Table 4 Themes regarding use of printed intervention to address mental health in the orthopedic care setting

Feasibility

Superior to a digital intervention: Orthopedic clinicians and clinical support staff expressed that delivery of a printed intervention would be even quicker and easier to integrate into current workflows than delivery of a digital intervention.

“This would be, to me, like handing out a piece of paper on icing instructions. You can provide the resource for them to get more information, but this is more of a passive approach where patients, if they need it, can look at it. I think this would be more reasonable [than an app] because then I’m not providing their care. They’re able to go to this and say, ‘Hey, gosh, if I really want to do yoga training or whatever, I can go click on that.’ Or, ‘If I really truly need mental health resources and I don’t know how to get it, oh, that’s a nice resource.’ But it’s very passive. And I prefer that because then I don’t think any of that’s going to come back as me trying to provide care.” (Physician)

“I think there are easier flows on this end [compared to an app]… My nurse could very easily print this out and hand this to the patient as she’s handing them all their other stuff for their appointment.” (Physician)

Acceptability

Sometimes preferred over a digital intervention: Orthopedic patients, clinicians, and clinical support staff agree that a printed resource option is more appealing than a digital intervention for some patients. The printed intervention was especially appealing to orthopedic patients who: (1) are not frequent mobile device users, (2) prefer “tangible” information, and (3) prefer local, in-person support for mental health matters. Estimates for the proportion of clinicians’ patient populations who might be interested in a printed intervention was similar to estimates for the digital intervention.

“Someone like me that is not used to just looking at their smartphone or their iPad for everything – they might prefer [this guide] to the app.” (Patient 78-year-old White woman)

“Some people just like paper.” (Patient, 46-year-old White woman)

“I like this a lot, because again, it’s local. It’s resources within our city, and it’s easy. I like this. Honestly, I would prefer this to [an app], if it was a one-or-the-other…I like the idea of an app, and once I start using it, I might change my mind. But I like that this [guide] lists resources within the state I live. It’s like, tangible places that are conceivably here.” (Patient, 40-year-old White woman)

“I think the same number as the app. I think I would give this to the same patients that I would try to set up with the app.” (Physician)

Engagement concerns: Potential patient-facing barriers to using a printed guide include: (1) affordability for the resources listed on the guide, and (2) the potential to lose the paper on which the guide is printed.

“For this [resource on the guide], you mention the fee is set on a sliding scale ranging $15 to $40. I think putting information about insurance and also the price has effect on our decision…So one decision rule is, what is the price, not just, which kind of service [the resource] is offering.” (Patient, 30-year-old Asian man)

“If there is a space in MyChart where people can find resources, or even send an e-mail out – because I lose paper.” (Patient, 35-year-old Black woman)

Facilitators for implementation: Orthopedic patients, clinicians, and clinical support staff suggested that a facilitator to delivering a printed intervention to patients could include making the handout available at multiple time points during the orthopedic encounter (e.g., in the waiting room, on the clinic’s public-facing website, as paperwork received at clinic discharge, and/or via patients’ online medical portal). It could be offered to all patients who screen positively for high symptoms of depression or anxiety, and/or it could be offered to patients who are identified by the clinical team to have symptoms of depression or anxiety that interfere with their orthopedic clinical care. Orthopedic patients largely prefer receiving the printed guide after their encounter with the clinician, as a response to their interaction with the clinical orthopedic team.

“You can leave something like this in the rooms and with flyers that they can post on the walls. And I mean, that’s something you put on the wall in the room that says, ‘Resources.’ If anybody wants to take a picture of it on their phones or go to the QR codes, they can.’ And that way they can also do it if they’re by themselves in the room.” (Physician)

“For our patients in our [more complex] clinics, we have a packet that we give to patients, so having this incorporated in that would be really helpful.” (Physician)

“I might not give it to the [straightforward] patient, but if they, on their own, are looking and find out that this is a resource for them – they may also have chronic pain [in another body part] that I’m unaware of or that wasn’t a focus of our visit – then they may avail themselves of this. So, I think having it for everybody, but not necessarily printing it out for everybody, is probably helpful.” (Physician)

“I also think that maybe you should put it on the MyChart app. (Patient, 35-year-old Black woman)

“I’d want to see this after I see the doctor…And it could come from the doctor or the nurse.” (Patient, 71-year-old Black woman)

Facilitator for use: Many orthopedic patients would prefer for the orthopedic clinical team to select and briefly discuss a few resources from the printed guide which they are most encouraged to pursue.

“I think it’s a good option, but I believe they have to explain some of the stuff, at least in the guidance. So it’s not like, just give [patients] the guidance and they read it later. Maybe give them some idea about how everything works, make some motivation for the people to use it. If [patients] have some extra information other than having just the guide, I think if you discuss it, maybe they take it more seriously and do one of the steps.” (Patient, 30-year-old Asian man)

“I think the provider would need to probably circle one or two things they want the person to do because I think if you just hand them this resource list, I feel like they’re not going to do anything, or they’re not really going to know what to do. I think if you have one thing you want them to do and point them to that, there’s a higher chance they’ll actually do it. But I think this is a great resource for providers, too – like a menu box of which ones we’re going to choose for this particular patient, something like that.” (Physician)

Usability

Format preferences: Orthopedic patients, clinicians, and clinical support staff preferred that a printed guide be no longer than two double-sided pages, with large font, simple language, bullet points, clear cost information, bold colors, and an intuitive, yet pleasing format. When delivered electronically, URLs should be active hyperlinks. When delivered on paper, QR codes can be included on the guide to facilitate access to resource URLs, but QR codes may overwhelm and deter some patients from further exploring the guide.

“I like that it’s narrowed down. Because I’ve looked for stuff like this before, and if you Google it, it’s overwhelming. Because you have so many options and it’s like, ‘How do I boil it down?’” (Patient, 40-year-old White woman)

“This is paper. If this were electronic and these were clickable, I might find it more useful. I could click on [a resource], and I wouldn’t have to type it in.” (Patient, 70-year-old Hispanic woman)

“I think this would be great. I think the only drawback I see with this would be our patients that are not tech savvy. I just learned how to use QR codes. I’m 40, so I don’t think… I don’t know that my 75-year-old mom could use the QR code. I don’t know. So I think that just making sure it’s all-around age friendly. Making sure it’s functional and easy for those patients who may not be tech savvy is going to be a big priority.” (Medical assistant)