Patients want to be seen: The top 3 information needs of patients with inguinal hernia.

BACKGROUND: Good patient information has shown to improve surgical outcomes. In this study we explore what kind of pre-surgical information patients need and if the provision of a 360˚ video of a surgical procedure can be of added value to the information provided by the hospital.
METHODS: An explorative qualitative study using semi-structured interviews on information needs was conducted among 17 inguinal hernia patients to gain more insight in the patients' present surgical information needs. Patients either were planned to receive or already had received a surgical procedure. Questions were asked about the current information provision and, after being shown a 360˚ video of the surgery, whether this would be of added value.
RESULTS: Of the total group of 17 patients (mean age 56, interquartile range 45-64) 16 were male and one was female. Most had no previous experience with virtual reality (14/17), already had undergone a surgical procedure (11/17). Patient information needs were all about "seeing" which can be viewed from three different perspectives [1] being seen as a unique person in the treatment process, [2] being seen as a partner, and [3] seeing is understanding. Patients wanted the contact with the doctor to be more personal, with the possibility to see the anesthetist in person, the surgeon to see their wound in the recovery phase, and to receive personal answers to questions about their specific situation. Patients found the 360-video not fearsome, and believed that visual content could be beneficial as it appeals more to their imagination than written or oral information and increases their understanding. It also provided them with a better understanding of their treatment options, their pre-, peri-, and post-surgical procedures and identification of the cause of post-operative side effects.
CONCLUSION: To address patients' information needs, complementary tools or services are needed that increase personal contact as well as tailor it to individual patient's needs. Even though video-apps are a partial alternative, hospitals should still offer patients the possibility of having face-to-face meetings with physicians as this is highly valued by patients and leads to increased trust in physicians' performance.

Introduction

Research suggests that adequate information provision can reduce preoperative anxiety and may be beneficial for postoperative outcomes such as pain, behavioral recovery and the length of hospital stay [1, 2]. Furthermore, the information discussed in consultations forms the basis for informed consent for treatment, and patients look to clinicians to fulfil information needs [2, 3].

However, it is not always clear what information patients want as some prefer receiving very general information about just the procedure [4, 5], whilst others prefer detailed information on, for example, outcomes and survival [4, 6]. On the one hand, presenting large amounts of information may result in ‘information overload’ and extended pre-operative consultations, while on the other hand, just answering patients questions is only possible if patients have sufficient baseline knowledge [4].

Technological developments in the last decades have changed information provision. Most patients have access to the Internet, which offers unlimited amounts of health information [7]. In addition, many modern technology tools such as videos and e-health tools including apps and virtual reality have entered the health care market [1, 8, 9]. If patients are better informed this could impact information provision. For example, virtual reality (VR) offers patients the opportunity to watch videos in a different form; viewers are able to experience specific environments or situations which are not available in real-life, such as the sights and sounds of receiving and recovering from an anesthetic procedure [10]. Virtual reality has been used to train physicians or residents to improve their communication skills towards the patient [11]. Furthermore, one study suggested that informing patients on a surgical procedure via VR might improve patient comprehension of their condition [12].

In our hospital we had the impression that patients were missing certain information and that they did not read or (fully) understand the provided (written) information. This is important as during their meeting with their surgeon, patients are offered two options for surgery, as well have the option to postpone their procedure, and being well-informed beforehand may affect the patients choices [13]. Therefore, we aimed to explore what kind of pre-surgical information patients need, if modern electronic information tools could be an added value to current information provision, and if this information could influence their choices on their treatment.

Methodology

This study was conducted and described according to the COnsolidated criteria for REporting Qualitative research (COREQ) checklist [14].

Study design

We conducted an explorative qualitative study using semi-structured interviews to collect data on information needs of inguinal hernia patients at the surgical department of the Spaarne Gasthuis hospital—a 400—bed teaching hospital -, Hoofddorp, The Netherlands. Interviews were held between September and December 2018. A laparoscopic hernia repair was chosen as the targeted surgical procedure as it is a often conducted surgical procedure and suitable and relevant for exploring patient’s information needs.

Participants

We selected participants using the purposive sampling technique. Only patients were included that had undergone a laparoscopic hernia repair during the preceding four weeks or that were scheduled to undergo this surgical procedure and already received all the pre-surgical information. A member of the surgical department approached patients by phone and after consent the interviewing researcher contacted them to plan the interviews. Interviews in Dutch were conducted at a time and place that patients preferred and all patients were interviewed once.

Data collection

We collected data using semi-structured interviews, with the use of probes and prompts as interviewing technique. The interviews were audio recorded with the patients’ permission and were guided by a topic list and consisted of two parts (Table 1). In the first part, the patient journey was used as a guide to direct the interview. Patients were asked about their information needs, the received information from the hospital and their information search behavior during the different stages of the health care process (from the first appointment with a general practitioner until discharge from the hospital and the post-operative period). In the second part of the interview, patients watched a 360˚ video with the VR headset. In this 360˚ video patients could virtually experience parts of the day of the surgery and see parts of a laparoscopic inguinal hernia repair procedure. Specifically, it showed scenes of patient’s arrival in the holding area, the introduction of the surgical team, the anesthesia procedure, the transportation to the operating room, and some scenes of the laparoscopic surgery: the inguinal hernia, the insertion of the mesh and images of the repaired hernia (including the mesh). Voice-over was used to explain the procedure and the video had a length of 3.20 minutes. After having seen the video, patients were asked about their opinion of the video content, the VR headset and if this video was perceived of added value to the current pre-surgical information provision. The data collection was ended after saturation was reached.

Table 1

Topic list interview.

	Main topic	Sub-topic
1.	Diagnostic consultation	Preparation prior to consultation
		Experience of the consultation
		Needs regarding the consultation
2.	Period between diagnostic consultation and date of surgery	Experience of this period
		Activities during this period
		Mental state during this period
		Needs during this period
3.	Impression of the VR-video	Experience of this video
		Opinion of the design and content of the video
		Opinion regarding the potential added value of the video
		Preferences regarding form: 2d or 3d
		Opinion regarding the user convenience (e.g. VR-headset)
		Opinion about when in the treatment process this video should be presented

Research team and reflexivity

LR, a female researcher with a master’s degree in clinical psychology conducted the interviews. KS and CO, both experienced researchers and responsible for study conduct and data analysis. JF is a junior researcher who assisted in the data-analysis. VS is member of the innovation board and together with RB (surgeon) responsible for the VR application. No relationship between the researchers and the patients was established before the study commencement. Patients were informed that the researchers were employed as researchers at the hospital where the patients were under treatment. Further information about the researchers was unknown to the patients.

