a systematic review of ehealth interventions to improve health literacy

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published online 10 June 2014Health Informatics JournalRobin J Jacobs, Jennie Q Lou, Raymond L Ownby and Joshua Caballero

A systematic review of eHealth interventions to improve health literacy

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A systematic review of eHealth interventions to improve health literacy

Robin J Jacobs, Jennie Q Lou, Raymond L Ownby and Joshua CaballeroNova Southeastern University, USA

AbstractImplementation of eHealth is now considered an effective way to address concerns about the health status of health care consumers. The purpose of this study was to review empirically based eHealth intervention strategies designed to improve health literacy among consumers in a variety of settings. A computerized search of 16 databases of abstracts (e.g. Biomedical Reference Collection, Cochrane Central Register of Controlled Trials, Computers & Applied Sciences Complete, Health Technology Assessments, MEDLINE) were explored in a systematic fashion to assess the presence of eHealth applications targeting health literacy. Compared to control interventions, the interventions using technology reported significant outcomes or showed promise for future positive outcomes regarding health literacy in a variety of settings, for different diseases, and with diverse samples. This review has indicated that it is feasible to deliver eHealth interventions specifically designed to improve health literacy skills for people with different health conditions, risk factors, and socioeconomic backgrounds.

Keywordscomputer, eHealth, health literacy, Internet, systematic review

Introduction

Patients with limited health literacy may not have the requisite skills to effectively interact with the health system and engage in appropriate self-care, such as know-how to take their medica-tions and to understand labels and other health information. Literacy for health information is emerging as a key factor related to health status.1,2 There are many definitions of health literacy, but for the purpose of discussing the role of eHealth applications, the working definition of health literacy is the following: “The degree to which individuals have the capacity to obtain,

Corresponding author:Robin J Jacobs, Biomedical Informatics/Preventive Medicine/Public Health/Psychiatry and Behavioral Medicine/International Medicine, College of Osteopathic Medicine, Nova Southeastern University, 3200 S. University Drive, Terry Bldg 1421, Fort Lauderdale, FL 33328, USA.Email: [email protected]

534092 JHI0010.1177/1460458214534092Health Informatics JournalJacobs et al.research-article2014

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2 Health Informatics Journal

process and understand basic health information and services needed to make appropriate health decisions.”3 This definition focuses on individual capability and does imply needed skills.4

Low health literacy has been linked to poorer health status, increased hospitalization rates, and non-adherence to medications across a number of diseases.1,5,6 It has been related to self-reported poor health,7 risk for hospital admission,8,9 reduced participation in cervical cancer screening,10 poor self-management in patients with diabetes,11 and unstable hemoglobin A1C concentrations in patients with diabetes.12 Low levels of health literacy are associated with greater use of health services7,13 and with higher health costs14 in Medicare enrollees. Elderly persons with low health literacy report that they have more chronic health conditions, worse physical functioning, and poorer mental health,15,16 and minority elderly persons with lower health literacy report more chronic health conditions than whites with similar health literacy levels.15,17 Additional studies have linked limited health literacy to medication dosing errors and increased mortality.18

While there is evidence to suggest that low levels of health literacy are associated with inferior health outcomes, increased hospitalization rates, and non-adherence to medications across a num-ber of diseases, relatively few effective interventions have been developed to address low literacy and even less have been developed that target ethnic minority populations prone to lower health literacy rates. The interventions that exist, however, rely primarily on communication and educa-tion alone and have mostly failed to achieve substantial and sustainable behavioral change.19 Increased interest in health literacy has emerged in part due to continuing changes in the delivery of health care services. These changes create new responsibilities for patients and their caregivers, which include finding and evaluating information, self-monitoring of health status, and under-standing financial constraints and obligations. Thus, a person’s health depends more and more on his or her ability and willingness to carry out a complex set of related behaviors. This set of behav-iors is essential for patients who often must make decisions about treatment with complex combi-nations of medications.

