Barriers and enablers to implementing environmentally sustainable practices in healthcare: A scoping review and proposed roadmap.

This scoping review sought to identify the barriers and enablers to implementing environmentally sustainable practices in healthcare, as well as propose a multi-phased approach to enable such implementation. The three concepts guiding the search were (1) environmental sustainability; (2) healthcare; and (3) barriers or enablers. The PRISMA checklist for scoping reviews was used to guide this search. A total of 16 articles were included and reviewed for data extraction. While most articles focused on healthcare in general, dentistry and surgery were the most recurring clinical areas of focus. Barriers and enablers were related to the individual (e.g. knowledge, skills, and attitude), institutional (e.g. budget, strategy, and readiness), geographical/infrastructural (e.g. infrastructure and public awareness), political (e.g. regulations and incentives), and other (e.g. patient awareness and knowledge). A key enabler identified was having transformational leadership with a clear vision and collaborative approach.

Weight Communication: How Do Health Professionals Communicate about Weight with Their Patients in Primary Care Settings?

This study aimed to investigate how health professionals (HPs) communicate about weight with their patients. Semi-structured interviews were conducted with 33 health professionals (7 family physicians, 13 nurse practitioners, and 13 dietitians) working in multidisciplinary healthcare settings in Canada. Thematic analysis revealed four main approaches used by HPs to communicate about weight: 1) Analyzing patient perspectives, 2) focusing on overall health rather than weight, 3) directly addressing the topic, and 4) avoiding the topic. The approach chosen was influenced by HPs' outlook on obesity; for example, those who believed obesity to be a chronic disease did not hesitate to communicate about weight. However, some HPs who reported having obesity mentioned avoiding the topic of weight with their patients and emphasized the importance of establishing a trusting relationship with patients before addressing the topic. The approach chosen by HPs also seemed to be influenced by patient receptiveness, level of readiness, and motivation. Weight communication can be sensitive and the approach used to begin the topic of weight may differ based on patient- and HP factors. Future clinical practice guidelines may benefit from shifting toward communicating about modifiable risk factors rather than weight.

Dietitians' Perspectives on the Impact of Multidisciplinary Teams and Electronic Medical Records on Dietetic Practice for Weight Management.

Purpose: To understand the perception of dietitians regarding the effects of multidisciplinary settings and Electronic Health Records (EHRs) on their dietetic practice for weight management. Methods: Individual semi-structured interviews were conducted with 14 dietitians working in multidisciplinary settings in Ontario. All interviews were audio recorded and transcribed verbatim. Two researchers coded the data independently using a thematic analysis approach. All themes emerged inductively and were refined iteratively. Results: Most dietitians believed that working in a multidisciplinary setting allowed for interprofessional collaboration and time-effective referrals. Multidisciplinary clinics were perceived to improve patient care due to convenient scheduling, consistent messaging, and ongoing support. However, some dietitians reported instances of conflicting approaches and beliefs regarding weight management across health professionals. Dietitians suggested ways to address these conflicting approaches through clinical meetings and education. EHRs were perceived to allow for collaboration through facilitated communication and knowledge exchange; however, lack of interoperability between EHR platforms across different types of health care settings was perceived to be a barrier for optimal care. Conclusions: Overall, multidisciplinary settings were perceived to positively impact dietitians' practices for weight management as they allow for interprofessional collaboration. Consistency in health messaging across health professionals should be emphasized through knowledge exchange.

Factors affecting access and use of preventive and weight management care: A public health lens.

Obesity is an important risk factor for various chronic diseases. While people with obesity use the health system more and incur higher costs, they may forego using preventive care services (e.g., gynecological cancer screenings) due to issues of service use and service access. The aim of this paper was to use a public health lens to elucidate system level factors that affect healthcare access and utilization for preventive and weight management care by patients with obesity. Some elucidated factors include lack of access to a Primary Care Provider (PCP) and multidisciplinary healthcare settings, gender of the PCP, duration of medical visits and health professionals' attitudes about obesity. We highlight potential strategies for leaders to use when improving access and use of health services by patients with obesity in Canada and the need for future empirical studies in this research area.

Nutrition care practices of primary care providers for weight management in multidisciplinary primary care settings in Ontario, Canada - a qualitative study.

