Psoriatic arthritis (PsA) is a form of chronic inflammatory arthritis associated with psoriasis and a multitude of other symptoms, most commonly arthritis, dactylitis, enthesitis and axial involvement. PsA is significantly heterogeneous, with a highly variable clinical course of PsA. Patients may experience significant or mild skin and joint symptoms, with some patients developing rapidly progressing joint destruction and skin symptoms. Despite the range of symptom severity, PsA is frequently associated with significantly impaired quality of life from joint destruction, as well as chronic pain and a range of comorbidities such as depression and cardiovascular disease. Currently, there are no definitive diagnostic tests for PsA, with diagnosis remaining challenging owing to the heterogeneous presentation and course of the disease. Presently, the CASPAR criteria are often used to aid rheumatologists in distinguishing PsA from other inflammatory arthritides. Treatment options for patients have been expanded over the last two decades with the emerging clinical utility of biological therapies. However, early identification and diagnosis of patients and effective disease control remain unmet medical needs within the PsA community. In addition, predicting response to treatment also remains a challenge to rheumatologists. This review highlights the current hurdles faced by healthcare professionals in the diagnosis and management of PsA patients and provides future action points for consideration by the members of the multidisciplinary team who treat PsA patients. In addition to musculoskeletal symptoms, up to 30% of patients have coexisting psoriasis or nail disease.Psoriatic arthritis (PsA) is a heterogeneous condition with musculoskeletal involvement, manifesting as a variety of symptoms including arthritis, dactylitis, enthesitis and axial involvement. Despite nearly 50 years passing since the first clinical description, diagnosis remains challenging for clinicians due to lack of validated diagnostic criteria, the inherently heterogeneous nature of the condition and poor identification of the disease, particularly in susceptible patients. Presently, diagnosis relies on identification of clinical signs and symptoms, assessed across multiple domains supported by classification criteria. Although the developed classification criteria have been well validated in established disease, there is currently an unmet need for early patient identification through the use of diagnostic biomarkers.PsA was first defined by Moll and Wright in 1970s as ‘an inflammatory arthritis in the presence of psoriasis with a usual absence of rheumatoid factor’. Although development of biological therapies has revolutionised the treatment of PsA and improved outcomes, predicting and measuring treatment outcomes in patients remains challenging. In addition, there is a growing consensus that identifying and treating patients before the development of clinical features of the disease may be achievable, allowing for the possibility of early intervention, with the goal of disease prevention.Pharmacological treatments for PsA have expanded exponentially over recent years, although long-term therapeutic effects are largely based on clinical experience rather than extensive head-to-head trial-based analysis. Over the last two decades, symptomatic treatments have evolved from traditional disease-modifying antirheumatic agents (DMARDs) to targeted biological therapies.This review will explore the prospects for the future of PsA for both clinicians and patients and provide suggestions around promising efforts to improve diagnosis, disease management and treatment as well as whether the goal of disease prevention is achievable. although studies performed worldwide often have significant differences in estimates of prevalence, reflecting a range of methodological differences including variations in classifications used use of incorrect diagnostic coding algorithms and diagnosis using low-sensitivity criteria such as those defined by European Spondyloarthropathy Study Group. These factors make it challenging to compare meaningful differences in prevalence between studies.Globally, the reported prevalence of PsA ranges from 0.3% to 1% There are no diagnostic criteria available for PsA. In 2006, the ClASsification of Psoriatic ARthritis (CASPAR) classification criteria were developed in 2006 to aid in standardising inclusion of homogeneous population of patients to trials and have been demonstrated extensively to possess both high sensitivity and specificity. However, classification criteria favour specificity over sensitivity and do not perform as well in diagnosis. Patients often experience a ‘diagnostic odyssey’ with delays in disease identification and prompt referral to secondary care.Despite significant advances in the understanding of the pathophysiology of PsA in recent decades, diagnosis remains a challenge. It is estimated that almost 50% of cases in primary and secondary care clinics are unrecognised. Presently, no serum biomarkers have been identified with the ability to correlate with diagnosis. A recent study retrospectively analysed serological markers and comorbidities in 629 psoriatic patients, including 102 with PsA. A range of serological markers were analysed, including anti-extractable nuclear antigens (ENA) autoantibodies, antiphospholipid autoantibodies, and antineutrophil cytoplasmic autoantibodies, as well as haematological and inflammatory parameters. No serological markers were able to distinguish PsA patients, although interestingly, certain comorbidities were more prevalent in the PsA population.Inflammatory markers such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are normal in approximately 50% of patients.et al. reported that levels of CXCL10 are elevated in patients who develop PsA compared with psoriasis patients who do not develop PsA at baseline. In 2020, the same group demonstrated that CXCL10 levels drop following the development of arthritis, with the authors suggesting that their findings warrant further investigation into the predictive value of CXCL10 in PsA diagnosis.Other studies have examined the potential role of chemokines as diagnostic biomarkers. In 2016, Abji Ultimately, timely diagnosis and early intervention are critical in PsA, with studies showing that aggressive targeted approach to treating psoriatic arthritis greatly improves disease-activity outcomes for patients, reducing long-term disability and long-term join damage. As outlined earlier, identification and subsequent diagnosis of PsA is based on clinical findings rather than strict biochemical or radiological findings, often making identification challenging.The majority of PsA patients present with a heterogeneous picture of the disease which may include skin and nail involvement, dactylitis, enthesitis, spondylitis and arthritis. It has been suggested that the lack of an established diagnosis may result from poor understanding of the link between the skin and arthritis, lack of rheumatological education among people with psoriasis, primary care physicians (PCPs) and treating dermatologists. To help drive early diagnosis in this ‘at-risk’ patient group, recent guidance by National Institute for Health and Care Excellence (NICE) for management of psoriasis recommends annual screening for PsA among patients with psoriasis both in primary and secondary care settings. Alongside guidance for healthcare professionals (HCPs), attempts to improve screening, such as the distribution of educational material to psoriasis patients, may help improve screening attendance. Targeting the time point within their psoriasis journey at which patients should be screened is also of importance. A recent study identified that physician associates and nurse practitioners in dermatology clinics and primary care practices are often first to see patients with psoriasis and are therefore ideally positioned to screen them for PsA and refer them to a rheumatologist as needed. Harnessing the ability for HCPs to screen for PsA in susceptible patients is an important approach to take to ensure timely referral and effective early disease treatment.The first step on the PsA patient journey is often self-identification of symptoms. The majority of patients with PsA also have pre-existing psoriasis; however, studies have shown that there are many cases of established PsA which remain unidentified for some time, despite an established diagnosis of psoriasis. To address the potential educational deficits among PCPs and other HCPs, it has been suggested that health authorities and academic societies should create educational awareness campaigns aimed at PCPs and dermatologists about the symptoms of PsA to improve understanding of the disease.Although screening is a potentially useful tool for the identification of PsA patients, it is likely to be only restricted to patients with psoriasis. The complex symptomatology of PsA means that identification of PsA by PCPs is often low, with a recent Multinational Assessment of Psoriasis and Psoriatic Arthritis survey of 391 dermatologists and 390 rheumatologists based in North America and Europe, > 75% stating that PsA is probably underdiagnosed due to a failure to connect skin and joint symptoms.As outlined earlier, early diagnosis is key to improving outcomes in PsA patients as it allows prompt, aggressive, targeted treatment with anti-inflammatory disease-modifying drugs such as methotrexate or biologics results in reduced progression of joint damage. Indeed, the 2018 American College of Rheumatology/National Psoriasis Foundation Guideline for the Treatment of PsA states that early commencement of therapy is critical for improving long-term outcomes in patients, suggesting a key window of opportunity exists for diagnosis and intervention in PsA patients.However, despite the overwhelming evidence for the importance of early referral, delayed referral and subsequent diagnostic delay is common among inflammatory arthritides, including PsA. A recent study examined the diagnostic delay in PsA patients using data from the National Clinical Audit for Rheumatoid and Early Inflammatory Arthritis, undertaken by the British Society for Rheumatology. Analysis demonstrated that patients with PsA had a significantly longer delay to presentation and diagnosis than those with rheumatoid arthritis (RA), with a mean time to referral of 5.4 weeks following consultation with their general practitioner (GP), compared with 4.0 weeks for RA patients. In addition to standard of care guidance, multidisciplinary care is important for prompt referral of patients. A recent 12-point recommendation framework suggested that improved collaboration between dermatologists, PCPs and rheumatologists may hold the key to reducing time to PsA diagnosis. The authors suggested that this may take the form of standard referral pathways, multidisciplinary team meetings, or ‘one stop’, rapid-access combined clinics in which the patient is seen by multiple specialists at the same time. To help facilitate these referral pathways, a variety of screening tests such as Psoriatic arthritis UnclutteRed screening Evaluation (PURE-4), Psoriatic Arthritis Screening and Evaluation (PASE) and the Psoriasis Epidemiology Screening Tool (PEST) have been validated, which may aid clinicians in expediting referrals for at-risk patients.In order to help reinforce the importance of early referral, several measures have been proposed to help reduce diagnostic delay. Guidelines, such as European League Against Rheumatism (EULAR) standard of care, have been developed to help encourage patients to be referred early to a rheumatologist by their PCP if PsA is suspected. Although this suggests that there may be an emerging stronger awareness of the importance of early diagnosis in PsA, the findings were within one country, and in healthcare systems which have lower levels of integration across specialities, these observations may not translate to other populations. It is therefore of importance that combined clinics between dermatologists and rheumatologists focus on screening psoriasis patients and this may in turn drive earlier diagnosis.Although diagnostic delay remains an issue for PsA patients, a study published in 2015 demonstrated that between 2000 and 2011, a significant reduction in diagnostic delay was observed in inflammatory arthritis patients, including PsA in Denmark through analysis of the DANBIO registry.Action points:Encourage regular screening and education of at-risk patients such as those with psoriasisEnsure educational opportunities are tailored towards localised referral and diagnostic pathwaysPromote disease awareness and collaboration among HCPs including PCPs, dermatologists and other allied HCPs.2527 Choice of treatment varies according to guidance: EULAR recommends the use of TNF inhibitors, ustekinumab and IL-17 inhibitors for peripheral arthritis which is unresponsive to DMARDs. The treatment recommendations by EULAR help support treatment decision making and address the spectrum of disease phenotypes seen in PsA patients. As the authors note, however, the guidelines will need to be updated regularly, in light of emerging data following treatment of patients.Over the last 20 years, therapeutic options for rheumatological conditions such as PsA have evolved at a considerable pace. Over the last decade, treatment has shifted away from traditional DMARD drugs such as methotrexate towards the development of biological therapies such as tumour necrosis factor (TNF) inhibitors, interleukin (IL)-12 and IL-23 inhibitors and IL-17 inhibitors, which have proved highly efficacious in a range of clinical trials. The guidelines by ACR suggest this approach as early treatment with TNF inhibitors could delay or avoid the irreversible joint damage seen in PsA patients, supporting an overall improvement in quality of life (QoL).In contrast to EULAR, the ACR guidelines recommend first-line treatment with a TNF inhibitor over oral small molecule DMARDs in order to ‘treat to target’. The authors suggested considering which domains are involved, as well as patient preference and any previous or concomitant therapies. Furthermore, the choice of therapy should address treatment across as many domains as possible . Alongside these factors, comorbidities and any other associated conditions should be considered which may impact the choice of therapy. Patients should be periodically re-evaluated following commencement of treatment and therapy modified as required.In addition to the EULAR and ACR guidelines for treatment, the Group for the Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) developed treatment recommendations in 2015. These were updated in 2021, following emergence of new treatment data and therapeutics.However, despite a range of treatment options and durable efficacy among therapies, along with carefully considered guidelines, predicting response to treatment remains an issue yet to be addressed. Furthermore, it remains unclear why certain treatments fail to adequately control disease in certain patients. Alongside predicting treatment responses, ascertaining and implementing nonpharmacological management of PsA patients remains a priority for the future. Although precision medicine has been applied to other areas of disease, for example, determining Her2 status in breast cancer patients, the use of precision medicine in rheumatology remains very much in its infancy.Precision medicine is defined as ‘an emerging approach for disease treatment and prevention that considers individual variability in genes, environment, and lifestyle for each person’. Although patients demonstrate common immunological dysregulation, such as overt Th17 activation, the individual immunophenotype of each patient is unique and driven by a range of genetic, environmental and tissue-specific differences. It is likely, therefore, that the individual immunophenotype influences response to treatments. This influence has been demonstrated in a study examining the use of immunophenotyping in guiding choice of biological therapy in PsA patients. In the study of 64 PsA patients, half of the patients received lymphocyte phenotyping which guided treatment towards ustekinumab for patients with activated Th1-dominance status, secukinumab for patients with activated Th17-dominance status and adalimumab (ADA) or infliximab (IFX) for patients with activated Th1/Th17-high status. The other half of the patients were managed according to physician or patient preference of biologic. Disease activity was assessed in all patients using simplified disease activity index (SDAI) as well as psoriasis area and severity index. After 6 months, the rate of low disease activity achievement according to SDAI at 6 months was significantly higher in the strategic biological treatment group compared with that of the physician/patient preference biological treatment group. These optimistic findings suggest that further elucidation of the pathways involved in immune dysregulation in PsA patients may allow for the use of immunophenotyping in helping guide appropriate treatment, through the sampling of peripheral blood. Although this offers a potentially attractive approach to personalised treatment in PsA patients, whether immunophenotyping can reflect disease severity accurately in a range of tissues remains to be ascertained. In order to further characterise any potential correlations, other disease areas such as RA have explored the use of collaborative approaches such as the formation of Maximizing Therapeutic Utility in RA (MATURA) consortium. A similar approach in PsA may help determine the real-world analysis of peripheral blood collected from large cohorts of patients, who are then followed to assess response in order to identify immunophenotypes predictive of response, alongside other factors that correlate with treatment outcomes.PsA presents a unique opportunity for driving a rationalised target-driven therapeutic approach through the application of personalised medicine. A plethora of studies have attempted to elucidate the immunological components underpinning PsA, which has helped drive the development of such therapies as ustekinumab.Alongside predictive measures for forecasting treatment response, a range of novel therapies are currently under developmentAside from pharmacological treatments, there is an increasing wealth of evidence to suggest that holistic disease management in rheumatology patients is important, particularly with respect to managing QoL and psychosocial burden associated with PsA. The role of other HCPs in managing PsA patients spans a variety of domains including multidisciplinary care, psychological management and pain management. However, it is well recognised that other HCPs including primary care physicians and dermatologists play an important role in the treatment and management of PsA patients. Models for integrating multidisciplinary management have been described elsewhere, including dual rheumatologist–dermatologist assessment, as well as parallel and circuit models of patient review. Alongside management of joint complaints and skin symptoms, it has been shown that the comorbidity burden among PsA patients is significantly higher than the general population, with an increased prevalence of hyperlipidaemia, hypertension and inflammatory bowel disease. Compared with the general population, patients with PsA have a 55% increased risk of developing a cardiovascular event, with significantly higher prevalence of myocardial infarctions, cerebrovascular diseases, and heart failure in patients. Furthermore, patients with PsA appear to have a higher cardiovascular risk compared with patients with psoriasis alone. It has been hypothesised that the chronic inflammatory state characteristic of PsA contributes to the increased comorbidity burden observed in patients.Current guidelines issued by EULAR approach the management of PsA primarily from the perspective of a rheumatologist.The multisystemic nature of PsA therefore requires patients are managed and cared for by multiple specialities. The evolving model of multidisciplinary care is likely to incorporate a wider integration of HCPs than previously constructed guidelines. It should be remembered, however, approaches will likely be dictated by local healthcare systems and resource allocations. A recent study suggested that treatment of PsA and associated pain cannot be effectively achieved without addressing all psychosocial factors, including simultaneous management of physical and psychological concerns. Clearly the former may be addressed by the treating dermatologist and rheumatologist, with the latter evaluated by a psychologist. Furthermore, a cross-sectional study carried out across 131 PsA outpatient clinics showed fatigue, sleep disturbances, anxiety/depression, impaired physical function, unemployment and presence of comorbidities were independently associated with impaired health-related QoL (HRQoL) in patients.PsA is associated with a considerable psychosocial burden. Indeed, previous studies have shown that not only do PsA patients have considerably poorer QoL compared with the general population, but QoL and functional status is also considerably worse compared with patients with psoriasis or RA. Early aggressive treatment in patients with PsA patients targeting key cytokines involved in the neuroinflammatory components of depression may prove a potential course of action in managing mood changes. Of note, in other inflammatory arthritides, such as RA, longer standing depressive symptoms correlate with reduced treatment responses with respect to achieving disease control. These findings have also been noted in a prospective multicentre study in PsA patients in Norway, with depression and anxiety reducing the likelihood of joint remission following treatment.Alongside acknowledging this burden faced by patients, an important question that rheumatologists should be aware of is what role, if any, does the proinflammatory environment contribute to the greater psychosocial burden seen in PsA patients? Studies have demonstrated that a range of inflammatory cytokines, including IL-6 and IL-12, play a role in the development of depression.Extrapolating this study to PsA patients further lends weight to the argument that addressing