Interaction between functional health literacy and telehomecare: Short-term effects from a randomized trial
Abstract
This study was conducted as part of a randomized, controlled trial, and explored whether the introduction of a Danish telehomecare intervention, referred to as ‘the Telekit’, and its associated educational components affect functional health literacy. The study sample consisted of 60 chronic obstructive pulmonary disease patients in the intervention group who received the Telekit, and 56 in the control group; all participants were collected from the large-scale, randomized TeleCare North trial by consecutive sampling. To avoid recall bias, the design did not include a baseline measurement, comparing instead the post-intervention measurements between the intervention and control groups. First, the comparability of the two groups was determined, and statistically significant differences in their functional health literacy scores were examined using an independent t-test. Furthermore, the associations between functional health literacy and both groups were tested using multiple regression analysis. No statistically significant difference was observed between the intervention and control groups, suggesting that the introduction of the Telekit and its associated educational components has no effect on functional health literacy. However, further research should be conducted using a larger sample.
Introduction
Health literacy is a research area that has received increasing attention over the past decades (Baker, 2006). Yet the existing literature does not provide a consensus definition of health literacy (Sørensen et al., 2012). One of the most cited definitions was developed by the World Health Organization (WHO): “the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health” (Nutbeam, 1986).
Don Nutbeam, a much-respected scientist in the realm of health literacy, divided the concept into three different levels based on the WHO's definition. The first and lowest level is “functional health literacy” (FHL), which includes the basic literacy skills needed to function in healthcare systems. The second, slightly more advanced level, is “interactive health literacy”, wherein people are able to retrieve health information and actively engage in dialogue about health. The third and most advanced level is “critical health literacy”, wherein people are able to critically evaluate health information and act upon it accordingly (Nutbeam, 2000).
The following factors are associated with health literacy in the existing literature: educational attainment, chronic disease, physical activity, and age. People with low health literacy tend to have a lower educational attainment (Kutner et al., 2006; HLS-EU Consortium, 2012), more sedentary lifestyles (Wolf et al., 2007), and a greater risk of chronic diseases. These individuals also tend to be less capable of managing their conditions effectively (Nutbeam, 2000; US Department of Health and Human services). Health literacy is also said to decline with age (Kutner et al., 2006; Berkman et al., 2011), which can make it difficult for older people to keep up with a modern, rapidly-changing society, especially in technological areas.
Telehomecare is a relatively new (technological) area of research under the umbrella of telemedicine, which has evolved over the past decades to meet the demands of 21st century healthcare systems. Telehomecare includes the remote exchange of data between patients and healthcare professionals to enable easy information transfer. For instance, telehomecare is used in the management of patients with chronic conditions (Wootton, 2012). Developments in technology not only change structures and courses of treatments within modern healthcare systems, but also patients' roles by compelling them to play a more active role in the management of their diseases, setting higher requirements for their levels of self-management and empowerment (Ratzan, 2001). Two studies that use self-management and behavior modification (components in the empowerment concept) to support the management of a chronic disease demonstrate an improvement in knowledge of health, self-efficacy, health behavior, and quality of life (Ounnapiruk et al., 2014; Jaipakdee et al., 2015). As the use of telehomecare is intended to support chronic patients in their everyday life and includes elements of empowerment, it could have the potential to produce similar effects. However, patient empowerment is concerned with the ability to conduct health-related actions that ideally should be based on a solid foundation of health literacy, as these actions should be based on sufficient expertise and knowledge. Thus, sufficient health literacy can be considered beneficial for, or a prerequisite to, the use of telehomecare (Ishikawa & Kiuchi, 2010). The use of telehomecare has been shown to enhance patient empowerment among various groups of patients with chronic conditions (Paré et al., 2007); however, whether this is this also true for health literacy is unknown.
Literature review
Before undertaking this study, the authors conducted a systematic review of literature on the relationship between telehomecare interventions and health literacy (Haesum et al., 2016), and four relevant studies were identified. The results of these studies conflicted, so there was no clear picture of how telehomecare interventions affect health literacy. Two studies showed that telehomecare interventions tend to be beneficial for people with low health literacy (DeWalt et al., 2006; Piette et al., 2012). None of the four studies explored the relationship between telehomecare interventions and health literacy as the primary outcome. Furthermore, these telehomecare interventions included educational components, which made it difficult to distinguish between the effects of the actual intervention and effects that can be ascribed to the educational portions. As the relationship between the use of telehomecare interventions and health literacy is almost unexplored, further research is needed. Such studies should clearly distinguish between the telehomecare intervention and the associated educational component(s), and the primary outcome should be the relationship between the telehomecare intervention and health literacy.