BACKGROUND: Despite the recommended guidelines on addressing diet for the management and prevention of obesity in primary care, the literature highlights that their implementation has been suboptimal. In this paper, we provide an in-depth understanding of current nutrition-related weight management practices of primary care providers (PCPs) working in relatively new multidisciplinary health care settings in Ontario. METHODS: Three types of multidisciplinary primary care settings were included (2 Family Health Teams, 3 Community Health Centres and 1 Nurse Practitioner-Led Clinic). Participants (n = 20) included in this study were nurse practitioners (n = 13) and family physicians (n = 7) supporting care for adult patients (18 years or older). In-depth interviews were transcribed, coded and the content was analyzed using an integrated approach. RESULTS: Our analysis showed that most PCPs used anthropometric measures such as weight for screening patients who would benefit from nutrition counselling with a dietitian. The topic of nutrition was generally brought up either during physical examinations, when patients were diagnosed with a chronic disease, or when blood markers were out of normal range. Participants also mentioned that physical examinations are no longer occurring annually, with most PCPs offering episodic care. All participants reported utilizing dietetic referrals, noting the enablers for providing the referral, which included access to an on-site dietitian. Nonetheless, dietetic referrals were mostly used when patients had an obesity-related co-morbidity. Participants mentioned that healthy eating advice was reinforced during follow-up visits with patients only when there was enough time to do so. Electronic Health Records (EHRs) were utilized to facilitate message reinforcement by PCPs, who perceived EHRs to be helpful for viewing what was discussed in the session with the dietitian. CONCLUSIONS: PCPs mostly used objective measures to screen for patients who would benefit from nutrition counselling rather than diet assessment, which undermines the importance of dietary intake and overemphasizes weight. With physical examinations occurring less frequently, there will be additional missed opportunities for addressing nutrition-related concerns. The presence of a dietitian on site allowed for PCPs to refer patients to nutrition counselling. Having sufficient time during medical visits and EHRs seemed to facilitate message reinforcement by PCPs in follow-up visits with patients.

Current Weight Management Approaches Used by Primary Care Providers in Six Multidisciplinary Healthcare Settings in Ontario.

BACKGROUND: Obesity management in primary care has been suboptimal due to lack of access to allied health professionals, time, and resources. PURPOSE: To understand the weight management approaches used by primary care providers working in team-based settings and how they assess the most suitable approach for a patient. METHODS: A total of 20 primary care providers (13 nurse practitioners and 7 family physicians) working in 6 multidisciplinary clinics in Ontario were interviewed. All interviews were recorded, transcribed verbatim, and coded using NVivo qualitative software. Conventional content analysis was used to inductively elucidate codes, which were then clustered into categories. RESULTS: A referral to on-site programming was the most frequent weight management approach used. The pharmacological approach was underutilized due to adverse side effects and cost to patients. Primary care providers assessed the most suitable weight management approach based on patients': preference, level of motivation, income status and access to resources, body mass index and comorbidities, and previous weight loss attempts. Primary care providers perceived that referring to health professionals and educational resources were the approaches preferred by patients. CONCLUSIONS: The team-based nature of these clinics allowed for referrals to various on-site professionals and/or programs. Some barriers to pursuing weight management avenues with patients were patient dependent.

Latent classes associated with the intention to use a symptom checker for self-triage.

It is currently unknown which attitude-based profiles are associated with symptom checker use for self-triage. We sought to identify, among university students, attitude-based latent classes (population profiles) and the association between latent classes with the future use of symptom checkers for self-triage. Informed by the Technology Acceptance Model and a larger mixed methods study, a cross-sectional survey was developed and administered to students (aged between 18 and 34 years of age) at a University in Ontario. Latent class analysis (LCA) was used to identify attitude-based profiles that exist among the sample while general linear modeling was applied to identify the association between latent classes and future symptom checker use for self-triage. Of the 1,547 students who opened the survey link, 1,365 did not use a symptom checker in the past year and were thus identified as "non-users". After removing missing data (remaining sample = n = 1,305), LCA revealed five attitude-based profiles: tech acceptors, tech rejectors, skeptics, tech seekers, and unsure acceptors. Tech acceptors and tech rejectors were the most and least prevalent classes, respectively. As compared to tech rejectors, tech seekers and unsure acceptors were the latent classes with the highest and lowest odds of future symptom checker use, respectively. After controlling for confounders, the effect of latent classes on symptom checker use remains significant (p-value < .0001) with the odds of future use in tech acceptors being 5.6 times higher than the odds of future symptom checker use in tech rejectors [CI: (3.458, 9.078); p-value < .0001]. Attitudes towards AI and symptom checker functionality result in different population profiles that have different odds of using symptom checkers for self-triage. Identifying a person's or group's membership to a population profile could help in developing and delivering tailored interventions aimed at maximizing use of validated symptom checkers.