Data analysis

The recorded interviews were transcribed verbatim and thematically analyzed in Dutch. Data analysis was performed by coding both during and after the interviewing process, using MAXQDA software. Although both inductive and deductive coding was used to identify themes within the data, the analysis was more bottom-up than top-down. The analysis was based on the six-phase framework for doing a thematic analysis developed by Braun and Clarke [15]. During the first phase of the coding process interviews were transcribed and read by LR, CO and JF to become familiar with the data and identify possible interesting codes. During the second phase, initial codes were generated based on the data itself by using patients’ words for codes (inductive). The third phase involved searching for themes by grouping and linking the data-driven codes. In the subsequent phase, grouped codes were reviewed and renamed by using a more deductive approach as we wanted to focus on identifying patients’ information needs. The fifth phase included defining the themes and the last phase was used for reporting the themes. The interviews were coded by LR and reviewed by CO and JF to reach consensus about the coding tree, e.g. the codes used and the way they were grouped and linked.

Ethical consideration

The local research ethics committee of the hospital (advies commissie lokale uitvoerbaarheid—ACLU) evaluated the ethical acceptability of this study and gave approval. Furthermore, each participant gave written informed consent at the start of the study. Additionally, all data were treated as confidential and participant’s anonymity was warranted by dissociation of names. Data were stored under identification numbers, which were randomly designated and conserved by one of the researchers (CO).

Results

In total, 21 patients were contacted and 17 patients participated in the study. One of the four patients that refused to participate found it too stressful to take part as this patient still had to undergo the surgery. Another patient who still had to undergo the surgery had mental issues and therefore his wife preferred that this patient would not participate in the research. The last two patients refused to participate due to upcoming exams and time constraints. The mean age of the participating patients is 56 years (SD: 17; min. 35, max. 79) and 16 were men (94%). Eleven of the seventeen patients (64.7%) had undergone surgery while six were scheduled to get surgery. Interviews lasted 40 to 60 minutes and were held in the home setting (n = 5), hospital (n = 8), at work (n = 3) and one took place by phone (this patient was not interested in the video or any other information about the surgical procedure apart from the time and date). During three of the interviews the partner of the participant was present while otherwise only the participant and interviewing researcher were present.

During the coding and analyses phases, it became clear that most of the patient remarks were referring to an overall theme of “seeing”. Apparently, a visual tool helped them to be seen as a unique person and partner in the treatment process. Here, ‘being seen as a unique person’ reflects a more personal (authentic) connection with the healthcare providers. ‘Being seen as a partner’ refers to the value of being viewed as a partner or equal in the treatment process. The actual use of visual tools resulted in the third theme “seeing is understanding”, which provides insights into whether visual tools help patients to better understand pre-surgical information and getting involved in the treatment process (Table 2).

Table 2

(Sub)Theme	Definition
Being seen as a unique person	Having a personal (authentic) connection with the healthcare providers
Being seen in person	Being seen physically by the physician and not via the telephone
Use of tools	Being informed through online contact via messaging apps
Being seen as a partner	Being viewed as a partner or equal in the treatment process to allow for shared or informed decision making
Seeing is understanding	Use of visual tools to help understand pre-surgical information

Being seen as a unique person

Several patients emphasized the importance of personal contact, either in person or via visual tools. This gave patients the feeling of being seen as an authentic person and not as a number as it also provided them with more tailored advice.

In person

During the preoperative phase, after patients decided to opt for surgery based on a personal surgical assessment, patients have an appointment with the anesthesiologist. During this consultation, information is provided about the different methods of anesthesia and the behavior requirements before surgery. In several cases, this appointment took place by phone. Various patients stated they (had) preferred to go to the hospital for this consultation, as it made them feel treated as an individual and not as one of the hundreds of patients. For instance, patients mentioned that seeing the anesthesiologist enabled the anesthesiologist to better determine the patient’s individual needs and to adjust the treatment process according to these needs. Moreover, patients indicated that seeing the face of the anesthesiologist in person brought them trust in his or her expertise.

“They asked questions to ensure the process would fit my needs. They checked my pulse and whether I have loose teeth or prostheses etcetera, so they ensured they would act safely later on. We also decided that I would get a light tranquilizer on my arrival at the hospital because I was very worried about the fact that when you get anesthesia you stop breathing, and they take over the breathing process.”–P3

In addition, patients found it important to be seen by the surgeon in the postoperative phase because they wanted reassurance about the recovery process. Nowadays this is only done by phone. Patients mentioned that they found it difficult to judge their own recovery process and therefore preferred to show their wound to the surgeon (either in person or via video apps) and not reporting about the wound via phone.

“I was surprised to receive a phone call regarding my state after the surgery. I thought to myself it would be better if this was by FaceTime because then I could show the doctor what the wound looked like.”–P11

Using tools

When patients were informed or kept up to date through online contact, they had the feeling they were taken more seriously in the treatment process. Some patients stated they were in touch with their surgeon through messaging apps during the recovery process. Patients mentioned that online contact during the trajectory could provide the opportunity to get more tailored advice.

“So I sent a [WhatsApp] message to the surgeon… ‘I would like to know how long it takes before I am able to go back to school and how much rest I really should take’. The surgeon told me I should be conservative the first week and after that I could restart things if it feels ok. The only thing I couldn’t do yet was carry heavy things. The information I received from the surgeon was the information I specifically needed and was clearer than the information I got from the outpatient department.”–P1

Furthermore, various patients indicated that it was necessary to be informed earlier about the date of surgery. Patients sometimes needed to wait for months until they were offered an appointment and only knew the exact operation date shortly in advance. As a result, patients found it difficult to plan their personal activities due to a lack of an indication of the operation date. One patient suggested that the waiting list could be posted online with a personal login code. This way the patient could have a better indication of when the surgery will take place.

“Patients should receive the same kind of notifications as they get from the dentist, there you also receive a notification like ‘hello, you need to go to the dentist tomorrow’<…> That you at least receive an update about the status.”–P13

Another patient suggested that on the day of surgery it would be useful if the family of the patient receives an SMS when the patient has awakened after the surgery procedure.