Study aim
This study examined whether the level of FHL is affected by the introduction of a telehomecare intervention and its associated educational components.
Methods
This study was conducted as part of doctoral research on the interaction between FHL and telehomecare use, which is part of a large-scale telehomecare project, TeleCare North – a randomized, controlled trial targeting patients diagnosed with chronic obstructive pulmonary disease (COPD). A total of 1225 COPD patients were included in the TeleCare North project, providing a randomized sample of 647 patients in the intervention group and 578 in the control group. Written, informed consent was obtained with enrollment in the trial. The TeleCare North project was presented to the Regional Ethical Committee for Medical Research in the North Denmark Region, which determined that no ethical approval was necessary; it has been registered at clinicaltrials.gov (NCT01984840). Details regarding the randomization process and an outline of the TeleCare North project have been published (Udsen et al., 2014).
Sample and setting
Participants were recruited from the TeleCare North project consecutively following randomization. The total sample size was 116 COPD patients – 60 in the intervention group and 56 in the control group – all residing in the area of Northern Jutland, Denmark. The COPD patients were recruited by telephone by the principal investigator. Upon recruitment, they received an oral explanation of the study, and were informed of their right to withdraw at any time; they were assured that their confidentiality and privacy would be protected at all times during the study. The principal investigator collected the relevant data at the times most convenient for the participants in their own homes. The following clinical parameters were assessed for each COPD patient upon enrollment in the TeleCare North project: weight, height, systolic blood pressure (SBP), pulse, forced vital capacity (FVC), and forced expiration in 1 s (FEV1).
Telehomecare intervention
The 60 COPD patients in the intervention group received a telehomecare solution that included a tablet (Samsung Galaxy Tab2, 10.1; Samsung, Seoul, South Korea) and software developed by Silverbullit, Aarhus, Denmark (http://opentele.silverbullet.dk). The tablet contained general information on the management of COPD and software that automatically provided instructions on how to manage COPD during exacerbations. The tablet could also be used to collect and transmit relevant disease-specific data and to provide information on the current state of the patient's health: weight, oxygen saturation, blood pressure and pulse. A digital blood pressure monitor (UA-767, plus BT-C; Nonin Medical, Plymouth, MN, USA), an attached fingertip pulse oximeter (Nonin, Onyx II% SpO2, Nonin Medical), and a scale (Precision Health Scale, UC-321PBT-C; A & D Medical, Tokyo, Japan) were used to obtain these measurements. The tablet and all related equipment are collectively referred to as the Telekit.
Healthcare personnel (primarily community care nurses) were responsible for patient care and monitoring in the intervention group. COPD patients in the intervention group were instructed in the use of the Telekit by a nurse from their municipality. This initial instruction session lasted approximately 45 min for COPD patients who preferred to receive the Telekit at home, and 75 mins for those who wished to receive the Telekit at a municipal health center (instruction was conducted in groups of 3–4 patients). The nurse demonstrated how to use the tablet and how to obtain the physical measurements and also guided the patients through the tablet manual before allowing them test the tablet on their own. Participants were asked to measure their vital signs on a daily basis during the first two weeks (on both weekdays and weekends) and one-to-two times per week subsequently (specific days were agreed upon and programed into the tablet by the nurse). The nurse also described the monitoring procedure and provided the patients with community nurse contact information. Finally, a 45 min follow-up visit was scheduled 3–4 weeks after the first appointment to ensure appropriate use of the equipment, and to check whether the threshold values of the physical measurements needed adjustment. A study protocol describing the design and intervention details of the TeleCare North project has been published (Udsen et al., 2014).
Data collection
- The principal investigator conducted a face-to-face interview with each COPD patient to collect the following demographic data: age, sex, civil status, and years of education. Information on participation in rehabilitation or exercise programs was also collected. These interviews provided the information (combined with the clinical data collected at enrollment in the TeleCare North trial) required to establish comparability between the intervention and control groups, and were aimed at creating a comfortable setting for the COPD patients and developing a sense of trust.