Young Adults' Perspectives on the Use of Symptom Checkers for Self-Triage and Self-Diagnosis: Qualitative Study.

BACKGROUND: Young adults often browse the internet for self-triage and diagnosis. More sophisticated digital platforms such as symptom checkers have recently become pervasive; however, little is known about their use. OBJECTIVE: The aim of this study was to understand young adults' (18-34 years old) perspectives on the use of the Google search engine versus a symptom checker, as well as to identify the barriers and enablers for using a symptom checker for self-triage and self-diagnosis. METHODS: A qualitative descriptive case study research design was used. Semistructured interviews were conducted with 24 young adults enrolled in a university in Ontario, Canada. All participants were given a clinical vignette and were asked to use a symptom checker (WebMD Symptom Checker or Babylon Health) while thinking out loud, and were asked questions regarding their experience. Interviews were audio-recorded, transcribed, and imported into the NVivo software program. Inductive thematic analysis was conducted independently by two researchers. RESULTS: Using the Google search engine was perceived to be faster and more customizable (ie, ability to enter symptoms freely in the search engine) than a symptom checker; however, a symptom checker was perceived to be useful for a more personalized assessment. After having used a symptom checker, most of the participants believed that the platform needed improvement in the areas of accuracy, security and privacy, and medical jargon used. Given these limitations, most participants believed that symptom checkers could be more useful for self-triage than for self-diagnosis. Interestingly, more than half of the participants were not aware of symptom checkers prior to this study and most believed that this lack of awareness about the existence of symptom checkers hindered their use. CONCLUSIONS: Awareness related to the existence of symptom checkers and their integration into the health care system are required to maximize benefits related to these platforms. Addressing the barriers identified in this study is likely to increase the acceptance and use of symptom checkers by young adults.

Use of symptom checkers for COVID-19-related symptoms among university students: a qualitative study.

OBJECTIVE: Symptom checkers are potentially beneficial tools during pandemics. To increase the use of the platform, perspectives of end users must be gathered. Our objectives were to understand the perspectives and experiences of young adults related to the use of symptom checkers for assessing COVID-19-related symptoms and to identify areas for improvement. METHODS: We conducted semistructured qualitative interviews with 22 young adults (18-34 years of age) at a university in Ontario, Canada. Interviews were audio-recorded, transcribed, and analysed using inductive thematic analysis. RESULTS: We identified six main themes related to the decision of using a symptom checker for COVID-19 symptoms: (1) presence of symptoms or a combination of symptoms, (2) knowledge about COVID-19 symptoms, (3) fear of seeking in-person healthcare services, (4) awareness about symptom checkers, (5) paranoia and (6) curiosity. Participants who used symptom checkers shared by governmental entities reported an overall positive experience. Individuals who used non-credible sources reported suboptimal experiences due to lack of perceived credibility. Five main areas for improvement were identified: (1) information about the creators of the platform, (2) explanation of symptoms, (3) personalised experience, (4) language options, and (5) option to get tested. CONCLUSIONS: This study suggests an increased acceptance of symptom checkers due to the perceived risks of infection associated with seeking in-person healthcare services. Symptom checkers have the potential to reduce the burden on healthcare systems and health professionals, especially during pandemics; however, these platforms could be improved to increase use.

Dietitians' perspectives on patient barriers and enablers to weight management: An application of the social-ecological model.