any mood changes early on following diagnosis should be a priority in providing holistic care to patients. Ultimately, these findings highlight the importance of psychosocial management of patients and, importantly, given the chronic nature of PsA, suggest patients should be regularly evaluated, in particular, following any increase in disease activity. Even with the development and use of both DMARDs and biological therapies, persistent pain is often a significant issue for PsA patients. In a study by EULAR, a questionnaire, Psoriatic Arthritis Impact of Disease (PsAID), identified pain as the most important health domain affecting HRQoL. Around a third of PsA patients receiving biological therapies report no or mild pain, with a third reporting moderate pain and a further third describing severe pain. Pain is clearly common among PsA patients receiving treatment and the more severe the pain, the greater impact on physical functioning, work productivity and engagement in activities.Despite the prevalence of pain in PsA patients, historically, therapeutic trials did not routinely report pain specifically as an outcome, although more recent trials, such as the FUTURE 2 study, have demonstrated that secukinumab treatment offers a significant and sustained reduction in pain over a 2-year period.Even in light of improved pain symptoms in treated PsA patients, speedy, effective and long-term management is required to improve QoL for patients. Prompt referral to pain specialists for the treatment of refractory or difficult to manage pain should be considered under the umbrella of multidisciplinary management of PsA patients. In order to help rationalise pain management approaches in patients, further studies are required to draft consensus guidelines on optimum pain management strategies in PsA patients.Action points:Implementation of multidisciplinary management of PsA patients should remain a priority in all rheumatology departmentsConsider regularly incorporating psychological outcomes and pain management into clinical trial designsConsider prompt referral to pain specialists if pain remains uncontrolledGuidelines on optimum pain management in PsA patients should be developed using emerging evidence from recent trials47 Given this, developing novel tools to assess disease activity through biomarkers and technological based approaches is a subject of keen interest within the field. These assessments can then also help in directing care and act as a triage tool; for example, whether the patient needs to be seen promptly or whether they can be seen at a later timepoint.The assessment of disease activity is pivotal in guiding treatment. Over recent years, a range of composite scoring systems have been developed in order to accurately and reliably assess disease. However, despite the creation of assessment tools, such as Minimal Disease Activity (MDA), Psoriatic Arthritis Disease Activity Score (PASDAS) and Disease Activity Index for Psoriatic Arthritis (DAPSA), the inherent heterogeneity of PsA makes translating such symptoms into a validated relevant for all measure challenging.Given the clinical heterogeneity of PsA, potential biomarkers have long been sought by rheumatologists that are reflective of treatment response.+ cell number, C-reactive protein and matrix metalloprotease-3 to name only a few. A recent systematic review of treatment response biomarkers suggested that CRP and subsequent response to biological therapy is potentially of significant clinical utility, although the studies examined only patients treated with anti-TNF therapy.With respect to treatment response, a range of potential biomarkers have been suggested including synovial CD3The ability for rheumatologist to accurately diagnose and predict treatment responses in PsA patients remains an unmet medical need which warrants careful consideration in future clinical trials. Such technologies provide a unique opportunity to not only help monitor and guide treatment in patients, but also help collect real-world evidence (RWE) of long-term outcomes in treated patients.As rheumatology clinics become increasingly ‘digitally mature’, the development and integration of technology to support self-monitoring and self-management has expanded dramatically.The use of digital technology has already been examined in patients with RA in a range of applications including reporting symptoms prior to clinic attendance, remote monitoring, symptom tracking and racking symptoms through increased insight into changes in their disease through time.Psorcast to assess PsA symptoms affecting joints domains as shown in Digital Jar Open tool uses the gyroscope to measure inward and outward rotation of each arm to generate an inward symmetry score and outward symmetry score that are normalised within each participant. The 30-Second Walk tool measures gait with the smartphone in a pocket during a walk to generate a symmetry score using PDKit. The Finger/Toe Photo captures finger and toe images, normalising them with the contralateral nail bed width to measure relative digit widths. Assessment of this novel tool in the patients recruited so far has demonstrated that the three sensor-based measurements can distinguish some clinical features of PsA. Although further validation is required, these and other Psorcast tools may provide for remote self-assessment when clinical visits cannot be performed. Importantly, longitudinal and frequent symptom measurement could be of high value to study disease progression and assessing treatment response.The COVID-19 pandemic has presented significant challenges to both rheumatologists and patients alike. Along with the direct consequences of the pandemic, the management and follow-up of patients has been severely impacted due to a range of factors including social restrictions, travel restrictions and re-deployment of HCPs. Considering the challenges faced by clinicians following up PsA patients, the use of smartphone sensor technology has been explored as a tool for quantitatively measuring disease symptoms in patients. Recently, three novel smartphone sensor-based measurement tools were developed as part of  Indeed, in 2019, EULAR published a range of points for developers and HCPs to consider when evaluating the implementation of mobile health applications in rheumatological patients.In addition to tools such as Psorcast, the use of artificial intelligence (AI) has also been proposed as a tool to help predict disease progression, flares and ‘at risk’ patients who have a higher propensity to develop PsA on a background of psoriasis.et al., and although the authors are optimistic about the potential of mHealth uptake in PsA patients, several barriers to successful implementation remain, including poor levels of technological literacy among older patients, a lack of high-quality apps in terms of scientific accuracy and compliance to evidence-based guidelines.Alongside AI, the use of mHealth, as defined by the World Health Organization (WHO) as ‘the use of mobile and wireless technologies to support the achievement of health objectives’ may also prove useful in encouraging self-management of disease in patients with PsA. The potential of mHealth in managing patients has been reviewed by Fagni Action points:The clinical relevance of biomarkers should be further established in larger, more well-defined cohortsFurther validation of novel technological tools for determining disease activity and patient outcomes should continueConsider the implementation of artificial intelligence for prediction and forecast of disease progression and symptomsAlthough a significant amount of effort has been placed on the management and treatment of PsA, there is growing evidence to suggest that targeting patients who are at an increased risk of developing PsA may be amenable to interventions that slow disease onset or even prevent disease. The questions are therefore clear: which patients are at risk of developing PsA and how may disease progression be prevented? Furthermore, psoriasis often precedes inflammatory joint involvement by an average of 7 years, suggesting there is ample time for intervention. Within this patient population, a range of risk factors have been shown to suggest an increased risk of the development of PsA including a range of major histocompatibility complex (MHC) mutations, such as HLA-Cw*0602, HLA-B27, HLA-B38, HLA-B39, as well as non-MHC mutations, increased body mass index (BMI) and bodily distribution of psoriasis and severity. Current analysis of available data has, however, failed to find a single variable which adequately predicts transition to synovio-entheseal disease.Over recent years, the theory that psoriasis and PsA are in fact overlapping conditions, both of which are underpinned by a proinflammatory environment, has gained considerably traction. As discussed earlier, there has been a long and well-demonstrated link that psoriasis is a strong risk factor for PsA, with up to 30% of patients with psoriasis developing inflammatory synovio-entheseal manifestations. Following a three-round Delphi process, consensus was reached for three terms and definitions: ‘increased risk for PsA’, ‘psoriasis with asymptomatic synovio-entheseal imaging abnormalities’ and ‘psoriasis with musculoskeletal symptoms not explained by other diagnosis’. It is hoped that identification of these terms will allow for more well-defined populations in studying patients who may have an increased risk of developing PsA.Reflecting on disease stages apparent in PsA may also offer insight for how to target patients at risk of developing PsA. A recent Delphi consensus study has aimed to help define specific subgroups of individuals during early preclinical and clinical phases of PsA for use in research studies. The authors identified 26 articles that were deemed suitable for inclusion and analysis. Psoriasis patients with arthralgia and imaging-musculoskeletal inflammation were at high risk of developing PsA, along with increased body mass index (BMI) and a family history of PsA. These findings may prove useful for helping to identify PsA in its preclinical phase and will potentially allow for the design of trials aiming to prevent development of PsA.A recent systematic literature review and meta-analysis examined a range of predictors of PsA development in psoriasis patients. The authors demonstrated that biologic DMARDs may delay or reduce the risk of incident PsA in moderate-to-severe plaque psoriasis patients, suggesting that treatment modality may play an important role in long-term risk. Further to this study, a retrospective cohort study examined 193,709 patients with psoriasis but without PsA. The authors demonstrated that biologic use was associated with the development of PsA among patients with psoriasis although acknowledged this may have been related to confounding by indication and protopathic bias. It is therefore clear that further studies, in particular those that are prospective in nature, are required to further elucidate the relationship between risk and PsA development.The role of treatment and development of PsA has also been studied in psoriasis patients. A retrospective