take notes and be prepared to discuss the team’s answers.

Use the following notes to enhance discussion generated by the questions.

• Yes. Although Jill’s school nurse could have taken action earlier, the dentist, physician, and school nurse communicated in a positive manner that reflects collaborative practice.
• Yes. All U.S. states and territories have laws that mandate the reporting of suspected abuse by specified individuals. These typically include physicians, nurses, and other health professionals. The need to be alert to nonmedical issues also highlights a potentially overlooked aspect of patient-centered care delivery. All health care providers should be concerned about a patient’s overall health and wellbeing, including those conditions whose treatment extends beyond the provider’s training.
• Jill’s health care team exhibited effective communication, mutual respect, and concern for comprehensive care.
• The physician addressed Jill’s oral health concerns and provided a dental referral. This illustrates patient-centered, comprehensive care.
• The dentist followed up with Jill’s physician and also consulted with her school nurse. This illustrates effective communication and collaboration.
• Participate in interprofessional education opportunities such as this one.
• Learn about the roles and responsibilities of other health care providers.
• Contact local health care providers once in practice to facilitate collaboration.

Case study for Mr. Jones (10 minutes).

Option 1 Ask students to form new teams with at least one person from each profession present on each team. Teams should designate one person to take notes and report on team findings. After the students have formed teams, direct them to read the case study for Mr. Jones silently, then answer the questions as a team.

Option 2 Ask students to remain with their present teams but designate a new person to take notes and report findings. Direct students to read the case study for Mr. Jones silently, then answer the questions as a team.

• The primary care provider (PCP) prescribed oral medication—a poor choice for patients with difficulty swallowing—and failed to refer Mr. Jones to a dentist for further evaluation.
• The speech language pathologist (SLP) did not perform an adequate oral examination, even after noticing Mr. Jones’s bad breath and food accumulation.
• The pharmacist filled the prescription for oral antibiotics in pill form without questioning the patient’s ability to swallow, even though the pharmacist recognized his facial paralysis and difficulty speaking.
• Mr. Jones’s health care team members did not communicate or collaborate with one another regarding his health care delivery.
• The PCP could have spoken to the SLP over the phone and explained that he prescribed Mr. Jones antibiotics and pain medication for an infected tooth. This may have prompted the SLP to point out the need for liquid antibiotics to ensure patient compliance. It may also have prompted the SLP to follow up with Mr. Jones regarding his oral condition at his appointment.
• Even without a call from the PCP, the SLP could have performed a comprehensive oral examination as part of Mr. Jones’s appointment and noted the infected tooth, which should have prompted an immediate dental referral.
• The pharmacist could have questioned Mr. Jones about his facial paralysis and ability to swallow. This would have prompted a change in prescription from pill to liquid form, enabling Mr. Jones to take the oral antibiotics more easily.
• Yes, the PCP could have referred Mr. Jones to a dental provider when the oral antibiotics were prescribed.
• Yes, cost and unnecessary pain and stress for the patient.

Wrap-up (5 minutes).

To facilitate a wrap-up discussion, ask students the following questions.

• Did working with students from other professions highlight aspects of health care delivery that you had not considered before?
• How will you apply what you learned today about teamwork and communication in health care to your education and in practice?

To close the session, summarize the following points for your students.

• Patient-centered health care requires all health care providers to communicate and collaborate effectively.
• A lack of communication and teamwork has been shown to negatively impact patient health outcomes.
• Patient health and safety is at risk when health care providers do not work together.

Post-assessment (2–5 minutes). Ask students to complete the post-session portion of the Pre- and Post-Session Assessment Questionnaire before they leave. Impress upon them the value of their feedback in helping you hone the session for future students.

< Previous Page: Session 1. Team-Based Care

First Published: 10/2015 Last updated: 03/2016

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Healthcare communication: case studies and best practices for communicating critical findings.

Communication failure — especially failure to communicate critical findings in a timely manner — can cause patient injury due to treatment delay, delayed diagnosis or misdiagnosis, or lack of follow-up, and is a frequent allegation in malpractice lawsuits. Especially in primary care practices, expedited follow-up on critical or significantly abnormal test results is a major aspect of liability risk management and patient safety.

Part 1: From Radiology to ED

To ensure timely delivery of critical radiology findings to referring ED clinicians, everyone involved must consider the entire communication loop. The process starts when the ED clinician orders an imaging examination and continues when radiology personnel create the images. The next piece is the communication of the results. The conclusion of the process occurs when the referring ED clinician receives and confirms receipt of the findings. 1 A break at any point in the communication loop can result in communication delay, diagnosis delay, patient injury, and the filing of a lawsuit.