“It should be possible to tell in phases what is going to happen and at which moment, for example.. that the family members or contact person receive an SMS when the patient, daughter or family member, is ready when the surgery procedure is finished, and he or she lies in the recovery room”–P11

Being seen as a partner in the treatment process

The majority of the interviews with patients outlined the necessity of a (perceived) control over the treatment process and active involvement in decision-making.

Patients who had informed themselves via, for example, the internet perceived themselves as a more active and equal partner in the treatment process than those who had not. Half of the patients had searched for information on the Internet; some patients stated that they used the Internet to check if the given diagnosis and advised treatment were correct. Other patients just wanted more information, about what an inguinal hernia is, the treatment options, possible complications and anesthesia. Some patients even watched surgical procedures on YouTube.

“I had a look on the internet to see if it actually could be that I had an inguinal hernia, so whether the symptoms were matching. I was also a bit curious about what options there were to recover from it.”–P15

For others, the Internet was not perceived as helpful in providing sufficient confidence for an active role in the shared decision-making process. These patients experienced an information overload on the Internet or too much complexity within the information. Hence, some patients found it difficult to filter information and to draw the right conclusions. A few patients believed that there was too much misinformation or exaggerated information on the Internet. For some patients this was the reason to not search further for information on the Internet.

“I looked a bit on the Internet to see what the consequences of the surgery are, but you can better not look on the Internet as only negative experiences have been posted online and not positive ones. I also had a look at the different treatments, but I could not get any wiser from that.”–P7

After being provided with the 360˚ video some patients indicated that it helped them in asking relevant questions. This gave them the feeling that they had enough understanding to have a valuable dialogue with the physician. Therefore, most of the patients indicated that the best moment for presenting this 360˚ video would be just before the first consultation in the hospital, so that they would be able to address this information during the consultation.

“Hospitals need to be more flexible, transparent and I think this is a very good step towards it. You know, this contributes to that and in the past it used to be like.. you need to go the hospital, you undergo surgery and you know, what we say.. take it or leave it, you know, that’s how it is. And with this sort of things you feel taken seriously as a patient, and we want to be more informed these days and this [the video] helps.”–P3

However, a few patients stated that they only needed information about the date of surgery and recovery time. These patients did not want much information because they needed to undergo surgery anyway; they did not see it as a choice and just wanted it to be over.

“For me it is just important to know how long this thing will last and when I will be able to get back to work and feel good again, these kinds of things. This was the most important to know. How the surgery procedure is performed exactly and how it works, as far as I understand, a mesh is inserted. How it looks like, how it works etc. to be honest, it does not really interest me. As long as my problem is solved, I am fine”.–P2

The pre-operative phase is also a phase in which a patient must choose between various options with respect to the surgery. In this particular case, there were two different options with regard to the type of surgery, two different options with respect to anesthesia, and sometimes they could choose not to undergo the surgery or to postpone it. In some cases only one option was suitable due to certain circumstances, whereas in other cases more than one option was suitable.

“Oh, so I had the endoscopic surgery.. ooh.”–P14

“I wanted to know how the anesthesia would go. Well.. sometimes you will get the spinal.. I did not know, you have a spinal block and I do not have a clue what else. I think they can also inject something, somewhere else in an infusion… or something with nitrous oxide, I also did not know so well how that was going. The anesthesiologist said that I do not have to worry.”–P1

Only a few patients were actively involved in the decision-making regarding the options for the type of surgery or the form of anesthesia, or whether to undergo the surgery.

Sometimes this was because the physician provided them with the choice, but mostly this was because the patient had a different preference due to previous experience with an inguinal hernia surgery repair.

“The doctor explained it could be a spinal block or a complete anesthesia. I will just have general anesthesia as I find that more comfortable.”–P4

One of the patients suggested that the hospital could share experiences from other patients, so that it would become easier to make a decision and patients would know what they should or should not do.

“Well, now we are talking.. I think.. this surgery is a surgery that happens a lot. They told that when we entered the department. Then you should ask the people who had undergone that surgery this year.. well that might be too much people, but if you would ask 100 people about their experiences, than people could benefit from this information and know when a choice was not so bad”.–P11

Noteworthy is that some patients who had not yet undergone the surgery, were thinking about postponing the surgery after seeing the 360˚ video, as the video made them realize what the impact of the surgery would be. As a result, this made them think about which period would be a suitable period for them to undergo the surgery. This implies that the video triggered some involvement in decision-making.

“I was thinking maybe I should postpone it until after summer.. now I see how long it could take before I fully will function again after surgery..”.–P14

Seeing is understanding

Several patients experienced a need for additional information and believed (or were under the impression) that visual content could be beneficial as it appeals more to their imagination than written or oral information and therefore increases their understanding. Visual content proved to be especially suitable to provide procedural information pre-, peri- and post-surgical.

The majority of the patients did not know what would happen between the moment they would arrive at the hospital for the surgery and the moment they would leave the hospital again. Patients noted that the 360˚ video corrected this lack of information. Moreover, patients expressed that the provision of this information in written or oral form would not have been as effective as visual content. Patients stated that the visual content in the 360˚ video increased their trust as they could see that the hospital would really take care of them before and during the surgery. Also, they indicated that they would be more at ease on the day of surgery as they better knew what to expect.

“You are able to see something which you are not going to see later on because you will be unconscious.. but you know in advance you’re going to a kind of familiar environment.. you have already seen it once so you can.. it makes me feel relaxed. Oh, this is how it looks like.. someone is monitoring my heartbeat continuously and you know… my physical condition. There’s someone who’s just monitoring, well fine, I am happy with that. Good to know, I didn’t know.”–P3

However, some patients wondered if the hospital should always inform people about the surgical procedure by showing real procedure images.

“If you have a huge tumor in your belly… it is an operation of 12 hours, should you use such a video to inform patients? This is what I am asking myself.. Look, this [inguinal hernia repair] is a simple surgical procedure and some people might want to know how it works, well, put the video on the internet with a link and patients are able to watch it if they want to.”–P6

Various patients that already had undergone the surgery noted that seeing the 360˚ video helped them to understand some post-operative outcomes. For instance, because of seeing the 360˚ video, a handful of patients came to realize why they had abdominal distension after surgery. The reason for this is that during surgery, the patient’s abdomen will be filled with gas to identify the weak spot in the abdominal wall.