nonrandomised study in patients with moderate-to-severe plaque psoriasis who were prescribed  > 5 years of biologic DMARD therapy were assessed for development of PsA and the annual and cumulative incidence rates analysed.64 The proposed transition includes establishment of a proinflammatory environment alongside psoriasis through the interaction of genetic and environmental factors. The preclinical phase includes activation of the IL-23-IL-17 axis alongside TNF-α production. Following this, a subclinical phase is apparent with appearance of soluble biomarkers and emergence of to synovio-enthesitis, shortly followed by a prodromal phase of arthralgia. The final phase results in clinically evident PsA with classical symptoms such as synovitis, enthesitis, dactylitis and asymmetric axial disease. It is clear, therefore, that early identification of patients before they progress past the preclinical phase of psoriasis–PsA disease evolution. Early identification of these patients remains challenging, although the expanding role of identifiable biomarkers, stratified to risk of disease progression, remains an active area of interest in PsA patients. Although there are currently no validated biomarkers, high baseline serum concentrations of CXC-chemokine ligand 10 (CXCL10) in patients with psoriasis correlate with risk of developing PsA. Furthermore, a number of other potentially clinically relevant biomarkers including M2BP and ITGB5 show potential promise in aiding clinicians identify patients at risk of disease progression. In addition to biomarker identification, use of imaging modalities such as ultrasound and magnetic resonance imaging may help detect patients with silent joint disease, although the predictive ability of detection of such changes remains unknown. Although identification and screening for PsA in psoriasis patients should remain an important focus, this approach relies on patients presenting with skin disease prior to join symptoms, which is not the case for all patients. The subset of patients without skin disease may require alternative approaches to ensure early diagnosis. In addition, developing a predictive tool that utilises data from psoriasis patients who may be at risk of developing PsA may aid in the design of preventive trials.Along with underlying risk factors, the transition from psoriasis to PsA is likely an interplay between genes, immunity and the environment and has been proposed to evolve through stages.Action points:Elucidation of biomarkers to predict patients at risk of disease progression should be prioritisedEstablishment of dialogue between patients and HCPs to ascertain the level of disease severity before treatment should be commenced to ensure a balance of treatment benefit and any potential risksContinuing to further define specific subgroups of individuals during early preclinical and clinical phases of PsA for analysis in preventive research studiesHarness a range of methods to communicate disease education to at-risk patient populationsDevelop designs for interventional studies to prevent or delay PsA developmentIt is clear that the understanding and treatment of PsA has evolved rapidly over recent years. Despite the rapid advancements outlined in this review, there are still a range of clear unmet medical needs within the PsA community. In particular, the ability to identify disease early and facilitate rapid access to treatment is a key priority for both clinicians and patients.Although there have been a variety of efforts over recent years to address these challenges, progress and implementation has been slow, often accompanied by unrealistic expectations. We believe that the PsA community is now at a precipice: Now is a time to pause, reflect and consolidate ideas and pursue the most appropriate avenues to explore in order to achieve optimum patient care and outcomes.It is likely that over the next decade, our knowledge of disease assessment and prediction of disease in patients will shift rapidly, in conjunction with the application of personalised medicine and biomarkers. Although these tests will undoubtedly help to guide diagnosis and treatment, they still remain a significant challenge to develop and validate from both clinical and financial perspectives.Ultimately, even in the absence of no significant changes in treatment efficacy, it is hoped that we should be at a point where patient outcome and QoL is better simply because the rheumatology community has learnt how to manage and treat patients from a more holistic and integrated approach.


Pulse oximeter apps became of interest to consumers during the COVID-19 pandemic, particularly when traditional over-the-counter pulse oximeter devices were in short supply. Yet, no study to date has examined or scoped the state of privacy policies and notices for the top-rated and most downloaded pulse oximeter apps during COVID-19.The aim of this study was to examine, through a high-level qualitative assessment, the state and nature of privacy policies for the downloaded and top-rated pulse oximeter apps during the COVID-19 pandemic to (1) compare findings against comparable research involving other mobile health  apps and (2) begin discussions on opportunities for future research or investigation.During August-October 2020, privacy policies were reviewed for pulse oximeter apps that had either at least 500 downloads (Google Play Store apps only) or a three out of five-star rating (Apple Store apps only). In addition to determining if the apps had an accessible privacy policy, other key privacy policy–related details that were extracted included, but were not limited to, app developer location (country); whether the app was free or required paid use/subscription; whether an ads disclosure was provided on the app’s site; the scope of personal data collected; proportionality, fundamental rights, and data protection and privacy issues; and privacy safeguards.Six pulse oximeter apps met the inclusion criteria and only 33% (n=2) of the six apps had an accessible privacy policy that was specific to the pulse oximeter app feature . Variation was found in both the regulatory nature and data privacy protections offered by pulse oximeter apps, with notable privacy protection limitations and gaps, although each app provided at least some information about the scope of personal data collected upon installing the app.Pulse oximeter app developers should invest in offering stronger privacy protections for their app users, and should provide more accessible and transparent privacy policies. This is a necessary first step to ensure that the data privacy of mHealth consumers is not exploited during public health emergency situations such as the COVID-19 pandemic, where over-the-counter personal health monitoring devices could be in short supply and patients and consumers may, as a result, turn to mHealth apps to fill such supply gaps. Future research considerations and recommendations are also suggested for mHealth technology and privacy researchers who are interested in examining privacy implications associated with the use of pulse oximeter apps during and after the COVID-19 pandemic. Symptom and health behavior tracking applications or smartphone apps continue to grow in popularity along with government interest and oversight over the privacy practices of such apps . NotablyPulse oximeter apps became of interest to consumers during the COVID-19 pandemic, particularly when traditional over-the-counter pulse oximeter devices were in short supply, as consumers sought to personally monitor themselves for hallmark symptoms of SARS-CoV-2 infection  ,17. TradConsumer Reports recently outlined the pros and cons of using pulse oximeter apps, noting a specific app that is available on smart Android phones, called the Pulse Oximeter-Heart Rate Oxygen Monitor App, developed by digiDoc Technologies. This app is meant to be used only for athletic or fitness purposes and not for medical purposes given its technical performance limitations . HoweverTraditional, over-the-counter pulse oximeters became in short supply during the pandemic amid supply chain shortages. Yet, no study has been published to date broadly examining the privacy policies of pulse oximeter apps at the height of the broad societal impact of the COVID-19 pandemic . Specifically, the literature offers no high-level qualitative assessment on the state or nature of privacy policies for the most downloaded and top-rated pulse oximeter apps during this challenging period. Therefore, the aim of this study was to address this gap to compare findings against comparable research involving other mHealth apps, which can begin discussions on how future research can fill important knowledge gaps about the state of privacy practices for pulse oximeter apps during and after the COVID-19 pandemic.In August 2020, the Google Play Store and Apple Store were searched to scope and identify pulse oximeter apps that had either at least 500 downloads (Google Play Store apps only) or a three out of five-star rating (Apple Store apps only). The total number of pulse oximeter apps available on both the Google Play Store and Apple Store was not tallied for purposes of the analysis. Under the direction of the author, two junior analysts reviewed privacy policies for pulse oximetry–specific apps that met the inclusion criteria between August and October 2020.The following information was extracted from policies and statements found on the app developers’ publicly available websites and respective app stores: software purpose; developer location (country); whether the app was free or required paid use/subscription; mobile device access permissions stated on the app’s download site; whether an ads disclosure was provided on the app’s site; scope of personal data collected; how personal data are collected; who can access personal data; why personal data are used; where the data are stored; how long the data are stored; proportionality, fundamental rights, and data protection and privacy issues; privacy safeguards; and whether the privacy policy was accessible via the app store.This specific information was extracted to align with our prior work to examine the extent to which each pulse oximeter app “appropriately and ethically balanced public health and safety with privacy risks and other interferences with civil liberties” during the COVID-19 pandemic .These details were captured and summarized independently by the same two junior analysts and the summary was reviewed by RHS for accuracy and clarity. The finalized summary of findings was not reviewed and verified by the developers of the apps that met the inclusion criteria for further accuracy.Six apps in total met the study-specific inclusion criteria. Three of these six apps connect to or are compatible with an externally associated oximeter device. Among these three, only one provided a statement of FDA approval as a pulse oximeter device (EMAY Bluetooth Pulse Oximeter). The app developer’s headquarter locations were disclosed for all except one of the six apps (OxyCare-[Pulse Oximeter]); apps were developed in Vietnam, Spain, the United States, China, and Canada. Two apps required payment