- Each COPD patient completed the Danish Test of Functional Health Literacy in Adults (TOFHLA), which had been translated and adapted for use in the Danish context prior to this study (Haesum et al., 2015b). The Danish TOFHLA consists of a 17-item numeracy section and a 50-item reading comprehension section, as does the original US TOFHLA (Parker et al., 1995). The numeracy section assesses skills, such as the participant's ability to understand financial assistance, keep a clinical appointment, as well as understand instructions for taking medication. For example, a participant might be asked to read an appointment reminder card or prescription medication instructions and then be asked about what had been read. In the Danish TOFHLA, the test of reading comprehension is conducted as a modified Cloze procedure, in which random words are deleted from a passage (Sadeghi, 2004). In this case, every fifth-to-seventh word is deleted from a health-related passage, and the participant is asked to select the best-fitting word from a list of four words. The total scores for the Danish TOFHLA test are divided into three levels: inadequate (0–59), marginal (60–74), and adequate (75–100), where inadequate and marginal scores are considered low FHL (Parker et al., 1995).
Outline of data analysis
The design of our data analysis can be regarded as a bit unconventional, because it was focused solely on post-intervention measurements of FHL and did not comprise a baseline measurement for comparison within groups. The risk of retest bias is introduced when using the same screening instrument twice within a relatively short period (Streiner et al., 2014); FHL was therefore only measured once in the intervention and control groups, because repeated assessments using the Danish TOFHLA (Haesum et al., 2015b) might improve understanding of the items, thus resulting in higher subsequent FHL scores. Therefore, instead of making a comparison between a baseline measurement (prior to the introduction of the Telekit) and a follow-up measurement (after the introduction of the Telekit) in the two groups, the comparison of FHL was made between the intervention and control groups. The measurement of FHL was obtained approximately 2 months after the introduction of the Telekit and the associated education to reduce the likelihood of experiencing technical problems with the equipment. Furthermore, the challenges associated with the use of the Telekit during the start-up phase (e.g. becoming familiar with the telehomecare equipment, feeling secure using it) are less likely to affect the results.
Data analysis
The basic characteristics and the results of the Danish TOFHLA were entered into SPSS Statistics software version 21 (IBM, Armonk, NY, USA) and STATA version 13 (StataCorp, College Station, TX, USA). The results were described in terms of group means, standard deviations (SD), frequencies, and percentages.
The exploration of the introduction of the Telekit and of its potential effect on the level of FHL was carried out in two steps. The first step assessed the basic characteristics and clinical parameters to determine statistically significant differences between the intervention group and the control group. The differences were assessed based on the following variables: age, sex, civil status, years of education, participation in rehabilitation or exercise programs, and clinical parameters (weight, height, SBP, pulse, FVC, and FEV1). An independent t-test was used to compare differences in the means between the groups for metric data (age, years of education, SBP, FVC, and FEV1), and a χ2-test was used to compare differences between the groups for categorical data (sex, civil status, and participation in rehabilitation or exercise programs). The average FHL scores were then tested for statistically significant differences between the groups using an independent t-test, and this association was also assessed through a multiple regression analysis.
Results
The mean age was 70.1 years (SD: 8.37) in the intervention group and 69.6 years (SD: 9.16) in the control group.
The basic characteristics of the 116 COPD patients by group are shown in Table 1. These characteristics were relatively balanced between the intervention and control groups, including a fairly even distribution of education, averaging 11.2 and 11.6 years, respectively. The majority in both groups was skilled workers, and a relatively small percentage had a higher education. More than half of the COPD patients in both groups had adequate FHL, and the unadjusted mean scores were 71.3 (SD: 17.37) and 71.4 (SD: 20.79) for the intervention and control groups, respectively. The percentage of women was slightly higher in the control group (58.9%) than in the intervention group (45%). The percentage of patients who participated in rehabilitation or exercise programs was higher (44.6%) among COPD patients in the control group than among those in the intervention group (33.3%). Additionally, 36 (60%) reported being married or living with a partner in the intervention group compared with 23 (41.1%) in the control group.