The task of obtaining optimal care is likely to be difficult for individuals with low levels of health literacy. As the US health care system becomes more complex, this problem is likely to increase further.20 One possible approach to addressing low health literacy is to create interventions that can be easily understood, are acceptable, easily deployed, cost-effective, and readily accessi-ble on the Internet. Yet few studies have systematically reviewed the current information technol-ogy (IT)-based interventions related to improving health literacy.

eHealth applications

eHealth is the application of information communication technologies across all range of func-tions involved in the practice and delivery of health care.21,22 IT-based interventions used to pro-mote health literacy have the potential for being readily available over the Internet and on handheld devices such as smartphones and tablets. The field of eHealth is promising in that it can support and enable health behavior change and aid in the prevention and management of dis-ease.23 Once created, these interventions can be easily sustained as costs for their continued main-tenance and deployment are relatively low. One study suggested that new advances in multimedia could be used to better disseminate patient education25. Technology-enabled health research and care has emerged in the past decade as a dynamic field that may offer great potential to help pro-duce better outcomes in key risk patients. This alternate strategy for increasing patients’ knowl-edge of pertinent health care related information has been to provide it through computers and mobile devices.



Jacobs et al. 3

Trends in eHealth applications and health literacy

Strategies to promote health literacy at the individual patient level have relied heavily on paper materials such as pamphlets and brochures. Some recommend emphasizing the need for drawing upon communication and social science theories of information behavior, using a range of tradi-tional and novel formats, gaining better understanding of the public’s health information needs, and developing medical informatics solutions for tailoring applications to patients’ needs and abilities.25 However, some studies have shown that the effectiveness and patient satisfaction with web-based health education materials are greater than if presented in a traditional format.26 For individuals who have learned to rely upon oral forms of communication or who have low literacy levels, written information sources may be of little or no use. Current trends indicate eHealth technology will con-tinue to expand. Due to the multiple variables involved with health care, any health literacy applica-tion will need to be multi-faceted, comprehensive, and culturally and linguistically appropriate. As a result, it is important to understand patients’ individual health decision-making abilities.

Regarding technology use, a survey conducted in Harlem27 found that 77 percent of the 646 adult residents aged 18 years and older said they had used a computer and 87 percent reported hav-ing friends or family who use the Internet. This is useful information for understanding diffusion of and normative support for technology use. The survey also found that 68 percent of respondents had one or more computers at home and 57 percent used the Internet at home. For those who did not have a computer at home, 76 percent said they knew where a computer was publicly available. Of the respondents, 60 percent said that the most important problem in accessing the computer is overcrowding. Other problems in access were cost (2%), equipment problems (4%), location or transportation (8%), and hours of operation (13%). Such data show an interest exists in using tech-nology in low-income minority communities.

The Harlem study also revealed that native English speakers are more likely to use the Internet, African-Americans are more likely to be Internet users than Hispanics/Latinos, and Internet users are more likely to have higher educational attainment, be employed, and have higher incomes than those who do not use the Internet. Little is known about the extent to which certain racial/ethnic minority groups have access to, or interest in, using the Internet for health-related activities. More research is needed to gain information about how health consumers from racial/ethnic minority communities use technology and seek health information.

The goal of this article was to review empirically based eHealth intervention strategies designed to improve health literacy among health care consumers. Specifically, this review aimed to (1) identify and summarize types of eHealth applications and technologies being used to improve health literacy; (2) discuss effectiveness of eHealth applications to improve health literacy based on reports of attributes; and (3) assess the gaps in knowledge and make recommendations for future research in eHealth applications to improve health literacy. This literature review also strives to add to the biomedical informatics knowledge base and demonstrates how existing health literacy strategies might be used with various populations.

Rationale for the research question

The challenge facing biomedical informatics researchers is to disseminate knowledge and enrich the perspective of both health practitioners and consumers to ensure the highest quality of care possible. One common, but incorrect, assumption is that all health consumers understand medical and health information related to their illness and are thus able to make informed decisions about their treatment protocols and health care options. In fact, physicians often overestimate patients’ literacy levels.28




Creating eHealth interventions to improve health literacy will aid in extended duration and quality of life for patients. Traditional methods (i.e. pamphlets, talking) may not be as effective as delivering information through alternate venues. In order to promote continued research on the impact of eHealth applications that improve health literacy in patients, it is important to continually and empirically evaluate the research literature to better understand what is known, what remains unknown, and any future trends in the field. To address this gap in knowledge, we sought to iden-tify and review the most current technology-based applications designed to improve health liter-acy. Observations and implications for future study in the area will also be explicated.

