PLoS ONE plos plosone PLOS ONE 1932-6203 Public Library of Science San Francisco, CA USA 10.1371/journal.pone.0271100 PONE-D-22-09574 Research Article Medicine and health sciencesHealth carePatients Medicine and health sciencesMedical conditionsSkin diseasesAcne Medicine and health sciencesDermatologySkin diseasesAcne Medicine and health sciencesHealth careHealth education and awareness Research and analysis methodsResearch designClinical research designAdverse events People and placesPopulation groupingsAge groups Medicine and health sciencesDermatology Biology and life sciencesNeuroscienceCognitive scienceCognitive psychologyDecision making Biology and life sciencesPsychologyCognitive psychologyDecision making Social sciencesPsychologyCognitive psychologyDecision making Biology and life sciencesNeuroscienceCognitive scienceCognitionDecision making Medicine and health sciencesPharmaceuticsDrug therapy Clinician-created educational video for shared decision-making in the outpatient management of acne Education video to SDM https://orcid.org/0000-0001-7138-7757 Hung Chih-Tsung Conceptualization Data curation Funding acquisition Methodology Project administration Writing – original draft 1 2 3 Chen Yi-Hsien Formal analysis Investigation Methodology 1 3 Hung Tzu-Ling Data curation Formal analysis Methodology 1 Chiang Chien-Ping Formal analysis Investigation Methodology Resources Validation 1 Chen Chih-Yu Data curation Formal analysis Methodology 1 2 Wang Wei-Ming Conceptualization Formal analysis Methodology Supervision Validation Writing – review & editing 1 2 4 * Department of Dermatology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan Department of General Medicine, Tri-Service General Hospital, Taipei, Taiwan Vice Chairman, School of Medicine, National Defense Medical Center, Taipei, Taiwan Rinaldi Fabio Editor IHRF / Studio Rinaldi, ITALY

The authors have declared that no competing interests exist.

 * E-mail: ades0431@ms38.hinet.net 8 7 2022 2022 17 7 e0271100 31 3 2022 23 6 2022 2022 Hung et al This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Shared decision-making (SDM) provides patient-centered care. However, the limited consultation time was the main factor hindering the application. Patient education is crucial in the process of SDM. The use of visual aids as health education materials is an effective way to improve patients’ health literacy and medication adherence. This study aimed to determine the effectiveness of the clinician-created educational video of acne, accessed by patients during the waiting time, including knowledge level and satisfaction. This study was conducted in dermatology outpatient clinics and collected patient responses through electronic devices. During the waiting time, patients with acne would read educational pamphlets and complete the test first. Then, a clinician-created 8-minute educational video, as a patient decision aid (PDA), was accessed by patients using their own mobile smart devices, followed by a test and questionnaire about the satisfaction of the pamphlet and video. We enrolled 50 patients with acne, including 33 males and 17 females. The mean age is 25.55 ± 6.27 years old, ranging from 15 to 47 years old. About the patients’ knowledge, the test score improved significantly after watching the video (P < .001). The same findings were observed in the subgroup analysis of gender and different age groups. A higher proportion of patients preferred the educational video over the pamphlet in both genders and different age groups. All patients agreed with the video helped them to understand the educational information and impressed them more than reading pamphlets. The application of clinician-created educational videos in patient education seems to be an efficient solution to implement SDM in the daily clinical work. Besides, we could remind patients to watch the video anytime when they were not sure about the treatment choices, side effects, or the precautions of medications.

 http://dx.doi.org/10.13039/501100010425 Tri-Service General Hospital TSGH- E110219 https://orcid.org/0000-0001-7138-7757 Hung Chih-Tsung http://dx.doi.org/10.13039/501100010425 Tri-Service General Hospital TSGH-E111201 https://orcid.org/0000-0001-7138-7757 Hung Chih-Tsung This study was supported by grants from Tri-Service Hospital Research Foundation (TSGH- E110219 and TSGH-E111201). The funders had no role in study design, data collection, analysis, decision to publish, or preparation of the manuscript. Data Availability We uploaded study’s minimal underlying data as supplement file. Introduction