| Intervention group | Control group | |
|---|---|---|
| No. participants | 60 | 56 |
| Age, unadjusted mean (SD) | Mean = 70.1 (8.37) | Mean = 69.6 (9.16) |
| Sex | ||
| Male | 33 (55%) | 23 (41.1%) |
| Female | 27 (45%) | 33 (58.9%) |
| Civil status | ||
| Living alone | 24 (40%) | 33 (58.9%) |
| Married or living with a partner | 36 (60%) | 23 (41.1%) |
| Educational level | ||
| Elementary school | 21 (35%) | 14 (25%) |
| High school | 4 (6.7%) | 1 (1.8%) |
| Higher education | 8 (13.3%) | 10 (17.9%) |
| Skilled | 27 (45%) | 31 (55.4%) |
| Years of education (unadjusted mean, SD) | 11.2 (2.35) | 11.6 (2.44) |
| Clinical parameters, unadjusted mean (SD) | ||
| Systolic blood pressure | 129.7 (16.57) | 135.4 (18.69) |
| Diastolic blood pressure | 75.6 (8.07) | 81.1 (11.97) |
| Pulse | 73.8 (13.32) | 78.4 (13.14) |
| Forced expiration in 1 s | 47.5 (15.47) | 49.9 (18.04) |
| Forced vital capacity | 67.4 (18.37) | 74.4 (18.59) |
| Health literacy level, n (%) | ||
| Inadequate health literacy | 14 (23.3%) | 14 (25%) |
| Marginal health literacy | 12 (20%) | 13 (23.2%) |
| Adequate health literacy | 34 (56.7%) | 29 (51.8%) |
| Health literacy score, unadjusted mean (SD) | 71.3 (17.37) | 71.4 (20.79) |
| Participation in rehabilitation or exercise programs | 20/60 (33.3%) | 25/56 (44.6%) |
- SD, standard deviation.
The basic characteristics and clinical parameters of the intervention and control groups tested for statistically significant differences (P < 0.05) are presented in Table 2. Civil status was the only variable that produced a significant P-value (0.042). None of the remaining demographic characteristics (age, sex, and education) was significant, nor were any of the clinical parameters significant, as all these had P-value above 0.05.
| Variable | P-value | Type of test |
|---|---|---|
| Basic characteristics | ||
| Age | 0.754 | t-test |
| Sex | 0.134 | χ2-test |
| Civil status | 0.042* | χ2-test |
| Years of education | 0.392 | t-test |
| Participation in rehabilitation or exercise programs | 0.436 | χ2-test |
| Clinical parameters | ||
| Weight | 0.502 | t-test |
| Height | 0.437 | t-test |
| Systolic blood pressure | 0.090 | t-test |
| Pulse | 0.086 | t-test |
| Forced expiration in 1 s | 0.488 | t-test |
| Forced vital capacity | 0.085 | t-test |
- * P-value is significant.
The average FHL scores in the intervention and control groups were also tested for statistically significant differences (P < 0.05). The average unadjusted FHL score was 71.3 (SD: 17.37) in the intervention group and 71.4 (20.79) in the control group. The independent t-test of the difference in average FHL scores between the two groups produced a P-value of 0.972.
As shown in Table 3, there was no significant association between the FHL scores of the two groups, as the regression analysis produced a P-value of 0.434. The FHL score was found to be significantly associated with age, years of education, and participation in rehabilitation or exercise programs, which is consistent with the existing literature (Kutner et al., 2006; Wolf et al., 2007).
| Independent variable | Unstandardized coefficients | Standardized coefficient | |||
|---|---|---|---|---|---|
| B | Standard error | β | t | P-value | |
| Group | −2.337 | 2.975 | −0.062 | −0.786 | 0.434 |
| Age | −0.950 | 0.171 | −0.436 | −5.548 | 0.000 |
| Sex | 1.248 | 3.097 | 0.033 | 0.403 | 0.688 |
| Years of education | 2.948 | 0.661 | 0.371 | 4.462 | 0.000 |
| Rehabilitation/exercise program | 3.650 | 1.681 | 0.174 | 2.171 | 0.032 |
- *Dependent Variable: Health Literacy Score
Discussion
The intervention and control groups in this study were very similar; only civil status was significantly different between the two groups. People with a partner are assumed to have a higher level of health literacy than those living alone, because they are likely to obtain help and support in tasks, such as interacting with the healthcare system, decoding health information, and managing their disease (Javadzade et al., 2012; Reisi et al., 2014). In this study, more patients in the intervention group (n = 36, 60%) than in the control group (n = 23, 41.1%) had a partner. The FHL score should therefore be higher in the intervention group than in the control group, because more were living with a partner. However, there was no difference in the FHL score between the groups, which indicates that civil status was not an essential parameter in this study.