Judging from malpractice plaintiffs’ allegations and referring physicians’ testimony in NORCAL closed claims, there is an expectation that radiologists will directly communicate critical findings to the referring ED physicians in a timely manner. This apparent focus on radiologists as the party responsible for pushing critical results out (as opposed to the ED physician being responsible for pulling the results in) is apparent in the Joint Commission’s National Patient Safety Goals for the Hospital Program (Goal 2, NPSG.02.03.01) and in the American College of Radiology’s Practice Guideline for Communication of Diagnostic Imaging Findings . This is not to say that diligence and hard work by radiologists will guarantee timely treatment of a critical condition, or that no one else shares in the responsibility of timely critical results communication. As the case studies below demonstrate, everyone in the communication loop can contribute to the success or failure of critical results reporting.

While radiologists and ED physicians have differing opinions about communication responsibilities, radiologists can increase patient safety and decrease liability risk with timely, direct reporting of critical results to referring ED physicians, even when the results are available in the EHR. Redundancy in communication systems increases patient safety and reduces malpractice liability risk. It is worth the extra effort.

The case studies and articles linked below focus on radiologist and radiology department/group administrator strategies for timely reporting of critical results to referring ED clinicians, but any individual involved in the critical result communication loop between the radiology and emergency departments can use the critical result communication strategies presented to increase patient safety and reduce liability risk exposure.

More Information About Communicating Critical Findings from Radiology to ED

• Closed Claim Case Study: Failure to Communicate Critical Radiology Findings Leads to Loss of Testicle
• Closed Claim Case Study: Failure to Close the Loop on Critical Findings Leads to Negligent Patient Death
• Closed Claim Case Study: Ambiguous Radiology Report Results in Below-the-Waist Paralysis
• Closed Claim Case Study: Failure to Follow Critical Results Reporting Policy Leads to Incorrect Diagnosis and Patient Death
• Best Practices: Develop a Process for Communicating Results Based on Criticality to Improve Clinical Decision-Making

Part 2: From Anatomic Pathologist to Ordering and Primary Care Physician

Considering that the processes required in anatomic pathology diagnosis often take hours or even days, the concept of critical results reporting requires an adjustment of terminology and analysis. 2,3,4 For example, “critical” in clinical pathology, radiology, and other medical specialties is generally associated with a life-threatening condition that requires communication within minutes. 5 However, few pathological diagnoses require immediate communication to the ordering physician. 2,5 Most pathological diagnoses might be better described as “actionable, noncritical results.” 2 Consequently, for a pathologist, effectively communicating a diagnosis to the person in the best position to use it for the patient’s benefit is usually more important than expediency. 5

This is not to say that there aren’t circumstances in which an anatomical pathology diagnosis should be immediately communicated. It is generally agreed upon that immediate communication is necessary when a delay may harm the patient. For example, a pathologist should immediately contact the ordering physician when they diagnose transplant rejection. But there is significant disagreement among pathologists — and even more disagreement among pathologists and ordering clinicians — regarding which diagnoses require a STAT telephone call. 3,4

Treatment delay caused by a communication failure between a pathologist and ordering or primary care physician is a frequent allegation in malpractice lawsuits against pathologists. Because of disagreement over which diagnoses require immediate and direct communication, experts and defendants frequently have strong differences of opinion regarding the standard of care for communicating these diagnoses. These case studies and articles provide strategies for communicating urgent, unexpected, and actionable anatomic pathology diagnoses.

More Information About Communicating Critical Findings from Anatomic Pathologist to Ordering and Primary Care Physician

• Closed Claim Case Study: Prioritizing Urgent Diagnosis List Over Medical Judgment Leads to Patient Death
• Closed Claim Case Study: Failure to Directly Communicate Unexpected Cancer Finding Leads to Delayed Treatment
• Closed Claim Case Study: Failure to Communicate a Significant Diagnosis Change Leads to Worsened Prognosis
• Closed Claim Case Study: Failure to Communicate a Positive Biopsy Leads to Delayed Cancer Diagnosis
• Best Practices: Develop a Policy for Timely Diagnoses Communication to Facilitate Prompt Treatment
• Best Practices: Avoid Ambiguity in Pathology Reports to Improve Communication

Part 3: From Primary Care Physician to Patient

Critical value reporting guidelines for pathologists.

Critical value reporting is required by various laws, regulations and accreditation programs. 3 For the purposes of these case studies and articles, the most relevant guideline for Surgical Pathology and Cytopathology is the “ Consensus Statement on Effective Communication of Urgent Diagnoses and Significant, Unexpected Diagnoses in Surgical Pathology and Cytopathology from the College of American Pathologists and Association of Directors of Anatomic and Surgical Pathology ” (CAP/ADASP Statement). Among other recommendations, the statement urges the use of “urgent diagnosis” as an alternative to “critical diagnosis,” and “significant, unexpected diagnosis” for diagnoses that are clinically unusual or unforeseen. 5 For the sake of consistency, these case studies and articles use the terms “urgent diagnosis” and “significant, unexpected diagnosis.”