“Gas.. the gas I did not know.. the gas. When I came home after surgery, I had the feeling that I had a big belly although I am someone who, in general, is watching my figure. I thought why.. why on earth did I get this big belly? But now I see that it is because of the gas they put into my belly.”–P5

Other patients only realized after seeing the 360˚ video why they had felt the pain at a particular location of their body. They did not know that that was the spot where the surgical mesh was placed as they thought it was placed elsewhere. Some patients finally understood some complications that they were concerned about, and they would have appreciated seeing this 360˚ before surgery.

“I really felt pain in my shoulder during the night and I did not like that because I did not know it was normal to feel pain in my shoulder after the surgery. Yes, it happened to be that a friend of mine knew it was one of the side effects of an inguinal hernia repair and now in this video they let you know, so that is very good.”.–P10

After watching the 360 video, several patients mentioned that the VR headset gave them the feeling that they were really inside the operation room. They really felt present. Most of the patients found the VR glasses entertaining and fun to use and wanted to be provided with information through VR more often.

“I don’t think you can get this effect on a normal television screen. Now you can.. it is like you are really there. It is an experience.”—P12

However, some did not find it necessary to experience the surgery in such a way. They mentioned that looking at an animation video at a 2D screen would be sufficient for them.

“If it just had been an animation video, it would also fine to me.. or just a doctor explaining it to me without the real images of the inside of the belly, but just highlighting with a pencil the part of the belly which they will enter and where they will place the mesh”.–P10

Still, the use of the VR-video was accepted by all patients and none of the patients found it fearsome themselves. Beforehand we had expected that patients might find it fearsome to view a surgical procedure in 360. Some patients indicated that it could scare people off to get so close to the real surgery, although they did not find it problematic themselves. In addition, there was one patient who indicated not to be interested in the video and who had the interview by phone.

Discussion

This study explored the pre-surgical information needs of patients nowadays and investigated whether the provision of a 360˚ video can be of added value to the information that is currently being provided by the hospital. The results revealed the main theme ‘seeing’ with respect to information needs of patients, which can be viewed from three different perspectives [1] Being seen as a unique person and [2] being seen as a partner, and [3] Seeing is understanding. Patients wanted the contact with the doctor to be more personal, with the possibility to see the anesthetist in person, the surgeon to see their wound in the recovery phase, and to receive clear answers to questions regarding their specific personal situation. Experiencing the surgical procedure by VR helped them in understanding treatment options, pre- peri- and post-surgical procedures and post-surgical side effects.

Being seen as a unique person and partner

Patients indicated that they wanted to be seen as a unique person in the treatment process. Currently, healthcare changes are focused on making processes more efficient. Even though research has shown that a preoperative evaluation and post-operative consultations can be safely done by phone in many cases, some patients indicated this made them feel like a number instead of a person. This is in contrast with the literature, showing a high satisfaction using telemedicine, with scores ranging from 4.5 to 5 out of 5 [16]. However, most of the studies included in this review were conducted before 2010. Since then, video apps have become widely common in everyday life and patients have gotten used to seeing their callers and their surroundings. Therefore, opinions with respect to contact by “normal” phone may have changed. Patients indicated that they wanted to show their wounds to the surgeon, instead of just reporting on it. Other studies have shown great effectiveness and satisfaction with video-calling which may increase the satisfaction, instead of just contact by phone [16].

Patients felt that the general information obtained from the brochures, the internet or doctors assistants, was not sufficiently tailored to their personal situation, for instance for questions regarding their recovery process. It had been shown previously that tailored information provided on the internet leads to higher satisfaction rates among patients, especially among younger patients, although no improvements in patients outcomes have been found [17, 18]. Some of our patients had WhatsApp contact with their surgeon, which was highly appreciated. However, this would be nearly impossible to provide to all patients, as physicians are often afraid of being overloaded with questions from patients. Still research has shown benefits of a short messaging system protocol leading to a reduced number of clinic visits and increased efficiency of clinic visits [19]. Alternative options could be for example use of chatbots. For the latter, studies in breast cancer patients, for example, have shown that an artificial conversation agent achieved equal satisfaction scores as “real” physicians [20].

Patients were not always a partner in the decision-making process concerning their treatment as they indicated that they were not aware of the treatment they had received and that there were multiple options. Some even indicated that they intended to postpone their surgery after seeing the video. They said they would have liked to see the video shortly before their preoperative consultation, so they would be able to memorize all the questions. Patient’s involvement in decision-making is only lately becoming more common and as a result more and more decision-making interventions and interventions that promote patient’s expertise are being developed [21]. A procedural 360˚ video might be one of these tools and such interventions enable patients to gain the right knowledge to negotiate with the physician about how the best treatment process would look like.

The majority of the patients believed that the 360˚ video enhanced their understanding, especially with regard to the surgical procedural information. Retrieving procedural information is crucial for proper psychological preparation prior to surgery [22] via for instance less surprise during the day of surgery [10]. In turn, the psychological preparation will influence the outcomes of the surgery as the way people think and feel have impact on the operation outcomes [2]. Patients noted that seeing the procedure increased their trust and familiarity with the operation environment, thereby decreasing their fear. Seeing is beneficial as it was found that diminishing the patient’s fear before surgery results in patients experiencing higher quality of the treatment in all its different phases [1].

Patients also indicated that it improved their knowledge on the post-operative outcomes. Patients, who already had undergone surgery, said that seeing the 360˚ video made them realize why they had certain side effects after surgery such as abdominal distension or pain in the shoulder. In case a patient expects to experience some soreness in his or her shoulder after surgery, the actual experience of soreness in the shoulder is seen as a normal side effect, which in turn diminishes the feeling that something went wrong. This is crucial, as catastrophizing would have been likely to increase the pain [23]. Also in other fields it has been suggested that VR can help in pharmacy education by providing immersive educational activities [24], having elderly patients coping with dementia [25] or teaching skills to health professionals [26].

Multiple patients expressed that the video helped them for instance to ask relevant questions during the consultation with the physician, which in turn is likely to promote informed decision-making. Furthermore, the patients might feel more comfortable in contact with the surgeon referring to a video (or another tool) provided by the hospital than provided by the Internet.

Strengths and limitations

When interpreting this study and its results, some strengths and limitations must be considered. The strength of this study lies in the use of a 360˚ video in a VR device to prepare adult patients for surgery. The majority of research on the use of VR in the clinical setting focuses on how this medium can contribute to physician’s surgical practice and not on the potential added value this medium can have for patients. Some studies that did investigate how VR could contribute to the patient’s preparation before surgery mainly focused on children rather than adults. As far as we know, the use of VR to prepare adult patients for a small surgical procedure has not yet been studied.