Acne is a common skin disease and affects patients’ life of quality a lot [1]. Oral isotretinoin, an isomer of retinoic acid, has been used to treat severe nodular acne, treatment-resistant moderate acne, and recalcitrant papulopustular rosacea [2, 3]. Isotretinoin has well-known teratogenic effects, and the American Food and Drug Administration (FDA) mandated that all patients receiving isotretinoin are required to enroll in the iPLEDGE risk management program. However, there were 4,647 pregnancies reported to the FDA for patients taking isotretinoin after the introduction of iPLEDGE in 2006 [4]. In Taiwan, the Ministry of Health and Welfare requires all patients taking isotretinoin have to read and sign the informed consent after the discussion with dermatologists at clinics. Nonetheless, it is difficult to determine the patients’ awareness level.

Shared decision-making (SDM) is a bidirectional process between healthcare professionals and patients to make treatment plans based on the medical evidence and patients’ values [5]. SDM has shown the benefit in the improvement of patients’ knowledge, satisfaction, and treatment adherence [6]. However, patients’ level of health literacy affects their engagement in SDM a lot [7].

Health literacy is the ability to read, understand health information and make decisions regarding health in clinical practice [8]. Low literacy is related to poor health outcomes, lower treatment adherence [9], and frequent hospitalizations [10]. Several studies revealed the use of visual aids as health education materials, including pictograms and videos, is an effective way to improve patients’ health literacy and medication adherence [11].

This study aimed to evaluate the use of a clinician-created educational video as a patient decision aid (PDA) to improve patients’ knowledge about acne pathogenesis, treatment choices, isotretinoin mechanism, and side effects. We aimed to identify the patients’ knowledge level, preference, and satisfaction with educational pamphlet and video.

 Materials and methods Study population and recruitment

The selection of the study participants is depicted in Fig 1. A single-center study was conducted involving 50 patients with moderate to severe acne. Patients were recruited from the authors’ daily clinical practice, all of whom are licensed dermatologists working at an academic institution. Relatives or caregivers were recruited via the participating patients whose ages were under 20 years old. Inclusion criteria for all participants can access YouTube and watch the online video.

10.1371/journal.pone.0271100.g001 The flowchart of study design and participants selection.

SDM, Shared decision-making.

 Study design

The flowchart of the study design is described in Fig 1. According to our Health Insurance, the patients preparing to take isotretinoin must read and sign the standard inform consent (S1 File). After reading the education pamphlet (S2 File) and consent, they will complete the assessment (S3 File). In this study, we want to know the patients’ awareness of acne and isotretinoin, and we designed an assessment of 5 quizzes reviewed by five dermatologists. Then, patients watched an 8-minute educational video on their mobile phones. After the video, they will complete the assessment and feedback questionnaire (S4 File). The questionnaire was designed as a 5-point Likert scale to evaluate the patients’ perspective of educational video. One open-ended question was provided to patients and their family to express their opinions and feedback on the educational video. During the consultation, doctors can discuss with patients to make their treatment plans. All doctors involved in SDM were instructed before the implementation.

 Educational video

An 8-minute educational video was developed by Dr. Chih-Tsung Hung from the National Defense Medical Center in Taiwan. The video was edited followed the three steps as proposed by Ziade N. et al. in 2021 [12]. The video (which can be accessed via this link: Traditional Chinese version https://www.youtube.com/watch?v=L-cdfZHosCE; English version https://www.youtube.com/watch?v=5uTwAkPjAP4) is designed to improve patients’ awareness of acne, treatment, and drug side effects. The topics addressed in the video and the spoken text were composed of acne pathogenesis, treatment choices, isotretinoin mechanism, and side effects. The video was reviewed and adapted by five dermatologists from the National Defense Medical Center in Taiwan.

 Statistical analysis

We used SPSS 22.0 software for Windows for all statistical analyses. To demonstrate the improvement of the medication awareness between educational pamphlets and the educational video, a comparison of assessment scores was done by using a paired t-test. A P value less than 0.05 was considered statistically significant.

 Ethics

This study was reviewed and approved by the Institutional Review Board of Tri-Service General Hospital (TSGHIRB No.: B202105191). The study was conducted along with the code of Helsinki.

