awareness regarding values and needs” to help patients reach their personal health goals (p. 140).8 Empowerment within the health context has frequently been operationalized in terms of how much patients participate in the medical decision-making process.8 Dupuits9 claims that the Internet and other such information media have had significant influence on patients’ empowerment and their participation in the decision-making process. However, other research asks whether high amounts of information are always beneficial to patients. Broom10 says that for some patients with prostate cancer, Internet health information has served as a source of empowerment, while for others, it has served as a source of confusion.11 Patients who seek health information in addition to that provided by physicians challenge the physician–patient relationship, and this can lead physicians to further limit collaboration in the treatment decision-making process.10
Therefore, further review of the effects of health information on patient empowerment and par- ticipation is warranted. This study offers a conceptual framework to examine the benefits of pre- senting information to women in waiting rooms prior to a genecology professional encounter to discuss initial results regarding positive Pap test indication.
Background Empowerment
Gibson12 defines empowerment as the process by which individuals or groups enhance their ability to meet their needs and gain a sense of control over their lives. Research indicates that
levels.12–14 At the individual level, empowerment is described as a family of variables that “includes participatory behavior, motivations to exert control, and feelings of efficacy and control.”13 This form of empowerment includes both individual perceptions (psychological aspects) and behavior.
In regard to health care, Webb et al.15 refer to empowerment as the process in which patients and providers equally contribute to the health decision-making process. Webb et al.15 measure empow- erment by asking participants generic questions about their perceived degree of involvement in and satisfaction with their treatment decisions. Thus, Webb et al.15 allude to the notion that empower- ment is a reconceptualization of participatory decision-making. Thus, there appears to be overlap and confusion among the constructs that relate to empowerment. Roberts16 clarifies that previous research has defined empowerment as the relationship between health and power, an informed and active patient, an equal physician–patient relationship, and a type of health education. According to Roberts,16 the various conceptualizations suggest psychological aspects of empowerment and empowered behaviors are likely to be intertwined.
Health information, including information provided by a physician as well as information sought by a patient, may have varying effects on patients’ senses of empowerment. It appears as though the information provided by a physician may allow patients to feel more empowered and efficacious; however, such information may also confuse patients and ultimately hinder the deci- sion-making process. A great deal of literature suggests that information is a useful tool in increas- ing a patient’s empowerment, while other literature suggests that extreme amounts of information lead patients to information overload and confusion.17,18
Information overload
According to Chen and Chang,19 humans have limited information processing capacity. As amounts of information increase, humans tend to increase their processing efforts accordingly. When indi- viduals are confronted with more information to process than they are able or willing to process, they may perceive themselves as experiencing information overload. Perceptions of overload are the result of the interaction between high amounts of information and limited processing capac- ity.19 When processing limits are surpassed, overload occurs and an individual may be left con- fused and more likely to make poor decisions as a result.17
Women’s health clinics
A good example to represent the influence of information overload in health sensitive and complex situations can be illustrated by cervical cancer diagnosis cases. Extensive information on this topic currently is available. The effectiveness of this information in reducing anxiety in women receiv- ing abnormal Pap tests is not clear since so much information exists and because information avail- able at home is not always accessible.20
Cervical cancer is the second most common cancer in women, affecting nearly 530,000 females worldwide and resulting in 275,000 deaths each year, including 31,000 cases and 13,000 deaths in Europe.21 Human papillomavirus (HPV) infection can lead to the development of pre-cancerous lesions and cervical cancer.22 Routine screening and HPV vaccination programs have increased the visibility of cervical cancer in the wider community, and may contribute to increased concerns about developing this cancer, particularly in younger women.23
Cervical cancer can be detected using a Pap test. A Pap test uses a sample of cells taken from a woman’s cervix or vagina. The test looks for changes in the collected cells that show cancer or con- ditions that may develop into cancer. The Pap test currently is the best tool to detect pre-cancerous
conditions and hidden, small tumors that may lead to cervical cancer. If detected early, cervical cancer can be cured.