AIM: Dietitians are nutrition experts who conduct nutrition assessments and provide support to patients seeking to manage their weight. The aim of the present study was to assess dietitians' perspectives on the barriers and enablers encountered by patients during their weight management journey. METHODS: Fourteen individual semi-structured interviews were conducted over a 3-month period in 2017 with dietitians working in Ontario, Canada. All interviews were audio-recorded and transcribed verbatim. Two researchers coded the data independently using a directed content analysis approach. RESULTS: Emerging themes were classified at societal, community, relationship, individual levels of the social-ecological model (SEM). Barriers included low socioeconomic status, 'go big or go home approach', lack of knowledge and cooking skills, lack of time, emotional eating, unsupportive home and work environments, discrimination and weight bias, lack of communication between health professionals, and low accessibility to healthy foods. Enablers included community programs, workplaces promoting healthy behaviours, and ongoing clinical support. Dietitians mentioned that patients encounter many barriers that may coexist and hinder weight management and/or maintenance of lost weight. CONCLUSIONS: Communication between health team members and ongoing patient support in the clinical setting are required. A whole-of-government, whole-of-society approach is needed to target the various aforementioned barriers at various level of the SEM.

The Use of Artificially Intelligent Self-Diagnosing Digital Platforms by the General Public: Scoping Review.

BACKGROUND: Self-diagnosis is the process of diagnosing or identifying a medical condition in oneself. Artificially intelligent digital platforms for self-diagnosis are becoming widely available and are used by the general public; however, little is known about the body of knowledge surrounding this technology. OBJECTIVE: The objectives of this scoping review were to (1) systematically map the extent and nature of the literature and topic areas pertaining to digital platforms that use computerized algorithms to provide users with a list of potential diagnoses and (2) identify key knowledge gaps. METHODS: The following databases were searched: PubMed (Medline), Scopus, Association for Computing Machinery Digital Library, Institute of Electrical and Electronics Engineers, Google Scholar, Open Grey, and ProQuest Dissertations and Theses. The search strategy was developed and refined with the assistance of a librarian and consisted of 3 main concepts: (1) self-diagnosis; (2) digital platforms; and (3) public or patients. The search generated 2536 articles from which 217 were duplicates. Following the Tricco et al 2018 checklist, 2 researchers screened the titles and abstracts (n=2316) and full texts (n=104), independently. A total of 19 articles were included for review, and data were retrieved following a data-charting form that was pretested by the research team. RESULTS: The included articles were mainly conducted in the United States (n=10) or the United Kingdom (n=4). Among the articles, topic areas included accuracy or correspondence with a doctor's diagnosis (n=6), commentaries (n=2), regulation (n=3), sociological (n=2), user experience (n=2), theoretical (n=1), privacy and security (n=1), ethical (n=1), and design (n=1). Individuals who do not have access to health care and perceive to have a stigmatizing condition are more likely to use this technology. The accuracy of this technology varied substantially based on the disease examined and platform used. Women and those with higher education were more likely to choose the right diagnosis out of the potential list of diagnoses. Regulation of this technology is lacking in most parts of the world; however, they are currently under development. CONCLUSIONS: There are prominent research gaps in the literature surrounding the use of artificially intelligent self-diagnosing digital platforms. Given the variety of digital platforms and the wide array of diseases they cover, measuring accuracy is cumbersome. More research is needed to understand the user experience and inform regulations.

Nutrition and obesity care in multidisciplinary primary care settings in Ontario, Canada: Short duration of visits and complex health problems perceived as barriers.

Nutrition care in the primary care setting is integral in obesity management, but there is a substantial gap between patients who would benefit from this service and those receiving it. This study provides an in-depth understanding of how relatively new multidisciplinary primary care settings may be affecting nutrition care practices of family physicians and nurse practitioners. This qualitative comparative case study sought to assess nutrition care practices in three different types of multidisciplinary clinics (2 Family Health Teams, 3 Community Health Centers, 1 Nurse Practitioner-Led Clinic) in Ontario, Canada. Individual semi-structured interviews were conducted with nurse practitioners (n = 13) and family physicians (n = 7) in fall 2017. Data analysis was conducted using NVivo Software. The integrated approach was used for elucidating codes and themes. Findings suggest that suboptimal duration of medical visits and increasing prevalence of complex patients were reported by most participants and were perceived as barriers for addressing nutrition and obesity. However, improved nutrition care was fostered through Electronic Medical Records, primary care providers' positive attitude towards nutrition and cost-free dietitian services at point of access. Site-specific challenges, such as duration of medical visits, incentive programs, access to dietitians on site, and continued professional development could enhance nutritional care for weight management in these multidisciplinary primary care settings.