It should be addressed that it is unclear to what extent the results can be generalized to patients undergoing another surgical procedure than inguinal hernia surgical repair. Patients believe that it should be used more often for relatively simple procedures. Furthermore, this study only used a non-interactive form of VR in which the patients could look up, down, left, right and around, but could not walk forward or interact with the virtual objects. Hence, the potential of an interactive virtual environment for informing patients before surgery has not been studied, but might be more suitable for educational purposes than information provision. Although this is normal in this patient population, there was only one female patient. Finally, the patient population was relatively young (56 years) as compared to the average patient population, so this might have biased the results towards needs for personal contact. Still, most of the patients were unfamiliar with a VR device.

Practical implications & conclusions

This study highlights the importance for hospitals to provide patients with modern tools such as a 360˚ video as to fulfill the information needs of the patients, and more specifically to enable patients’ involvement in informed decision-making regarding the treatment process. When creating or selecting these tools, hospitals should consider the following: the ability for personal contact, opportunities for tailoring to individual needs, visual content, immersion and procedural knowledge to facilitate shared decision-making. The 360˚ video used in this study did fulfill some of these needs, such as triggering informed decision-making with regard to the timing of the surgery, or providing visual content and immersion with regard to both procedural- and sensorial information thereby filling the information gap on what to expect during and after the surgery.

The current COVID-19 outbreak has moved many consultations out of the hospitals. To address to patients’ information needs, complementary tools or services are needed that increase personal contact as well as tailoring with respect to individual needs. Even though video-apps are a partial alternative, hospitals should still offer patients the possibility for face-to-face meetings with physicians as this is highly valued by patients and leads to increased trust in physicians’ performance.

17 Mar 2020

PONE-D-19-28443

Top 3 information needs of patients in 2020

A qualitative study among patients with inguinal hernia.

PLOS ONE

Dear Mrs van Stralen,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

I am sorry for the delay in processing this submission. I was not the original assigned editor. Please do give careful consideration to the reviewer's comments. I also have a query about language. I presume the interviews were originally done in Dutch, and have been translated into English. You should describe the translation process and how you tried to assure accuracy. I note that on two occasions, your interviewees are said to have referred to spinal anaesthesia calling it a "spinal tap." The correct term for spinal anaesthesia is a spinal block. (There are also more complicated terms for it.) "Spinal tap" refers to the extraction of cerebrospinal fluid for diagnostic purposes, a completely different procedure. If the interviews were done in English and the respondents did in fact say that, you should point out that they are in error. If these were translated, this is a mistranslation which leaves me uncertain as to the translation quality in general. The English in the text is generally readable, but at times stilted and there are some odd word choices. Please have this reviewed by a native or fully fluent English speaker. Also, the title refers to 2020 but this research was done in 2019 or earlier. You should delete the year from the title.

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M Barton Laws

Academic Editor

PLOS ONE

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Additional Editor Comments (if provided):

I am sorry for the delay in processing this submission. I was not the original assigned editor. Please do give careful consideration to the reviewer's comments. I also have a query about language. I presume the interviews were originally done in Dutch, and have been translated into English. You should describe the translation process and how you tried to assure accuracy. I note that on two occasions, your interviewees are said to have referred to spinal anaesthesia calling it a "spinal tap." The correct term for spinal anaesthesia is a spinal block. (There are also more complicated terms for it.) "Spinal tap" refers to the extraction of cerebrospinal fluid for diagnostic purposes, a completely different procedure. If the interviews were done in English and the respondents did in fact say that, you should point out that they are in error. If these were translated, this is a mistranslation which leaves me uncertain as to the translation quality in general. The English in the text is generally readable, but at times stilted and there are some odd word choices. Please have this reviewed by a native or fully fluent English speaker. Also, the title refers to 2020 but this research was done in 2019 or earlier. You should delete the year from the title.

[Note: HTML markup is below. Please do not edit.]

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: Yes

**********

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

Reviewer #1: N/A

**********

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

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

**********

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

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

**********

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: PONE-D-19_28443

Top 3 information needs of patients in 2020 A qualitative study among patients with inguinal hernia.

General Comments

The authors interviewed patients who had or were scheduled for a hernia surgery on the use of a 360 video of their surgery. Given the scope of patient interest in being engaged in their treatment as well as growing support for technology to support patients’ needs, this study is both timely and unique. The study was simple in design and thoughtfully conducted. The findings reflect themes elaborating the value of the innovative nature of the intervention the utility of supporting patients in non-traditional ways to improve follow-up and experience.

Abstract:

Please include some brief patient demographics

Introduction:

The background is simply insufficient. What is the context for this work. What else has been done. Why is this work important in the field, and for patients and physicians?

More discussion around patients involvement in treatment would be useful.

Also, this is such an important area of innovation and thinking, the authors should talk at some depth around the advancement of technology in medical decision making and patient-centered care.

Method:

Some further elaboration on what “coding” is, and how the process of coding was completed. In other words, how did the authors get from “coded” elements in the transcripts to “themes”. How were codes prioritized, how was meaning ascribed to the codes, and in what ways did inductive vs deductive approach assist in the process (bottom up vs top down). Essentially, a bit more explanation here in the way of definitions, an example, or a description of an inductive vs deductive code would be useful for non-qualitative researchers. In that way, a definition or explanation of a “coding tree” versus a concept map, might be helpful.

Results:

There seem to be three main themes or groups of themes presented. The authors could organize their results a little more to give more life to these important findings. I will try to illustrate this need below.

The set of findings (themes 1 and 2) would benefit from a bit more description in the themes or in the description of themes. What I mean to say is that the themes all link to the “visual tool” and would be more descriptive if they could reflect that connection, i.e., “Visual tool helped patients be seen as unique and partner in treatment process.”

A little more organization within the themes (1 and 2) would help pull the findings together around the two main ideas - being seen (literally) and being seen (figuratively). While these are generally okay, they obfuscate the subtle and arguably more important differences between them. In my view, your argument about being seen (visually) reflects a more personal (authentic) connection with the provider. The other theme, being seen (figuratively) seems to reflect more of a value of being trusted or being viewed as a partner or equal in the treatment process. While I recognize that the authors’ use of literal and figurative are correct, I worry in some way that their close association makes it harder to see the valuable differences in the themes.