to either download or access certain features within the app (Pulse Oximeter-Beat & Oxygen and Oxxiom).Only two of the apps covered in this review (Pulse Oximeter-Beat & Oxygen and Kenek Edge) had privacy policies that were accessible directly via the app store. The other four apps reviewed  either did not have privacy policies that are accessible directly via the app store or did not have an accessible privacy policy that is specific to the pulse oximeter app. However, one app offered a user guide that contains user privacy guidance (Oxxiom). One app’s privacy policy is specific to the developer’s website versus the pulse oximeter app (EMAY Bluetooth Pulse Oximeter).how personal data are collected, who can access the personal data, why personal data are used, and where and for how long personal data are stored. Half of the apps reviewed  provide an ads disclosure directly on the app download site. Two apps (OxyCare-[Pulse Oximeter] and Oxxiom) did not disclose deidentification commitments within the scope of proportionality, fundamental rights, and data protection and privacy issues. None of the apps’ policies explicitly stated if personal data would be used for research purposes. Only one app’s policy (Oximeter) explicitly stated that personal data are deleted once the app user permanently deletes the account. The five app developers that described who can access personal data in their privacy notices (excluding OxyCare [Pulse Oximeter]) discussed circumstances in which personal data are collected from and used by nonusers . Two of those five apps explicitly describe personal data access/use by law enforcement (Oximeter and Kenek Edge). Data collection and use for four of the apps are explicitly “opt-in”  and one app explicitly recommends disabling cookies as a privacy safeguard for personal data (EMAY Bluetooth Pulse Oximeter).All six apps reviewed provided some information about the scope of personal data collected upon installing the app. All but one app (OxyCare [Pulse Oximeter]) specifically described The present findings fill an important literature gap regarding the privacy policies of pulse oximeter apps during the COVID-19 pandemic. These findings are largely consistent with trends observed in prior research that has examined the accessibility, structure, and substance of commercial mHealth apps’ privacy policies -15. NameThere are limitations to the present analysis and findings such that the observations reported herein are limited to only the highest rated or most downloaded pulse oximeter apps, which effectively excludes pulse oximeter apps that have lower ratings or are downloaded less frequently. In addition, this analysis did not include technical verification and quality assessment criteria for the apps, such as pulse oximeter app usability. Within these limitations are opportunities for further research to explore these important components as a critical next step to this broad analysis. This study was also cross-sectional in time such that it was intentionally limited to capture the state of pulse oximeter app privacy policies at the height of the COVID-19 pandemic when traditional, over-the-counter pulse oximeters were in short supply. Future research should examine if and the extent to which popular pulse oximeter app privacy policies have been either developed or updated.Several recent studies examined privacy policies and notices for a wide range of mHealth apps, noting trends that are similar to those found in the present analysis of pulse oximeter apps during COVID-19 -15. The The findings of this study showed a relatively low percentage of the most downloaded or top-rated pulse oximeter apps during COVID-19 that provided an accessible privacy policy (33%) compared with the average for the current trend seen in the literature for various mHealth apps (50%). This is problematic given that pulse oximeter apps grew in popularity during the COVID-19 pandemic, leaving pulse oximeter app users with an overall low degree of certainty about the privacy and security of their personal data that could be collected, shared, or processed by or via the apps.Based on the present findings, it is recommended that future privacy research on pulse oximeter apps involve a deeper comparative analysis that would investigate the effectiveness of available privacy policies and/or offer a more technical analysis of privacy and security implications. Future work might also involve a systematic review, meta-analysis, or meta-synthesis of mHealth apps to more robustly capture and compare the state and substance of privacy policies and notices for mHealth apps, including pulse oximeter apps. Moreover, given that (1) certain pulse oximeter app user data could be considered as sensitive data under the EU General Data Protection Regulation (GDPR), and (2) each of these apps could function within the European Union and must therefore comply with the EU GDPR, future work should involve a robust risk assessment of pulse oximeter app and other mHealth app privacy policies against specific articles within the EU GDPR, most notably articles focused on user informed consent, data minimization, legal basis or grounds for data collection, data subjects’ rights, and consequential areas . Lastly,It is clear from the present review and related literature that mHealth apps, including pulse oximeter apps, hold vast opportunities—and perhaps necessity during and after the COVID-19 pandemic—to make their privacy policies more robust and aligned with these current privacy best practices and regulatory requirements. As the practice of medicine becomes increasingly digitized, offering consumers greater options to self-engage in health monitoring and data reporting using personal smartphones, the privacy and security of person-generated health data and traditional health become tantamount. Robust mHealth app consumer or user privacy protections, including, but not limited to, having an accessible and transparent privacy policy, are therefore needed to ensure that the data privacy of mHealth consumers cannot become exploited during public health emergency situations such as the COVID-19 pandemic, if patients and consumers feel compelled to purchase and download mHealth apps in response to short supplies of more traditional, over-the-counter personal health monitoring devices.


Cerebral palsy is a neurological and motor condition characterised by muscle balance and posture impairments. Bruxism and malocclusion were frequently observed in patients with cerebral palsy, in contrast to other oral anomalies. The report outlines how severe awake bruxism is managed in a 16-year-old Korean boy who has nonverbal spastic cerebral palsy and global developmental delay. The treatment protocol involved the fabrication of soft occlusal splints of three and four millimetres in thickness, followed by the placement of stainless-steel crowns on all first permanent molars whilst video recording and a bruxism diary was kept. Fixed restorations demonstrate increased endurance in withstanding bruxism force in persons who are dependent on their caretaker. Cerebral palsy (CP) is a neurological disorder characterised by disturbances in muscular control that occur during pregnancy, perinatal life, or postnatal life . The SurWhen the masticatory muscles are harmed, oral health may be compromised as a result of altered orofacial structure, the development of parafunctional behaviours, nutritional problems, and difficulties with oral hygiene care . IndividBruxism is an affliction of a repetitive jaw-muscle activity characterised by tooth clenching or grinding and mandible bracing or thrusting. Bruxism manifests itself in two distinct circadian patterns: during sleep (referred to as sleep bruxism) or during wakefulness (referred to as awake bruxism) . This reAdditionally, dental attrition/erosion, a possible consequence of spasticity/bruxism, is significantly greater in subjects with CP than in age-matched controls . ReducedA sixteen-year-old Korean boy presented to the Special Care Dentistry Clinic (for children), with spastic cerebral palsy (type quadriplegia) and global developmental delay diagnosed at the age of three months. He arrived with his mother in a wheelchair and was nonverbal. The mother concerned of his continuous grinding and clenching behaviours especially when he is stressful, which causing attrition and wear tooth facets generally on his dentition and generalised staining on the permanent tooth. The anamnesis reveals that the pregnancy and delivery were both normal, and he was born at full term. There was no family history of cerebral palsy or other hereditary disorders.He had previously experienced multiple convulsive crises triggered by a high fever and flashing lights during his five years of life and was previously prescribed with an anticonvulsant medication (Carbamazepine) only during that period. He is closely monitored by a multidisciplinary team comprised of a paediatrician, physiotherapist, psychologist, and neurologist. Physical examination revealed a weight of 47 kilogrammes and a height of 160 centimetres. He had a combination of movement impairments caused by abnormal reflexes, limb and trunk rigidity, abnormal posture, involuntary movements, and unsteady walking, which necessitated his reliance on a wheelchair for mobility. On a dietary note, he ate mostly semiblended or pureed foods.Extraoral palpation reveals hypertrophy of the masseter muscle on a class II skeletal pattern. Facial and hypoglossal nerve dysfunction were apparent, which exacerbates salivary drooling symptoms and poor in swallowing . The intThe treatment management started with a 3 mm thick oral protective appliance  fabrication. Impressions with alginate material were taken using a passive immobilisation technique. The splint issued within 2 weeks, with reassurance on the importance of proper oral hygiene. Unfortunately, patient returned within a month with a fractured split. Henceforth, a millimetre thicker (4 mm) splint is fabricated. Two splints were provided for daytime  and anotThe patient was followed up on a regular basis to remove and clean the appliances, apply topical fluoride, and be reminded to practise good oral hygiene. After a year of observation, the bruxism behaviour decreased, but the intensity is somewhat unchanged. It is noticed that the bruxism is more intense during daytime comparing to the nighttime as the daytime splint exhibits more wear off surfaces. As a result, a decision was made to increase the vertical height of the first permanent molars and thus reduce premature contacts. This is to achieve by placing stainless-steel crown (SSC) on the permanent molars.Due to his unfavourable behaviour, the procedures were scheduled under general anaesthesia (GA). To engage the optimal occlusal force, a thorough occlusal analysis was performed prior in the dental office and repeated under the influence of GA. The distal cusps of the second permanent molars are submerged; thus, the crown is placed only on the first permanent molars. The crowded lower anterior segment, which contributed to the premature contact, was relieved by extracting both lower right and left first permanent premolars