Primary care physicians (PCPs) receive a considerable number of test results. 6 One study found that a typical PCP reviews an average of 930 pieces of chemistry/hematology data and 60 pathology/radiology reports per week. 7 Volume is not the only reason test result management and follow-up is complex. 8 It requires multi-step data sharing among multiple physicians, staff, and patients across a variety of settings using different manual and electronic systems. 9,10 Lurking among the voluminous test results moving through various complex systems are critical and significantly abnormal findings that require expedited follow-up. These test results may be overlooked, misunderstood, or misdirected at any step along the way 6 and delays and failures can be deadly. 8,9

One aspect of managing the risks associated with significantly abnormal test result management and communication is anticipating potential errors and instituting processes that make them less likely. The following case studies based on NORCAL closed claims show the variety of ways significantly abnormal test result follow-up failures can result in patient harm and lawsuits against physicians. Risk management strategies are provided to help PCPs, staff, and administrators recognize and correct error-prone practices.

More Information About Communicating Critical Findings from Primary Care Physician to Patient

• Closed Claim Case Study: Lack of Redundancy and Coverage Contributes to Patient Death
• Closed Claim Case Study: Inadequate Follow Up on Abnormal Labs Leads to Permanent Injuries
• Closed Claim Case Study: Poor Test Result Communication Process Leads to Patient Injury
• Closed Claim Case Study: Failure to Convince Patient of Urgency of Follow Up Leads to Patient Death
• Closed Claim Case Study: Lack of Follow Up with “No Doc” ED Patient Leads to Patient Injury
• Closed Claim Case Study: Pre-Surgery Delay in Processing Abnormal Results Leads to Patient Death

Do You Have an Effective “Tickler System”?

Evidence of absent or poor follow-up systems can be used to support negligence allegations and to shed a generally negative light on the defendant physician during malpractice litigation. There are a variety of ways to ensure that patients receive test results in a timely fashion. Consider the following recommendations: 11

• Utilize the tracking and follow-up capabilities in an electronic medical record system to their full capabilities.
• Ask the laboratory/radiologist/pathologist how long it will take to provide results and use this time frame when developing a follow-up system.
• Requesting the patient’s involvement in follow-up should enhance, not replace, an office “tickler system.”
• Place copies of all ordered tests in a designated file.
• Monitor this file regularly to ensure that all ordered tests have been completed and that you have received the results.
• Contact patients, consultants, and the facility conducting the test (as appropriate) to determine the reason for delayed tests or missing test results.
• Utilize a tracking mechanism to compare all tests ordered with the corresponding results.
• Document follow-up communication in the medical record.
• Audit communication processes to ensure compliance with reporting procedures and the timeliness of abnormal test result follow-up.

Responsibility for Co-Managed Patients

In most circumstances, PCPs should take responsibility for follow-up on tests they have ordered. But PCPs often receive results from tests that have been ordered by other physicians. Determining responsibility for follow-up on results when a patient is receiving treatment from multiple physicians can be complicated. 9,12

A key to appropriate follow-up with patients who are co-managed by multiple physicians is establishing which physician is responsible for follow-up. 12 A common scenario in claims against NORCAL-insured PCPs often starts with a patient presenting to the ED. While there, the ED physician orders a variety of studies. In one of the studies there is an incidental finding of potential cancer. The specialist sends this report to the PCP and other specialists on the patient’s healthcare team. Each physician assumes someone else will follow up on the incidental finding but no one does and the patient never learns about it. Months or years later, the patient is diagnosed with cancer, but by that time the cancer has grown or metastasized and the patient’s chance of survival is diminished.

The defense of these claims against PCPs can be complicated, because in most cases the PCP has reviewed the report. During litigation, experts will often disagree about who among the patient’s healthcare team members had primary responsibility for following up with the patient. But all agree that someone should have communicated the results to the patient. A common outcome is all defendants contributing to a settlement.

1. David L. Weiss, et al . “ Radiology Reporting: A Closed-Loop Cycle from Order Entry to Results Communication .” Reference Guide in Information Technology for the Practicing Radiologist . 2013. DOI: 10.1016/j.jacr.2014.09.009

2. Lester J. Layfield. “ Critical Values: Has Their Time Arrived for Cytopathology? ” Cancer Cytopathology . 2014;122(3): 163-166. DOI: 10.1002/cncy.21378

3. Jonathan R. Genzen, Christopher A. Tormey. “ Pathology Consultation on Reporting of Critical Values .” American Journal of Clinical Pathology . 2011;135(4):505-513. DOI: 10.1309/AJCP9IZT7BMBCJRS