Then there is the third theme. The third theme, or category of themes, “Seeing is understanding” is very revealing and offers important insight into the patient experience. I worry that because the authors do not organize the results in a way to prepare the reader for three larger themes with sub-themes, this final section loses its punch.

The authors could elaborate a bit more using their own narrative between illustrative quotes. While very helpful, the quotes lose their strength when grouped together. In other words, subtlety in the quotes should be drawn out with the use of descriptive narrative. Or if the quotes seem to reflect the same idea, it would be better to pick one quote rather than use two or three to convey the same idea.

Given the work conducted by the authors to “identify, label, and code” the transcripts, it is hard to believe that the themes “emerged” from the transcripts. I believe the authors did lots of work to examine the text and make well-intentioned choices when they derived the final “themes”. The section would be improved if authors could use a verb other than “emerged” to describe how the “themes” were generated by a thorough process of coding, analysis, and achieving consensus.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

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Reviewer #1: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.]

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4 Aug 2020

Editor

I am sorry for the delay in processing this submission. I was not the original assigned editor. Please do give careful consideration to the reviewer's comments. I also have a query about language. I presume the interviews were originally done in Dutch, and have been translated into English. You should describe the translation process and how you tried to assure accuracy. I note that on two occasions, your interviewees are said to have referred to spinal anaesthesia calling it a "spinal tap." The correct term for spinal anaesthesia is a spinal block. (There are also more complicated terms for it.) "Spinal tap" refers to the extraction of cerebrospinal fluid for diagnostic purposes, a completely different procedure. If the interviews were done in English and the respondents did in fact say that, you should point out that they are in error. If these were translated, this is a mistranslation which leaves me uncertain as to the translation quality in general. The English in the text is generally readable, but at times stilted and there are some odd word choices. Please have this reviewed by a native or fully fluent English speaker. Also, the title refers to 2020 but this research was done in 2019 or earlier. You should delete the year from the title.

Thank you for your comments. We adapted the manuscript accordingly, changed the title, and had the manuscript checked by a native speaker. We thank both the editor and the reviewer for their comments as we believe that they greatly improved our paper.

Reviewer 1

The authors interviewed patients who had or were scheduled for a hernia surgery on the use of a 360 video of their surgery. Given the scope of patient interest in being engaged in their treatment as well as growing support for technology to support patients’ needs, this study is both timely and unique. The study was simple in design and thoughtfully conducted. The findings reflect themes elaborating the value of the innovative nature of the intervention the utility of supporting patients in non-traditional ways to improve follow-up and experience.

We thank the reviewer for these encouraging comments, and the comments as we believe that they greatly improved our manuscript.

Abstract:

Please include some brief patient demographics

We added some patient demographics, also to the manuscript itself

Introduction:

The background is simply insufficient. What is the context for this work. What else has been done. Why is this work important in the field, and for patients and physicians?

More discussion around patients involvement in treatment would be useful. Also, this is such an important area of innovation and thinking, the authors should talk at some depth around the advancement of technology in medical decision making and patient-centered care.

We agree with the reviewer that the introduction was a bit (too) short and therefore rewrote the introduction.

Method:

Some further elaboration on what “coding” is, and how the process of coding was completed. In other words, how did the authors get from “coded” elements in the transcripts to “themes”. How were codes prioritized, how was meaning ascribed to the codes, and in what ways did inductive vs deductive approach assist in the process (bottom up vs top down). Essentially, a bit more explanation here in the way of definitions, an example, or a description of an inductive vs deductive code would be useful for non-qualitative researchers. In that way, a definition or explanation of a “coding tree” versus a concept map, might be helpful.

We have added elaboration on the coding process by describing more specifically how the coding process was organized and how inductive and deductive coding was used. In addition, more explanation was given about the coding tree.

Results:

There seem to be three main themes or groups of themes presented. The authors could organize their results a little more to give more life to these important findings. I will try to illustrate this need below.

seeing”

The set of findings (themes 1 and 2) would benefit from a bit more description in the themes or in the description of themes. What I mean to say is that the themes all link to the “visual tool” and would be more descriptive if they could reflect that connection, i.e., “Visual tool helped patients be seen as unique and partner in treatment process.”

A little more organization within the themes (1 and 2) would help pull the findings together around the two main ideas - being seen (literally) and being seen (figuratively). While these are generally okay, they obfuscate the subtle and arguably more important differences between them. In my view, your argument about being seen (visually) reflects a more personal (authentic) connection with the provider. The other theme, being seen (figuratively) seems to reflect more of a value of being trusted or being viewed as a partner or equal in the treatment process. While I recognize that the authors’ use of literal and figurative are correct, I worry in some way that their close association makes it harder to see the valuable differences in the themes.

Then there is the third theme. The third theme, or category of themes, “Seeing is understanding” is very revealing and offers important insight into the patient experience. I worry that because the authors do not organize the results in a way to prepare the reader for three larger themes with sub-themes, this final section loses its punch.

To put more emphasis on the third theme we introduced the three themes more clearly, and restructured all themes by renaming themes, removing quotes and rephrasing and shuffling paragraphs.

The authors could elaborate a bit more using their own narrative between illustrative quotes. While very helpful, the quotes lose their strength when grouped together. In other words, subtlety in the quotes should be drawn out with the use of descriptive narrative. Or if the quotes seem to reflect the same idea, it would be better to pick one quote rather than use two or three to convey the same idea.

We carefully discussed all the quotes and checked which one were duplicates and removed them.

Given the work conducted by the authors to “identify, label, and code” the transcripts, it is hard to believe that the themes “emerged” from the transcripts. I believe the authors did lots of work to examine the text and make well-intentioned choices when they derived the final “themes”. The section would be improved if authors could use a verb other than “emerged” to describe how the “themes” were generated by a thorough process of coding, analysis, and achieving consensus.

The reviewer is correct. During the coding and analyses phase it became clear that many patients literally used the word seeing (or being seen etc) many times and that many of the other factors were relating to this same ‘overall topic”. We therefore reprased the introduction of the result section.

We hope that this revision will be followed by further reviewing/ publication of our article and are looking forward to hearing your response.

Yours sincerely, on behalf of all co-authors,

Karlijn van Stralen PhD

Submitted filename: reply_plos_one_CO.docx

Click here for additional data file.

7 Sep 2020

PONE-D-19-28443R1

Patients want to be seen: the top 3 information needs of patients with inguinal hernia.