that were buccally displaced. Additionally, the tooth appears to complicate oral hygiene measures, justifying its extraction. The incisal third of the fusion tooth's indentation was restored using composite resin as a preventive resin restoration Figures .Postoperatively, the patient was on close monitoring regime; First visit after 1 month, 2nd to 4th visit in every 3 months, followed by 5th visit after 6 month until the condition deemed nonaggressively progressive. Within the first seven-month review visit, the mother reported that his son continued to have bruxism, but only when he was stressed or bored. Intraoral examination revealed that only the palatal cusp of SSC placed on the upper left first permanent molar tooth (26) attritted, exposing the underlying GIC cement Figures . The proVarious modalities of treatment for the management of bruxism have been investigated such as occlusal intervention  Clenching Suppression System”—a small anterior splint). Biofeedback therapy is based on the principle that bruxers can “unlearn” their behaviour when a stimulus makes them aware of their adverse jaw muscle activities (“aversive conditioning”) and pharmacological approach like antidepressant drugs (benzodiazepine or L-dopa) or drugs that have paralytic effect on the muscle through an inhibition of acetylcholine release at the neuromuscular junction (botulinum toxin) which decreases bruxism activity .Bruxism was diagnosed in this patient using noninstrumental methods, where self-reported signs and symptoms by mother as well as clinical evidence of generalised attrition. Despite the low concordance with instrumental assessment, particularly in assessing sleep bruxism , self-reA systematic review by Canales et al.  showed tDental treatment of bruxism with an interocclusal appliance (splint) is based on Glaros and Melamed's local or mechanical theories . This thIn the initial treatment, the patient is prescribed with soft split (silicone type) to cover both maxillary and mandibular teeth, providing a cushion effect during intercuspation and preventing them from contacting one another, thereby preventing damage caused by the grinding habit and reducing masticatory activity . We deciThe consideration for a reversible and conservative treatment is crucial to avoid unnecessary treatment. However, the therapeutic effect appears to be limited to the duration of the device's ability to maintain the bruxism habit's frequency and usually recommended for short-term use because degradation can occur rapidly . Due to According to a previous study, the increased prevalence of Angle's Class II is due to an imbalance between the perioral and intraoral muscles, as evidenced by unusual tongue movement or positioning . BilaterNumerous studies have attempted to establish a link between stress and bruxism. Children who brux experienced a greater level of stress than children who did not brux and bruxers were significantly more likely to experience increased levels of anxiety . VanderaIn conclusion, the occlusal splint is a reversible intervention that acts as a provisional treatment for tooth grinding and tooth wear control. We foresee that by placing stainless-steel crown on first permanent molar once it is fully erupted may be a promising prophylactic measure in patient with cerebral palsy (CP) and global developmental delay (GDD).


There is a need to further investigate how persuasive design principles can change rural health professionals’ behaviors to look after their own health workforce capability. Several theories are used when developing apps to persuade people to change behavior, including the Persuasive System Design Model, consisting of primary task, dialogue, system credibility, and social support categories, and Cialdini’s principles of persuasion. These have not been analyzed yet in the field of health workforce capability.This study aims to determine the persuasive design techniques used in capability building–related apps and to provide recommendations for designing a health workforce app to increase their persuasiveness.A Python script was used to extract a total of 3060 apps from Google Play. Keywords centered around health workforce capability elements. App inclusion criteria were as follows: been updated since 2019, rated by users on average 4 and above, and more than 100,000 downloads. Next, 2 experts reviewed whether 32 persuasive strategies were used in the selected apps, and these were further analyzed by capability categories: competencies and skills, health and personal qualities, values and attitudes, and work organization.In all, 53 mobile apps were systematically reviewed to identify the persuasive design techniques. The most common were surface credibility  and liking (n=48), followed by trustworthiness , reminders , and suggestion . The techniques in the social support domain were the least used across the different apps analyzed for health workforce capability, whereas those in the primary task support domain were used most frequently. The recommendations reflect learnings from our analysis. These findings provided insight into mobile app design principles relevant to apps used in improving health workforce capability.Our review showed that there are many persuasive design techniques that can assist in building health workforce capability. Additionally, several apps are available in the market that can assist in improving health workforce capability. There is, however, a specific lack of digital, real-time support to improve health workforce capability. Social support strategies through using social support persuasive design techniques will need to be integrated more prominently into a health workforce capability app. An app to measure and monitor health workforce capability scores can be used in conjunction with direct real-world person and real-time support to discuss and identify solutions to improve health workforce capability for rural and remote health professionals who are at high risk of burnout or leaving the rural health workforce. Sustainability of the rural health workforce is paramount to meeting the health needs of rural Australia. Significant resources have been dedicated to identifying solutions to problems around recruitment or retention of the rural health workforce . HoweverA 2021 scoping review found that digital solutions can enhance the capability and retention of rural health professionals , the TecOne theory that can be used when developing apps to persuade people to change behavior include the Persuasive System Design Model (PSD-Model) . This moThe question remains whether these design principles can be used when developing a technical solution to assist rural health professionals in maintaining or improving their health workforce capability. There are no clear data on this yet. A 2017 study that has provided some insight was a meta-analysis conducted by Carolan et al  of 21 raGuidance delivered during a shorter period (6-7 weeks)Using secondary modalities to deliver the intervention Elements of persuasive technology Tailoring (57%), self-monitoring (43%), and tunneling (14%) were found to be used as persuasion strategies in studies included in the review and associated with the highest rates of engagement and adherence. Although the meta-analysis provided some useful insights, it did not focus on improving health workforce capability as such. There is a gap in the literature around how persuasive design techniques in digital solutions can change rural health professionals’ behaviors to look after their own health workforce capability.Therefore, this study aimed to determine:The persuasive design techniques used to improve use of capability building–related apps; andRecommendations for incorporating persuasive design techniques in the design of health workforce capability apps.We based our methodology primarily on the study conducted by Oyebode et al . A PythoTwo theories were used in the apps to persuade people to change behavior: the PSD-Model  and CialThe reviewers downloaded the apps on an Android smartphone or emulator and used the apps to determine whether the persuasive design techniques were present in the apps. The reviewers coded independently and then came together to compare scores to ensure interrater reliability. If there was a discrepancy, a discussion was held to reach consensus. The coders double-coded all apps and achieved a κ of .81, indicating very good agreement between the 2 coders.After scoring the 53 apps, the apps were divided in 4 broad workforce capability app categories to determine whether there were differences between the different persuasive design techniques used within each category, including competencies and skills, health and personal qualities, values and attitudes, and work organization. This classification was chosen as it aligned with findings from a qualitative data analysis that had been simultaneously conducted to explore user perspectives on building a health workforce capability app . The classification also mirrors elements of the work ability to explain sustainable employability among general practitioners . CompeteFollowing this classification, data were analyzed as follows:Total number of persuasive design techniques used per domain: primary task support, dialogue support, system credibility support, social support, and Cialdini’s principles of persuasionTotal number and percentage of each persuasive design technique used in each health workforce capability category: competence and skill, health and personal qualities, values and attitudes, and work organizationTotal number of persuasive design techniques used by the persuasive design technique domain across the 4 workforce capability categories developed for this systematic review: competencies and skills, health and personal qualities, values and attitudes, and work organizationFollowing the quantitative analyses of apps, implementation examples of the PSD-Model, consisting of primary task, dialogue, system credibility, and social support categories, and Cialdini’s principles of persuasion are provided.Ethical approval to conduct the feasibility study was received from the Northern NSW Local Health District Human Research Ethics Committee (2020/ETH03020).The following observations were made:reduction and self-monitoring being less evident in competence-related apps when compared to the health apps.Primary task support techniques demonstrated use among all workforce capability categories, with reminders  and competence (n=16) apps, which was similar for trustworthiness , while real-world feel was most frequently observed in health apps   .commitment and consistency played a large role in health and personal quality–related apps (n=9), followed by value- and attitude-related apps (n=5), while reciprocity barely played a role in any workforce capability category  and liking (n=48), followed by trustworthiness , reminders , and suggestion . Social support persuasive design techniques were the least used across the different apps analyzed for health workforce capability, whereas primary task support techniques were the most common, with the exception of simulation. The apparent lower inclusion of persuasive design