A Pap test is not comfortable and its negative perception can be increased by receiving news via phone that one’s test result is abnormal. Frequently, women are given little information about what the result means. This leaves them unsure about the next steps to take. In fact, studies report women commonly feel stressed and anxious after being informed of an abnormal Pap smear test result24–26 irrespective of the severity of the result.27 These emotions often are long lasting.28
Other research confirms that lack of accurate and understandable medical information about the causes, prevention, treatment, and consequences of an abnormal Pap smear result and cervical cancer leads to anxiety.29 When a doctor reports that a Pap test is abnormal, this means the test has identified abnormal cells on her cervix. But, having an abnormal test result does not mean the woman has cancer. In fact, the chances are very small. However, the patient is requested to sched- ule a follow-up with a professional genecology clinic and during the intervening time period, anxi- ety and worry may build. In response, a woman may access information on the web.
When the patient arrives at the medical encounter, she will be experiencing anxiety about the future. In this situation, it is unlikely that she will be involved in any decision-making, and this can add to confusion surrounding the forthcoming medical encounter.
She may have learned there are several options of treatment and all are considered effective to various degrees, but her information may be incomplete. For instance, she may not know the best treatment will depend on the type and extent of her problem. Some doctors will prefer one treat- ment method over another, and again she may not have access to this information. In this regard, it is important that a patient understand why a doctor recommends one approach or treatment over another. Therefore, it is important to empower, enable, and support women with the ability to ask questions without fear or reservation.30 This research seeks to examine, if women’s waiting times for gynecological consultations can be leveraged to inform them in a better way, thus empowering her to be an active participant in the medical encounter decision-making, therefore increasing her patient satisfaction.
Furthermore, we look at the waiting room time as an opportunity to trigger a woman’s education regarding such sensitive issues. We hypothesize that the use of mobile technology, which includes carefully controlled health-related information, can help a woman be better informed, empowered, and enable her to communicate better in the forthcoming medical encounter. She ultimately might perceive higher patient satisfaction related to communication with the doctor.
Being well informed is, indeed, critical for lowering anxiety over abnormal results. It may be the case that many women do not understand the meaning of an abnormal Pap result and wish for more information. An Australian study has shown that women wish to participate in decisions about their care but find it hard to ask questions.31 Physicians should bear in mind that patients may not spontaneously request further information, despite (or perhaps because of) high levels of anxi- ety.29 We therefore suggest the use of mobile technologies, such as tablets, in the waiting room to provide easy access to information that was carefully vetted and communicated by the doctor regarding treatment, procedures, and long-term effects,32 and to help reduce anxiety and improve general situational knowledge.33
Mobile use in the waiting room
The widespread adoption and use of mobile technologies is opening new and innovative ways to improve health and healthcare delivery.34,35 These applications are being assimilated quickly into health care.36 The use of mobile applications prior to physician encounters regarding birth control information can help foster a better understanding of how a particular method works and the
increased patient satisfaction with counseling and showed that mobile applications are best used in addition to physician consulting. A major limitation in the Sridhar et al.36 study was the lack of a follow-up. The study did not report whether visit times changed when the application was used after the consultation. Due to time constraints that limit a physician’s ability to deliver detailed information during a medical encounter, applications for mobile technology can be designed to educate patients and simplify communication between patients and providers.37 Therefore, there is the potential to examine mobile applications in the waiting room.
Little formal research has been conducted to evaluate time spent in waiting areas. The limited studies conducted have attempted to improve waiting area experiences for patients and their sup- porters regarding design of the space and reduction in waiting times.38 This often is specific to a local office, and is focused on patient comfort issues such as temperature, seating, coffee, televi- sion programming, or wait times.39,40 Although many opportunities for redesigning waiting room space for comfort, safety, and even entertainment exist, there also are opportunities to redesign the space to encourage learning. Traditional educational material in waiting areas is often ineffective and unacknowledged. Often, patients are provided with pamphlets and posters to learn about dis- eases and disorders. General practitioners agreed that patient curiosity regarding health-related information is growing and that the physician should consider the waiting room as a place for patient education.41
A previous study assessed the value of various techniques designed to reduce patient anxiety in waiting room.42 This study and others suggest provision of waiting room information may reduce anxiety when it concerns a care procedure the patient will subsequently experience.43 Waiting room time can become useful with formal patient education.44 This is particularly true in light of what is known about creating innovative, empowerment-based, educational materials.45