PLOS ONE

Dear Dr. van Stralen,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

I apologize for the delay in getting a review of this submission. While the reviewer has asked for major revision, most of the comments have to do with style, presentation and completeness. Please do pay particular attention to consistency, copy editing and English style. If these issues are satisfactorily addressed, it is possible that another round of peer review will not be necessary.

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We look forward to receiving your revised manuscript.

Kind regards,

M Barton Laws

Academic Editor

PLOS ONE

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: (No Response)

**********

2. 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 #2: Yes

**********

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

Reviewer #2: N/A

**********

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

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: (No Response)

**********

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

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

**********

6. 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 #2: The authors report their findings of qualitative interviews with patients who had or were going to have inguinal hernia repair surgery and use of a 360 video to help patients be informed. This is an interesting study and relevant, but I do have several suggestions outlined below that would improve the quality of the findings. Also, I agree with the editor that they should provide the translation procedure for the English quotes and have a native speaker review the revised manuscript.

Abstract

- I feel that the abstract is missing the actual conclusions. The results are stated but the implications of the findings are not clear.

Introduction

- Suggest review for minor typos (extra spaces, missing commas, “postpone” does not need to be hyphenated)

- The items in this sentence don't seem to be mutually exclusive: "However, it is not always clear what information patients want, as some prefer wide-ranging information (4, 5), whilst others prefer detailed information (4, 6)." Perhaps by wide-ranging, you mean more general information?

- For this sentence, “Currently, patients have access to the Internet, which offers unlimited amounts of health information(7).” Suggest changing ‘currently’ to ‘most’ – not all patients have internet access.

- I’m not sure how I feel about this sentence: “In our hospital we had the impression that patients were missing certain information and that they did not read or (fully) understand the provided (written) information (personal opinion).”

- The entire paper is about the provision of a virtual reality tool but there is only one sentence about VR in the introduction. This seems off – I would suggest adding more on the evidence and introduction of this concept.

Methods

- The authors state the used COREQ however they did not include a copy of the completed checklist as a part of their submission. Perhaps not a requirement for the journal but it strengthens the submission.

- Most methods section is written in the passive voice. This is a choice but the manuscript would be much more acceptable to a lay reader if it was written in the active voice.

- Most of the information provided under the subheading ‘Participants’ is really material that should be reserved for the results section. This includes all of the information starting with the sentence “In total, 21 patients were contacted…” through the end of this subsection. Along with the information in the next section on the length of the interviews.

- I think there is a word missing from this sentence: “This 360 ° video offered the patients to virtually experience some parts of the operation day and to see some real operation scenes of a laparoscopic inguinal hernia repair procedure.”

- Given that the themes in the results include in-person requests, I would suggest adding the dates of these interviews due to the COVID-19 shifts that you acknowledge in the conclusions.

- I see no mention of data saturation which is one of the COREQ checklist items and is important in qualitative research. The authors mention that they started coding before interviewing was complete so perhaps this was in fact done?

Results

- I’m not following the connection between the subheading ‘visual tools’ and the content under it – I don’t see references to visual tools here?

- The authors seem to have done a nice job responding to previous reviewers comments about breaking up the quotes and improving the clarity of the themes.

- I would highly suggest a table to layout the major themes from the analysis. With only one table in the manuscript at present, this could really strengthen the summarization of the findings.

- I’m don’t think the word ‘sparring’ is used correctly in this sentence: “For others, the Internet was not perceived as helpful in providing sufficient confidence for an active role as a sparring partner.”

- You mention in the abstract that the patients did not find the VR fearsome but I don’t see this as a theme in the results. Perhaps I missed it? I was sort of looking for a heading on the acceptability of the VR but perhaps not enough information emerged on this?

Discussion

- You say “these studies” but then only one citation, which I see is a systematic review. Perhaps you could say instead introduce citation 14 as a 2018 systematic review and then in the next sentence say “the studies in this review were mainly conducted…”

- This sentence sits at the end of a paragraph without further explanation: “Alternative options could be for example use of autobots.” I feel this contextual paragraph needs improvement. Surely there are other results in the literature that indicate if your findings are in agreement with other studies that patients felt there was a lack of tailored information?

- When I read sentences like: “The majority of the patients believed that the 360 ° video enhanced their understanding, especially with regard to the surgical procedural information.” In the discussion, I feel like this is missing from the results. Perhaps I missed it but again I do wonder if a section about the acceptability of the 360 tool would be appropriate in the results section.

- In the section under “seeing is understanding” – is there other research around VR that could be incorporated so that you are reviewing your results against the current literature on VR?

- I think you can remove “for instance” from the last line of the manuscript.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

25 Sep 2020

Abstract

- I feel that the abstract is missing the actual conclusions. The results are stated but the implications of the findings are not clear.

We changed the abstract and make a division between the results and the conclusion.

Conclusion: In order to address to patients’ information needs, complementary tools or services are needed that increase personal contact as well as tailoring with respect to individual needs. Even though video-apps are a partial alternative, hospitals should still offer patients the possibility for face-to-face meetings with physicians as this is highly valued by patients and for instance leads to increased trust in physicians’ performance.

Introduction

- Suggest review for minor typos (extra spaces, missing commas, “postpone” does not need to be hyphenated)

We reviewed the paper and adapted it accordingly

- The items in this sentence don't seem to be mutually exclusive: "However, it is not always clear what information patients want, as some prefer wide-ranging information (4, 5), whilst others prefer detailed information (4, 6)." Perhaps by wide-ranging, you mean more general information?

We changed it to the following:

“However, it is not always clear what information patients want as some prefer receiving very general information about just the procedure (4, 5), whilst others prefer detailed information for example on outcomes and survival (4, 6).”

- For this sentence, “Currently, patients have access to the Internet, which offers unlimited amounts of health information(7).” Suggest changing ‘currently’ to ‘most’ – not all patients have internet access.

Changed accordingly

- I’m not sure how I feel about this sentence: “In our hospital we had the impression that patients were missing certain information and that they did not read or (fully) understand the provided (written) information (personal opinion).”

We removed the word “personal opinion”. We want to indicate that we noted that patients had not read or understood the provided information as they for example had forgotten to take medication prior to the surgery, even though this was written in the instructions. Therefore we wanted to see whether we could improve the understanding of the procedure and the process.

- The entire paper is about the provision of a virtual reality tool but there is only one sentence about VR in the introduction. This seems off – I would suggest adding more on the evidence and introduction of this concept.