techniques around social support is a contrast, given that previous qualitative analyses have shown that rural health professionals perceive social and professional isolation to play a major role in building and maintaining their health workforce capability , and also provide multiple suggestions on how this could be achieved in this study. Examples given were related to online communities of practices, interprofessional learning , and telehealth improving trust between different disciplines, but also around having an online career coach (normative influence) and demonstrating online effectiveness of team performance and peer recognition, for example, by showcasing good news stories in health workforce capability. This study was based on the analyses by Oyebode et al [0.6% and Across health workforce capability domains, we found that health apps include the most persuasive techniques, as do the apps related to values and attitudes. Interestingly, the apps related to work organization have the least persuasive techniques, even though work organization plays a large role in maintaining or building health workforce capability . For exaIt appears that health apps include a wide array of persuasive techniques, and thus, building a health workforce capability app could learn from the design of capability-related health aps. It should be kept in mind, however, that Oyebode et al  did not Khakurel et al  conducteContent filtering and personalized interventions that match users’ needs have been demonstrated to improve persuasion power , such asWe propose to use a strengths-based approach to improving rural health professionals’ capability and include persuasive design techniques in digital solutions. For example, future applications can measure the health professional’s vitality or health workforce capability scores at different times throughout the day by asking them to rate their capability at random times or a set time throughout the week. Alternatively, some health professionals may be willing to use a hybrid model by augmenting self-ratings with wearable technology, such as vital signs or step counts. In either case, the health professional can view graphs or trends and analyses showing self-rated health workforce capability levels over time and time of day and display simple statistics, such as minimum, maximum, and average scores. This would reflect the persuasive design technique monitoring. Moving forward, the data can potentially also be used to predict future health workforce capability and recommend specific behavioral change interventions for the health professional to allow for tunneling and reduction. Furthermore, if the health workforce capability score falls, a reminder could pop up for the health professional to take appropriate action. This could include contacting a trusted organization or coach  to discuss the health workforce capabilities that they feel are hindering their current capability and identify solutions to increase their capability. It could also involve the health professional doing some exercise or other activity that helps them with their well-being and feelings of capability. Other simple persuasive design techniques, such as limited ads, will increase system credibility support through increased surface credibility. Given that health workforce capability is determined by the interplay of a complex array of factors   guidelines that may be important for health workforce capability.It should be considered that the numbers of apps analyzed was relatively small and is therefore only an exploratory investigation of the persuasive design principles by the health workforce capability domain. Nonetheless, the strength lies in the combination of looking at the persuasive design techniques used and in relation to their health workforce capability needs.A further limitation of the study is that it was beyond the scope to draw conclusions about the impact the number of persuasive techniques included has on app effectiveness. Further research is needed to explore this in relation to health workforce capability apps.There are many persuasive design techniques that can assist in building capability. Commonly used techniques are surface credibility, liking, trustworthiness, reminders, and suggestion, while less common are social support persuasive design techniques. Additionally, several apps are available in the market that can assist in improving health workforce capability. There is, however, a specific lack of digital, real-time support to improve health workforce capability. Social support strategies through using social support persuasive design techniques will need to be integrated more prominently into a health workforce capability app. An application to measure and monitor health workforce capability scores can be used in conjunction with direct real-world person and real-time support to discuss and identify solutions to improve health workforce capability for rural and remote health professionals who are at high risk of burnout or leaving the rural health workforce.


Real estate price growth affects credit risk for several reasons: it provides input for economic forecasts as it’s closely tied to economic growth; when used as collateral by banks, rising real estate prices may decrease both expected and actual losses; and banks may become less risk averse in lending practices in the presence of rising property prices. Therefore, we analyze these effects on loan portfolios’ estimated and realized risks on a local level. Using data of 390 German savings banks, however, we find that real estate prices have little or no impact on savings banks’ credit portfolio risk or risk precautions. Real estate markets and investments in real estate have gained increased attention in the aftermath of the financial crisis 2007–2008. Among other reasons, the steady lowering of interest rates has made real estate investments increasingly attractive, as they are not only highly leveraged but are also frequently considered safe investments. This has led to increased real estate prices in Germany, in a few cities in particular  Fourth, expected losses are not only based on current information, but also on expectations regarding real estate price growth. Real estate prices are publicly observable, which is not the case for other local indicators of economic performance such as GDP or figures on unemployment. Therefore, banks might base their expectations on future economic and real estate price growth on current and past property prices. Suspecting economic growth, banks might be willing to assign risky loans as they expect borrowers’ solvency to increase on average. If banks expect continued real estate price growth, their expected losses from collateralized losses will decrease. Risky lending, therefore, might increase, potentially creating a large gap between ex post and ex ante risk measures.As Gerlach and Peng  point ouAdditionally, banks’ own real estate assets increase in value and charge-offs of loans decrease with increasing property prices  using time-series techniques. Yet, real estate prices are highly heterogeneous between regions, hence aggregating loan and real estate data on a national level could miss a number of insights. Investigating data from a cross-section of spatial entities could provide additional understanding of the market power of banks, bank-specific loan growth in preceding periods and dependency on local economic development along with house price growth. Stable property price growth has special relevance, as non-sustainable price increases due to deviations from fundamental values can threaten banks’ solvency if their estimation of expected losses is based on current market prices that could be corrected in the future when loans are due. As a consequence, otherwise risky loans have similar expected payments as safe loans, such that loan loss provisions can hardly be correctly determined.The impact of a strong correction of house prices can be significant for the German financial sector. According to Siemsen and Vilsmeier , a drop H2: If local house price increases are not fundamentally driven, savings banks will decrease their lending.To detect some exuberance of real estate prices that might threaten financial stability, the deviation from real estates’ fundamental value is often considered an appropriate measure, as opposed to observed prices  capture the realized risk of a loan portfolio, i.e. ex post risk  for loans are willing to grant loans to borrowers with higher probabilities of default. Banks will continue lending to risky borrowers as long as the annual increase in the overall default probability is less than the expected annual growth of collateral value. This tendency may be exacerbated when relying excessively on collateral as opposed to screening; the deteriorating survival probabilities of loans cannot be observed directly, while properties can be appraised on an ongoing basis. Given the potential for unanticipated losses (see section 2.2), engaging in riskier lending behavior when relying on estimates of future collateral values may have considerable impact on banks.Therefore, on average, a lower ex post risk than suggested by ex ante risk measures occurs if banks have not anticipated the actual positive real estate price growth. When real estate price growth is weaker than expected, the ex post risk will be higher than suggested by the ex ante risk. In both scenarios, the gap between the two measures widens with recent real estate price growth.H5: Higher recent real estate price growth weakens banks’ risk forecasting ability.We consider this gap between loan risk provisions and realized loan risks as a potential scenario for German savings banks. Legal limitations on their business activities and their embeddedness in local economies may lead to overconfidence in forecasting local real estate prices. As political impacts concerning property price and economic growth may reinforce local forecasting  grew by almost 24% from the beginning of 2011 to the end of 2017, leading to a loan volume toward non-MFIs of 951 billion Euros (Data: Deutsche Bundesbank). Loans toward non-MFIs originated by savings banks constituted about 24% of all loans originated in Germany toward non-MFIs by the end of 2018, starting from 19% during the onset of the financial crisis of 2007/2008 (Data: Deutsche Bundesbank). This underlines the high relevance of savings banks within the German financial system. Aside from being highly relevant in Germany, savings banks are a commonly used representative for locally based banks: The focus of their business is deposit-lending; investment banking activities play a negligible role for most savings banks. This strong similarity of basic investment policies is an additional advantage for the analysis, as there should not be systematic variations of risk-taking . Because these banks are particularly sensitive to local economic variables , similar to Olszak et al. (CIRit) to take this into account. We used net interest margins (NIMit) to account for banks’ ability to generate earnings by assigning new loans and their general profitability  based on the procedure described in Berger et al.   