 Results Characteristics of patients

This study was conducted on patients with acne at the dermatology outpatient department. A total of 50 patients were enrolled, including 33 (66%) males and 17 (34%) females (Table 1). The mean age was 25.55 ± 6.27 years for the patients and the majority of the age group is between 20 to 25 years old, including 23 patients (14 males; 9 females). All patients read the educational pamphlets, completed the test, then watched the video, filled in the test and questionnaires. During the consultation, patients could discuss with the dermatologists if anything is remaining unclear (Fig 1).

10.1371/journal.pone.0271100.t001 Characteristics of study patients in the baseline.
Total
Variables n %
Total 50 100%
Gender
    Male 33 66%
    Female 17 34%
Age (years) 25.55 ± 6.27
Age groups (years)
    15–19 7 (M/F = 7/0) 14%
    20–25 23 (M/F = 14/9) 46%
    26-29- 11 (M/F = 6/5) 22%
    ≧30 9 (M/F = 7/2) 18%
Disease
    Acne 50 100%

M: male; F: female.

 Test results after reading educational pamphlet and video

The test scores were collated and expressed as a mean score ± SD to find out the patients’ learning efficiency (Table 2). The score improved significantly after watching the video (the score after reading the educational pamphlet was 81 ± 19.55, and the score after watching the video was 99 ± 4.79, P < .001). The same findings were observed in the subgroup analysis of gender and different age groups.

10.1371/journal.pone.0271100.t002 Test scores post-pamphlet and educational video.
Education pamphlet (n = 50) Educational video (n = 50) P value
Score 81 ± 19.55 99 ± 4.79 <0.001
Gender
Male (n = 33) 79 ± 19.96 99 ± 4.85 <0.001
Female (n = 17) 86 ± 18.39 99 ± 5 0.007
Age groups score
15–19 yrs (n = 7) 80 ± 16 100 0.018
20–24 yrs (n = 20) 80 ± 17 97 ± 7 <0.001
25–29 yrs (n = 14) 89 ± 17 100 0.026
≧30 yrs (n = 9) 73 ± 28.28 100 0.022

Mean ± Standard Deviation; P: Paired t-test

 Patients’ satisfaction with educational pamphlet and video

Feedback was taken from 50 patients, and it is summarized (Fig 2). Among them, 41 (82%) patients preferred the video to understand acne mechanism and side effects of oral Isotretinoin, 7 (14%) patients preferred the pamphlet, and 2 (4%) patients felt the same. Subgroup analysis of gender and different age groups, the higher proportion of patients preferred the educational video.

10.1371/journal.pone.0271100.g002 Patients’ satisfaction with educational pamphlet and video. Patients’ response to educational pamphlet and video

About the question (Q1): compared to the educational pamphlet, does the educational video impress you more about the acne mechanism, treatment, and side effects of oral isotretinoin? Feedback was taken from 50 patients, and it is summarized (Fig 3A). 38 (76%) patients strongly agreed and 12 (24%) patients agreed with it.

10.1371/journal.pone.0271100.g003 Patients’ response to educational pamphlet and video.

(a) Q1. Compared to the educational pamphlet, does the educational video impress you more about the acne mechanism, treatment, and side effects of oral isotretinoin? (b) Q2. Compared to the educational pamphlet, does the educational video help you to understand the acne mechanism, treatment, and side effects of oral isotretinoin more efficiently?

About the question (Q2): compared to the educational pamphlet, does the educational video help you to understand the acne mechanism, treatment, and side effects of oral isotretinoin more efficiently? Feedback was taken from 50 patients, and it is summarized (Fig 3B). 41 (82%) patients strongly agreed and 9 (18%) patients agreed with it.

There were 10 patients’ qualitative responses to the educational video. 6 patients responded “very good”, 3 patients responded “the content of video is clear and helped them understand efficiently”, and one patient suggested that adding clinical picture of side effect about oral isotretinoin would impress him more.