We added more information on the use of VR to the introduction.

“Virtual reality has been used to train physicians or residents to improve their communication skills towards the patient (11). Furthermore, one study suggested that informing patients on a surgical procedure via VR might improve patient comprehension of their condition (12).”

Methods

- The authors state the used COREQ however they did not include a copy of the completed checklist as a part of their submission. Perhaps not a requirement for the journal but it strengthens the submission.

- Most methods section is written in the passive voice. This is a choice but the manuscript would be much more acceptable to a lay reader if it was written in the active voice.

We made the method section more “active”.

- Most of the information provided under the subheading ‘Participants’ is really material that should be reserved for the results section. This includes all of the information starting with the sentence “In total, 21 patients were contacted…” through the end of this subsection. Along with the information in the next section on the length of the interviews.

We changed this accordingly

- I think there is a word missing from this sentence: “This 360 ° video offered the patients to virtually experience some parts of the operation day and to see some real operation scenes of a laparoscopic inguinal hernia repair procedure.”

We changed the sentence

“In this 360˚ video patients could virtually experience parts of the day of the surgery and see parts of a laparoscopic inguinal hernia repair procedure.”

- Given that the themes in the results include in-person requests, I would suggest adding the dates of these interviews due to the COVID-19 shifts that you acknowledge in the conclusions.

We added the period to the methods section (study design)

Interviews were held between September and December 2018.

- I see no mention of data saturation which is one of the COREQ checklist items and is important in qualitative research. The authors mention that they started coding before interviewing was complete so perhaps this was in fact done?

We added the COREQ checklist and added information on when the data collection was ended (methods – data collection)

The data collection was ended after saturation was reached.

Results

- I’m not following the connection between the subheading ‘visual tools’ and the content under it – I

don’t see references to visual tools here?

We changed the subchapter title to Using tools

- The authors seem to have done a nice job responding to previous reviewers comments about breaking up the quotes and improving the clarity of the themes.

We thank the reviewer for his/her nice comments – we believe that the comments of the reviewer strongly improved our paper

- I would highly suggest a table to layout the major themes from the analysis. With only one table in the manuscript at present, this could really strengthen the summarization of the findings.

We added a table 2.

- I’m don’t think the word ‘sparring’ is used correctly in this sentence: “For others, the Internet was not perceived as helpful in providing sufficient confidence for an active role as a sparring partner.”

We changed the wording to “for an active role in the share d decision making process”

- You mention in the abstract that the patients did not find the VR fearsome but I don’t see this as a theme in the results. Perhaps I missed it? I was sort of looking for a heading on the acceptability of the VR but perhaps not enough information emerged on this?

The VR video was strongly accepted, and not of the patients found it troublesome. There was too little information to have an entire theme on this topic. However, we combined the finding from various places to the end of the results section

Still, the use of the VR-video was accepted by all patients and none of the patients found it fearsome themselves. Beforehand we had expected that patients might find it fearsome to view a surgical procedure in 360. Some of the patients indicated that it could scare people off to get so close to the real surgery, although they did not find it problematic themselves. In addition there was one patient who indicated not to be interested in the video and who had the interview by phone.

Discussion

- You say “these studies” but then only one citation, which I see is a systematic review. Perhaps you could say instead introduce citation 14 as a 2018 systematic review and then in the next sentence say “the studies in this review were mainly conducted…”

We changed the wording

However, most of the studies included in this review were conducted before 2010.

- This sentence sits at the end of a paragraph without further explanation: “Alternative options could be for example use of autobots.”

We added some literature on this.

Alternative options could be, for example, use of chatbots. For the latter, studies in breast cancer patients, for example, have shown that an artificial conversation agent achieved equal satisfaction scores as “real” physicians (18).

I feel this contextual paragraph needs improvement. Surely there are other results in the literature that indicate if your findings are in agreement with other studies that patients felt there was a lack of tailored information?

We agree and added some more information and results from the literature

Patients felt that the general information obtained from the brochures, the internet or doctors assistants, was not sufficiently tailored to their personal situation, for instance for questions regarding their recovery process. It had been shown previously that tailored information provided on the internet leads to higher satisfaction rates among patients, especially among younger patients, although no improvements in patients outcomes have been found (17,18). Some of our patients had WhatsApp contact with their surgeon, which was highly appreciated. However, this would be nearly impossible to provide to all patients, as physicians are often afraid of being overloaded with questions from patients. Still research has shown benefits of a short messaging system protocol leading to a reduced number of clinic visits and increased efficiency of clinic visits(19). Alternative options could be for example use of chatbots. For the latter, studies in breast cancer patients, for example, have shown that an artificial conversation agent achieved equal satisfaction scores as “real” physicians (20).

- When I read sentences like: “The majority of the patients believed that the 360 ° video enhanced their understanding, especially with regard to the surgical procedural information.” In the discussion, I feel like this is missing from the results. Perhaps I missed it but again I do wonder if a section about the acceptability of the 360 tool would be appropriate in the results section.

See above.

- In the section under “seeing is understanding” – is there other research around VR that could be incorporated so that you are reviewing your results against the current literature on VR?

We added some literature

Also in other fields it has been suggested that VR can help in pharmacy education by providing immersive educational activities (24), having elderly patients coping with dementia (25) or teaching skills to health professionals (26).

- I think you can remove “for instance” from the last line of the manuscript.

- Adapted accordingly

Submitted filename: 2reply_plos_one_20200923_def.docx

Click here for additional data file.

28 Sep 2020

Patients want to be seen: the top 3 information needs of patients with inguinal hernia.

PONE-D-19-28443R2

Dear Dr. van Stralen,

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,

M Barton Laws

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

While I have recommended acceptance, I urge you to proofread the paper carefully before publication. In future submissions, you should always make sure to number the pages, as this is helpful to editors and reviewers. Because you have not done so it is difficult for me to point out specific issues. For example, in the first paragraph of the results there is a typographical error of "latest" for "lasted." You might also try to have a native English speaker review this as some of the wording is not really standard, though it is certainly comprehensible. Nevertheless this is a useful contribution that may inform practice.

Reviewers' comments:

2 Oct 2020

PONE-D-19-28443R2

Patients want to be seen: the top 3 information needs of patients with inguinal hernia.

Dear Dr. van Stralen:

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,

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on behalf of

Dr. M Barton Laws

Academic Editor

PLOS ONE