were used as the measure of ex-ante risk to capture how observed credit risk was priced before actual losses occurred. Ex post risk was gauged using the banks’ impaired loans, divided by gross customer loans (impairedit). This wider definition of ex post risk captures most of the credit that belongs to problem loans in the spirit of Salas and Saurina . Note that price-to-rent-ratios not only capture potential deviance from fundamental values, but also future expectations considering real estate prices. Price-to-rent-ratios therefore serve as an observation of local market expectations whereas past price developments are input data for individual expectations. Thus, PRRit captured the effects of the incentive channel .We used three different measures for real estate price growth: Two of them were growth of house prices within counties, matched with savings banks’ business areas  real estate price growth in order to identify correlations (Gerlach and Peng The results indicate that the major drivers of loan growth were losses and impaired loans of the previous period (i.e. recently made experiences in lending), monitoring efforts, the relevance of lending for the bank’s business, and branch growth. None of the real estate price growth variables, nor unemployment growth as a proxy for regional economic development, were statistically significant in any of the estimations.The results disprove the first hypothesis on a local short term (yearly) level. We suspect that savings banks’ reactions to real estate prices were not notable on an overall loan volume level, which could be due to a rather inelastic loan supply. A positive correlation on an aggregate level as graphically suggested by Fig. The coefficients on price-to-rent-ratio were not significant and changed signs, indicating that market expectations on real estate price growth did not have an impact on loan volumes. We also checked whether the reverse direction of causality would apply to the data and estimated the equation using loan growth as explanatory and house price growth and price-to-rent-ratio as dependent variables (including their lags as right hand side variables). This neither produced significant coefficients nor superior overall results. As loan volume is only available for savings banks, not for the whole county, results of this estimation could be biased.For testing hypothesis two, the change of loan growth and deviance of prices from the fundamental value, we conducted regressions with the same control variables using price-to-rent-ratio growth, squared price-to-rent-ratios, a dummy, if the current and lagged price-to-rent-ratio exceeds the yearly averaged ratio by more than 10 %, and interaction terms with this lagged dummy variable and house price growth Table . None ofLTAit). Yet, as savings banks are supported publicly and are not excessively large, those problems are not expected to be especially relevant for the estimation.Ex ante risk cannot be determined unambiguously, as higher loan loss provisions can either indicate higher expected loan losses or lower underwriting quality  indicate that banks reduced their loan loss provisioning (i.e. ex ante risk) in the face of increasing property prices, the effect was not robust. As can be seen from estimation (8), the coefficient of unemployment growth was stronger in terms of statistical significance. Local house price growth may reflect some degree of overall local economic growth effects, which is supported by the insignificance of condo price growth.The negative coefficient of the price-to-rent-ratio, indicating lower ex ante risk, was small in economic significance, and the changing sign for the coefficient of the preceding year indicated weak robustness. We will therefore perform a closer analysis of the effects of deviations of real estate prices from the fundamental value in the latter sections.Additional non-dynamic panel system GMM estimations using impairedit was transformed to Several ex post risk measures have been used in the literature. Sinkey and Greenawalt  employednd Udell  used loand Udell  who usednd Udell , which e Saurina , the resAs Balasubramanyan et al.  pointed In addition to efficiency, the most obvious finding was the persistence of loan portfolio riskiness, with the lagged dependent variable close to 100%. This variable explained a high share of the variation of the following impaired ratio, rendering at least some of the other lagged variables without individual explanatory power, but rather bundling their effects.The second finding is that there was a robust positive impact of loan growth on loan risk. Riskier borrowers could be the consequence of the bank already having saturated high quality borrower markets and being forced to lend to bad borrowers due to competitive pressure or bank strategy (closely related to winner’s curse effect). This result is especially meaningful, as we did not find robust effects of loan growth on loan loss provisions, hence the realized losses associated with previous loan volume growth seem to be unanticipated. This impression was reinforced by the even higher coefficient of the lagged growth variable, suggesting weaker predictability of loan losses due to a longer time horizon between loan approval and default.We expected banking competition to have a positive impact on NPLs, as in Zhang et al. . This isFinally, current and past house price growth, used as a proxy for expectations on future house price growth, did not appear to influence the ex post risk of savings banks’ loans. Unreported regressions, using eenawalt , confirmeenawalt , who fouex post loan loss reserves used in what follows compares loan loss reserves to realized credit risk, i.e. high/low values indicate bad loan loss reserves policy, which could be due to either speculations on rising values of collateral or to overall economic conditions. We tested how real estate price growth affects savings banks’ estimation of risks and their optimism using LLRIMPit, defined as A number of factors can explain the results with regard to ex post risks. As we found that loan growth did not affect risk provisions but realized losses, special attention should be paid to hypothesis 5. The term As loan loss reserves and impaired loans are affected by different lags of the explanatory variables, we included up to three periods of each variable. Again, we estimated a dynamic panel model, as the two components of the dependent variable were endogenous — loan loss reserves and impaired loans were highly persistent. In order to examine the effects of monitoring without including real estate prices, we estimated parsimoniously instrumented models without considering condo price growth as before, but rather estimating a baseline model without real estate variables.The results in Table Most importantly, the regression shows that local real estate prices did not induce banks to be over-optimistic. Hypothesis 5 thus is rejected. With regard to the previous estimations, this undermines the finding that savings banks’ loan portfolio risk was not determined directly by real estate prices, but rather by economic factors, which in term helped determine real estate growth. In unreported estimations, we found that the effects of population growth in certain places were even stronger than unemployment rate growth.As savings banks are backed by public entities and are exposed to less pressure to achieve high gains in the short run, they might unintentionally be less prone to engage in riskier lending. Furthermore, savings banks have strong links with local real estate markets, providing them with local knowledge and enabling them to observe the risks that stem from real estate related lending.Therefore, besides using price-to-rent-ratios as signal of house price deviations, we calculate fundamental house prices using Pooled-Mean-Group (PMG) estimation, as described by Pesaran et al.  and usedDue to availability, the data for the estimation span from 2005 to 2017. The results are displayed in Table  s. Fig. .Fig. 4QWe estimated the impact of this alternative specification of real estate price developments on loan portfolio risk of savings banks using previously used model specifications. The results are displayed in Table NCOit). The results can be found in Table As additional check of the robustness of the results, we investigate whether the local economy has a direct impact on loan risk or the former affect house prices which then pass these effects on to loan portfolios. Loan risk hence would be impacted by local economy rather than price increases, thus dismissing explanations via collateral. We estimated a panel vector autoregressive model where we used per capita GDP growth within the business area, unemployment rates, population density as indicator of local urbanization, house price growth, deviations from fundamental house prices and loan growth as endogenous variables besides the mentioned loan portfolio risk variables and, used as additional ex post risk indicator, net charge-offs to average gross loans , adopting the procedure described by Sigmund and Ferstl . TherefoWhile impulses of house price growth tend to reduce over the course of time, the effects of GDP growth are much more persistent, although on an economically low level. Furthermore, it becomes evident that house price and GDP growth do not move parallel, but in parts even in the opposite direction. The rather pronounced effect of house price growth in the short run is additional evidence that real estate prices could be used as first indicator when making loan decisions, rather than only reflecting local economic figures, which are the basis of loan decisions. Yet, while the effects of real estate growth decline quickly, GDP as underlying factor has a steadier effect on loan portfolio risk measures.This paper studies the effects of real estate prices on German savings banks’ risk taking in lending. It contributes to the existing literature in several ways: It analyzes the impact of real estate price growth on loan risk, uses a micro-level perspective to do so, and uses a forward-looking metric to reflect market expectations. In contrast to Koetter and Poghosyan , which iOn the other hand, lending to risky borrowers inflates real estate prices, which in turn leads to additional and even riskier lending. Extensive real estate lending, having a higher loan to asset ratio than other lending  I, Art. 181 (1) e))Additionally, due to their geographically-restricted business areas, savings banks are closely connected with their borrowers, allowing them the use of soft information (Berger and Black Future developments in business administration and management might thus be crucial for local banks and their environment: Shifting their techniques from relationship to transaction-based lending could not only decrease costumer relationships and induce banks to engage in higher risks, but also reduce the availability of funding in regions with weaker economic performance. The economic consequences of the ongoing pandemic-induced de-personalization of interaction and business could thus have long lasting effects on underperforming areas and widen interregional economic gaps.