 Discussion

In this study, we determined the efficacy of the educational video as a PDA supplement to the medical pamphlet to improve patients’ awareness of acne and isotretinoin. The patients’ knowledge level enhanced significantly after watching the video, and it made SDM perform efficiently during the consultation. This finding was observed in both males and females and the different age groups. Therefore, the educational video seems to be more effective at the enhancement of patients’ awareness than the pamphlet irrespective of gender or age. The questionnaire is intended to be subjective to know the personal preferences of health education that cannot be determined by the test score of patients. In our study, a higher proportion of patients favored the educational video than the pamphlet reading. Besides, compared to the pamphlet, most of them agreed that the video is more impressive and easier to understand the content.

SDM is composed of the following important elements: (1) it involves healthcare professionals and patients, (2) both sides share information, (3) both sides are in a course to build a consensus of the preferred treatment, and (4) a treatment agreement is reached and implemented [13]. Patient education plays an important role in the SDM [14]. It helps patients to be capable of asking more questions and expressing a greater desire for involvement during a consultation. In 2016, L. Tudor Car et al. used a priority-setting method to identify patient safety problems and solutions [15]. Inadequate patient education about their medication is one of the top three problems. The solution to the prevention is the improvement of patient education. In our study, we demonstrated the education video is a good supplement to the pamphlet on disease and medication. A higher score of awareness test was observed when the patients watched the video than that of reading pamphlet (P < .001). We proposed the educational video would be a solution to improve patient education.

SDM has been applied in dermatology for years [16], including melanoma [17], psoriasis [18, 19], and acne [19, 20], SDM provides patient-centered care, improves patient knowledge, satisfaction, and adherence to treatment [6]. However, there were several barriers to the application of SDM, including time, lack of training for healthcare professionals, lack of validated PDAs, and the inability of patients either due to low health literacy, lack of desire, or other factors [16]. The limited consultation time to implement SDM is the most mentioned barrier [21–23]. In this article, we used a clinician-created educational video as a PDA to let the healthcare professionals conduct SDM efficiently, and we reminded patients to watch the video anytime when they were not sure about the treatment choices, side effects, or the precautions of medications.

In agreement with previous studies, watching educational videos improved patient satisfaction and decreased patients’ anxiety [24–26]. However, only a limited number of studies were designed to know the patients’ knowledge improvement of medication safety after watching educational videos. In 2008, N Kinnane et al. demonstrated the use of video to standard chemotherapy education enhances patients’ knowledge about the management of chemotherapy side effects [27]. All patients were satisfied with the video which helped them to remember the information given by the nurse. In 2021, JG Kovoor et al. showed clinician-created educational videos of atrial fibrillation in improving patient decision-making ability, long-term treatment adherence, and anxiety reduction [28]. In this study, we created the education video of acne as a PDA to implement SDM at clinics. Patents could access the video, quizzes, and the questionnaire during the waiting time by using Quick Response (QR) code. The results demonstrated not only the improvement of the patient knowledge but also high satisfaction with the video. Besides, healthcare professionals could discuss the treatment plans efficiently with patients during the consultation.

To the best of our knowledge, there is no study applying educational video as a PDA in dermatology to implement SDM. However, there were some limitations in our study. First, there is no validated questionnaire for acne knowledge. Therefore, the content is designed and reviewed by five different dermatologists. Besides, the questionnaire was also pretested by the patients and modified. Second, the main study population was Taiwanese. Thus, the ethnic discrepancy could exist. Third, we did not request the participants not to consult other resources, such as searching on the internet, during the filling in the assessment. However, the purpose of this study is to improve the patients’ awareness of disease and medications. No matter which way the patients got the knowledge, it would be beneficial to increase patients’ safety.

 Conclusion

This study demonstrated that educational video can be a PDA for patient education. The video helps healthcare professionals to perform SDM. It is an efficient way to share information with patients and their relatives, help them understand the benefits, harms, and possible outcomes of different options.

 Supporting information Isotretinoin inform consent.

(DOCX)

 Education pamphlet of acne.

(DOC)

 Test quizzes of acne.

(DOCX)

 Questionnaire of educational video.

(DOCX)

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10 Jun 2022

PONE-D-22-09574Clinician-created educational video for shared decision-making in the outpatient management of acnePLOS ONE

Dear Dr. Hung,

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Additional Editor Comments:

The topic is interesting (patient education, the communication of the risks and benefits of a therapy) but the work does not give many useful indications except that communication via video is more appreciated than a pamphlet with the same explanations.