Methods

A review of the current state of the science regarding types of eHealth technology for health liter-acy interventions was conducted. We used the US Department of Health and Human Services18 Healthy People 2010 definition of health literacy, “the capacity to obtain, process and understand basic health information and services needed to make appropriate health.” The study selection criteria flowed directly from the review question (i.e. What are the current eHealth interventions to improve health literacy?) and were specified a priori. Interventions had to include at least one eHealth delivery component (e.g. touchscreen computer, handheld electronic device, Internet delivered, and one measure of (or components related to) health literacy to promote positive change in lifestyle behaviors for improved health outcomes). Studies also had to have been completed with outcome reports; interventions not yet implemented were excluded.

Search strategy

Inclusion and exclusion criteria. Inclusion and exclusion criteria were established in advance. Studies were included when their authors (1) were published in scholarly (peer reviewed) journals, (2) discussed eHealth interventions that included at least one health literacy component or measure, (3) evaluated eHealth applications addressing health literacy likely to be accessed by consumers, and (4) provided quantitative and/or qualitative results or information on the effectiveness of the applications.

Identification of studies. A computerized search of 16 databases of scientific abstracts were explored in a systematic fashion to assess the presence of eHealth applications to improve health literacy or conceptually related terms within their taxonomies, to identify refereed journals in which arti-cles explicitly referring to eHealth and health literacy are contained and the topics covered, and to identify published definitions of the concept. Using the initial keyword search “health literacy” AND “health information technology” AND “eHealth” OR “e-Health,” 466 articles were identi-fied from 16 databases: AgeLine, Applied Science & Technology Full Text (H.W. Wilson), Bio-medical Reference Collection: Comprehensive, CINAHL Complete, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Cochrane Methodology Regis-ter, Computers & Applied Sciences Complete, Family & Society Studies Worldwide, General Science Full Text (H.W. Wilson), Health Technology Assessments, International Pharmaceutical Abstracts, MEDLINE, Nursing & Allied Health Collection: Comprehensive, OmniFile Full Text Mega (H.W. Wilson), and Social Sciences Full Text (H.W. Wilson) with limits for English lan-guage, AND published within the past 10 years. Studies that dealt with development or evaluation of psychometric instruments to measure the construct of health literacy itself (e.g. Test of Func-tional Health Literacy in Adults (TOFHLA) and the Rapid Estimate of Adult Literacy in Medicine (REALM)) were excluded.



Jacobs et al. 5

Data extraction

After this broad search was conducted, a Boolean/phrase search using the keywords “health liter-acy” AND “computer” AND “technology” was conducted, yielding 45 citations (duplicate articles were eliminated). Journals associated with eHealth and health literacy (i.e. Journal of the American Medical Informatics, International Journal of Medical Informatics, Patient Education and Counseling, Journal of Medical Internet Research) were searched manually for relevant research. Reference lists from the most pertinent articles were also examined. General Internet searches using combinations of the search terms at the Google search engine were also conducted. After extracting only those studies on eHealth interventions that met the above inclusion, criteria were selected, leaving a total of 12 studies retained for this review (see Figure 1).

Due to differences in study methods and rigor, quality criteria, study population, and topic cho-sen (e.g. specific illness or condition), study results and conclusions on computer-based applica-tions for improving eHealth literacy vary widely. Thus, only overall descriptions of the major types of eHealth application technologies currently being used or tested are reported.

A number of health literacy outcome scales and measures were identified for the review. For functional health literacy, these included the Wide Range Achievement Test (WRAT), REALM, TOFHLA, Health Activity Literacy Scale, Newest Vital Sign, Short Assessment for Spanish

466 studies identified from searches

61 studies identified

45 research studies

16 duplicates excludedstudies identified from

searches

405 studiesexcluded title and

abstractscreening

12 studies reviewed

33 studies excluded atdata extraction

(no identified healthliteracy component)

Figure 1. Flowchart of review.




Speaking Adults, and the disease-specific knowledge assessment, the Diabetes Care Profile. Interventions were assessed to be effective if a statistically significant positive change was reported for health literacy and/or one health risk behavior. Experimental and quasi-experimental studies, descriptive, and controlled and non-controlled before and after studies were included.

Results

In total, 12 intervention studies identified were implemented in hospitals (n = 1), the community (n = 7), or other settings such as outpatient clinics (n = 3) and worksite (n = 1). Studies were from the United States (n = 9), Australia (n = 2), and The Netherlands (n = 1). There were four rand-omized-controlled trials, four before and after studies, two quasi-experimental/non-randomized-controlled trials, one descriptive study, and one beta test (see Table 1). Some studies used standard care to compare against eHealth intervention format (i.e. Gerber et al., Kiropoulos et al., Yager and O’Dea, and Cook et al.) or a no intervention waiting-list control group to compare against their eHealth intervention (i.e. Oenema et al.). The reminder used a “before and after” or descriptive study (see Table 1).