The independent t-test produced a P-value of 0.972, so there was no difference in FHL scores between the intervention and control groups. This finding was supported by the results of the multiple regression analysis, which showed no significant association between the FHL score in these groups. The fact that no statistically significant difference was observed between groups in either the independent t-test or the multiple regression analysis indicates that the introduction of the Telekit and its educational components had no effect on FHL.
The literature review identified two studies consistent with our findings. One study explored the effects of home monitoring combined with a tailored behavioral telephone intervention on blood pressure control, and found that the level of health literacy had no effect in this regard (Bosworth et al., 2009). The other study combined daily weighing with multisession education to guide diuretic self-adjustment, and found that the intervention was equally efficacious regardless of the participants' health literacy levels (Baker et al., 2011). The literature review also identified two studies partly contradicting these findings; one study found a heart failure self-management program that included education on self-care with an emphasis on daily weighing to guide diuretic dosing to be most beneficial to patients with low health literacy (DeWalt et al., 2006). In this regard, that study included an educational booklet designed for people with low health literacy. The other study combined home blood pressure monitoring with behavior change calls, and found that the participants with low health literacy experienced significant improvements in SBP (Piette et al., 2012). However, 117 of 181 participants were characterized as having a low level of health literacy in the latter study. It is questionable whether the intervention in the two latter studies produces these beneficial results for people with low health literacy.
Taken together, our results and those in the existing literature suggest that the use of telehomecare interventions do not impact the level of (functional) health literacy. Importantly, the average FHL score in our study was relatively high in both groups at the initiation of the study, which could influence the ability to identify a significant difference.
The observed lack of impact might not be surprising; telehomecare interventions draw on special types of health information and communication technologies, because they require no computer and information literacy. Computer literacy is defined as the ability to operate a computer and similar technologies (e.g. smartphones, tablets) with access to the Internet (Norman & Skinner, 2006), and information literacy is the ability to know which Internet sources to consult for relevant information on a desired topic (Norman & Skinner, 2006). Computer and information literacy are concerned with skills that are related to more general capabilities in health care, whereas telehomecare interventions are concerned with knowledge of the specific disease(s) in question. Therefore, if telehomecare interventions included tasks that were more concerned with computer and information literacy skills, then this might be reflected in the level of (functional) health literacy.
Limitations
A limitation to this study is that the TOFHLA was originally designed for US society, and although this was considered very carefully during the translation and adaptation process, which was conducted in accordance with international guidelines, it is difficult to adjust for the fact that free access to education and health care in Denmark might provide the Danish population with a set of prerequisites for interacting with the healthcare system that differs from that of the US population. These differences should be considered when interpreting results obtained with the Danish TOFHLA. However, health literacy has only recently been introduced as a concept in Scandinavia. No other screening instruments were available at the initiation of this study (Mårtensson & Hensing, 2012), so it was not possible to assess health literacy using an equivalence method.
It would have been beneficial to this study if technical skills and resistance to technology had been assessed for each COPD patient at baseline, as this could have identified important differences between the groups. Different attitudes to new and assistive technology play an important role in the implementation process; this does not apply to the users alone, but also to the key organizational charts involved in the process (Beedholm et al., 2015). Thus, a recommendation for future research in this area is to obtain a baseline assessment of these participant characteristics, primarily in the users of the technology, but assessing it in all crucial organizational charts will be ideal.
Furthermore, the sample size in this study was fairly small, and the relationship between the use of telehomecare interventions and FHL requires further testing on a larger sample.
Conclusion
This study explored if the mere introduction of the Telekit and its educational components affects the level of FHL, and found the relationship to be insignificant. The intervention and control groups were very similar, and no statistically significant differences were observed in basic characteristics or clinical parameters, except civil status, which we argued had no marked effect in this study. A test of the difference in the average FHL score between groups produced a P-value of 0.972, and the association in a multiple regression analysis yielded a P-value of 0.434, which suggests that the introduction of the Telekit and its associated educational components had no effect on FHL.
Acknowledgments
The authors wish to thank the TeleCare North project for establishing contact with the 116 COPD patients enrolled in this study. Furthermore, the authors wish to thank participants, and for finding the time for a home visit by the researcher.
Contributions
Study Design: LH, LE, OH
Data Collection and Analysis: LH, OH
Manuscript Writing: LH, LE, OH