It may be interesting to evaluate the video shown in the link, but unfortunately the text is in Chinese

It would also be interesting to expand the discussion with some indications (if there are any)on the response of patients after watching the video, to know if their approach to therapy is different from those who do not undergo an educational video

I think it would be easier to accept the manuscript at least by evaluating the video in English and and adding the reaction of patients to the educational video and some indications for doctors who want to adopt this approach.

In general, I agree with observations from reviewers.

Please provide clarifications.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

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Reviewer #1: No

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

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Reviewer #1: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: -Video is not in english and so not easy to evaluated correctly -

-Authors must clarify if dermatologists instructed in the same way the patients. Were they instructed before? This coul be a bias of the study.

- Did authors make a power analysis fo choising the number of subjects to be tested?

- Video was editing following some standard guideline for patient education? If yes, please clarify in the text

- Main limitations of the sutdies must be highlighted.

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Reviewer #1: No

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 10.1371/journal.pone.0271100.r002 Author response to Decision Letter 0 Submission Version 1

21 Jun 2022

Reviewer

Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: -

1. Video is not in english and so not easy to evaluated correctly.

Response:

Thanks for your kind comment and reminder. We provided an educational video in English in the article (page 8, line 4).

2. Authors must clarify if dermatologists instructed in the same way the patients. Were they instructed before? This could be a bias of the study.

Response:

Thanks for your kind comment and reminder. The content consisted of the treatment guide for acne in Taiwan. Besides, the video was reviewed by another 5 dermatologists, and the content was revised 3 times. All doctors involved in SDM were instructed before the implementation.

3. Did authors make a power analysis fo choising the number of subjects to be tested?

Response:

Thanks for your kind comment and reminder. A two-tailed 99% confidence interval is ± 2.6 standard error (S.E.) wide. For a ±1 logit interval, this S.E. is ±1/2.6 logits, this gives a minimum sample in the range 4*(2.6)2 < N < 9*(2.6)2, i.e, 27 < N < 61, depending on targeting. Thus, a sample of 50 well-targeted examinees is conservative for obtaining useful.[1]

4. Video was editing following some standard guideline for patient education? If yes, please clarify in the text.

Response:

Thanks for your kind comment and reminder. The patient education video was edited followed the three steps as proposed by Ziade N. et al. in 2021 (page 8, line 1-2).[2]

5. Main limitations of the sutdies must be highlighted.

Response:

Thanks for your kind comment and reminder. We revised the limitations in our article (page 15, line 13-19; page 16, line 1-4).

Reference

1. Khan MI. Recovery and stability of item parameter and model fit across varying sample sizes and test lengths in Rasch analysis with small sample. Social Science International. 2014;30(1):43.

2. Ziade N, Arayssi T, Elzorkany B, Daher A, Karam GA, Jbara MA, et al. Development of an Educational Video for Self-Assessment of Patients with RA: Steps, Challenges, and Responses. Mediterr J Rheumatol. 2021;32(1):66-73. Epub 20210304. doi: 10.31138/mjr.32.1.66. PubMed PMID: 34386703; PubMed Central PMCID: PMCPMC8314883.

Submitted filename: Reviewer opinion and response.doc

 10.1371/journal.pone.0271100.r003 Decision Letter 1 Rinaldi Fabio Academic Editor 2022 Fabio Rinaldi This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Submission Version 1

24 Jun 2022

Clinician-created educational video for shared decision-making in the outpatient management of acne

PONE-D-22-09574R1

Dear Dr. Hung,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Fabio Rinaldi

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Ok for publications given the answers the Authors

Reviewers' comments:

 10.1371/journal.pone.0271100.r004 Acceptance letter Rinaldi Fabio Academic Editor 2022 Fabio Rinaldi This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

29 Jun 2022

PONE-D-22-09574R1

Clinician-created educational video for shared decision-making in the outpatient management of acne

Dear Dr. Hung:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Fabio Rinaldi

Academic Editor

PLOS ONE