4. Christopher N. Chapman, Christopher N. Otis. “ From Critical Values to Critical Diagnoses: A review with an Emphasis on Cytopathology .” Cancer Cytopathology . 2011;119(3):148–57 DOI: 10.1002/cncy.20158

5. Raouf E. Nakhleh, Jeffrey L Myers, et al. “ Consensus Statement on Effective Communication of Urgent Diagnoses and Significant, Unexpected Diagnoses in Surgical Pathology and Cytopathology from the College of American Pathologists and Association of Directors of Anatomic and Surgical Pathology .” Archives of Pathology & Laboratory Medicine . 2012;136(2):148-154. DOI: 10.5858/arpa.2011-0400-SA

6. John U. Young. “ Failure to Communicate Clinical Test Results - A Legal Analysis for Pennsylvania .” Center for Health Law, Policy & Practice . Policy Brief . 2011, citing, Eric G. Poon, Samuel J. Wang, et al. “Design and Implementation of a Comprehensive Outpatient Results Manager.” Journal of Biomedical Informatics . 2003;36:80-91. DOI: 10.1016/S1532-0464(03)00061-3

7. Eric G. Poon, Samuel J. Wang, et al. “ Design and Implementation of a Comprehensive Outpatient Results Manager .” Journal of Biomedical Informatics . 2003;36:80-91. DOI: 10.1016/S1532-0464(03)00061-3

8. Angelica Montes, Michelle Francis, et al. “ Assessing the Delivery of Patient Critical Laboratory Results to Primary Care Providers .” Clinical Laboratory Science . Summer;27(3):139-42.

9. Joanne Callen, Andrew Georgiou, et al. “ The Impact for Patient Outcomes of Failure to Follow Up on Test Results. How Can We Do Better? ” Journal of the International Federation of Clinical Chemistry and Laboratory Medicine . 2015 Jan; 26(1): 38–46.

10. Joanne L. Callen, Johanna I. Westbrook, et al. “ Failure to Follow-Up Test Results for Ambulatory Patients: A Systematic Review .” Journal of General Internal Medicine . 2012;27(10):1334-1348. DOI: 10.1007/s11606-011-1949-5

11. Hardeep Singh, Meena S. Vij. “ Eight Recommendations for Policies for Communicating Abnormal Test Results .” Joint Commission Journal on Quality and Patient Safety. 2010 May;36(5):226-232. DOI: 10.1016/S1553-7250(10)36037-5

12. Kevin B. O’Reilly. “ Flood of Test Results Prompts New Attention on How to Manage Flow .” American Medical News . 5/24/2010.

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Communication Case Studies

As part of MastersinCommunications.com dedication to helping students research graduate programs and careers in the field of communication, we created a section dedicated to communication case studies so that students can learn more about real projects completed by communication professionals. We hope this section will help students understand both the diverse array of projects that fall under the field of communication and the skills associated with each type of project.

Business Communication Case Studies

Crisis Communication for a Public Employee Retirement System

This case study explores the creation of a crisis communication plan and how it was used to handle a delicate situation regarding changes to an employee retirement fund. It involves strategic use of public relations, content creation, teamwork, and more.

Human Resources Communication and an Integrity Pledge

This case study examines a company HR strategy that created deep divisions throughout the organization and was ultimately unsuccessful. It deals with the creation and implementation of an Integrity Pledge meant to address issues plaguing a small business.

Strategic Communication for Floodplain Education

In this case study, a communication specialist helps spearhead a strategic communication project for a non-profit conservation collective. Their work entails collaborative project planning and evaluation, content creation, event management, and public relations.

Health Communication Case Studies

Manual for Cancer Patients

This case study follows the creation of a printed manual containing information on cancer treatments. The design process involved gathering data from treatment facilities, as well as finding the right layout to optimize patient experience.

Public Health Communications for Measles Outbreak

When a measles outbreak hits a small rural community, health professionals must figure out how to inform the public about potential risks and prevention strategies. This case study examines how the local health department responded to the crisis.

Risk Communication and Social Media Campaigns

This case study details how one risk communication organization uses social media to provide up-to-date information during a natural disaster. It includes a breakdown of the strategy employed amidst such events, as well as the training involved to prepare.

Technical Communication Case Studies

Mountain Bike Race Guide

In order to help riders navigate the logistical issues involved in an international mountain bike race, as well as the course itself, a technical writer and a usability tester research and develop a detailed guide to the event.

New Employee Training

This case study explores the creation of onboarding materials for new employees hired by a growing non-profit organization. It discusses scope and goals of the project, along with the skills needed to complete the training program.

Online Help Tool

In this case study, a technical writer is tasked with building an online tool to help employees use a new software system. This project involved interviewing staff members, designing the tool’s interface, and writing step-by-step instructions.