The interventions targeted a variety of health risks, lifestyles, and disease (illness) management: cardiovascular disease risk of individuals with familial hypercholesterolemia; diabetes; colon can-cer; body image and eating disorder risk; dietary practices, stress, physical activity; depression; human immunodeficiency virus; neonatal intensive care issues; hypertension; hemodialysis; and multiple medical issues.

Theoretical underpinnings of the interventions included Transtheoretical Model (TTM), Theory of Planned Behavior, Social Learning Theory, Social Cognitive Theory, Health Belief Model, Information–Motivation–Behavior (IMB) skills model, The Precaution Adoption Process Model (PAPM), Gagne’s Theory of Learning, and the Component Design Theory. Of the 12 interventions, 4 did not specify a theoretical foundation.

The eHealth platforms included personal computers (desktops/laptops), tablets, netbooks, touchscreen computers, and personal digital assistants (PDA) with web-based applications that included multimedia applications such as videos and interactive self-help tools.

General characteristics of the interventions

Computer-based applications were the most common intervention delivery platform; three of those used touch-sensitive screen computers. Interventions of all types had a health literacy component and were associated with significant positive changes in health outcome and/or health literacy scores. The majority of studies compared electronically delivered interventions that measured changes in participant’s health-related behavior. All eHealth intervention types were similarly effective for changes in health behavior activity. Samples were multicultural and ages of partici-pants ranged from 11 years to adults aged 65 years and older. The majority of the interventions (n = 9) were in English only, one was offered in Spanish and English; one was offered in Greek, Italian, and English; and one was offered in Dutch only. Quantitative and/or qualitative reports of user satisfaction were high in all the interventions where satisfaction was evaluated.

Multiple interventions used a mix of modalities for delivering content. For example, one used multiple video segments (on HIV prevention, symptoms, and testing literacy) who otherwise not be reached and examined how context can be optimized for greater effectiveness as measured by cognitive and behavioral outcomes.29 Holubar et al.32 developed a multimedia educational module based on a PowerPoint presentation and included illustrations, custom three-dimensional (3D) animations, photos, text, and narration. Articulate e-learning authoring software was used to export



Jacobs et al. 7

Tab

le 1

. eH

ealth

inte

rven

tions

to

prom

ote

heal

th li

tera

cy.

eHea

lth in

terv

entio

n ty

peT

heor

ySt

udy

desc

ript

ion

Sett

ing

Out

com

es

Com

pute

r-bas

ed

video

s—Ar

onso

n et

al.2

9 —Ed

ucat

e ho

spita

l ED

pat

ient

s ab

out H

IV te

stin

g an

d pr

even

tion

Soci

al C

ogni

tive

The

ory;

In

form

atio

n–Be

havi

or–

Mot

ivat

ion

(IMB)

sk

ills

mod

el

Befo

re-a

nd-a

fter

stu

dy w

ith 2

02 E

D p

atie

nts

in

an u

rban

hos

pita

l cen

ter;

mul

ti-et

hnic

sam

ple

adul

ts a

ged

18 y

ears

and

old

er. T

o in

crea

se

know

ledg

e an

d un

ders

tand

ing

the

impo

rtan

ce

of c

ondo

m u

se, t

he in

terp

reta

tion

of H

IV

labo

rato

ry r

esul

ts a

nd w

heth

er p

eopl

e di

spla

y vi

sibl

e sy

mpt

oms

of H

IV in

fect

ion;

4 m

in t

o co

mpl

ete

pre-

test

inst

rum

ents

, 2 m

in t

o w

atch

th

e vi

deo,

and

2 m

in t

o ta

ke t

he p

ost-

test

.

Hos

pita

l ED

Com

pute

r-ba

sed

vide

os y

ield

ed b

ette

r ou

tcom

es in

incr

ease

d H

IV k

now

ledg

e an

d H

IV t

estin

g co

mpa

red

to t

hose

who

did

no

t vi

ew t

he v

ideo

. (Pe

ople

oft

en d

eclin

e an

HIV

tes

t be

caus

e th

ey fe

ar a

pos

itive

re

sult.

)

Web

-bas

ed c

ompu

ter

mul

timed

ia h

ealth

pr

omot

ion

prog

ram

for

the

wor

kpla

ce—

Coo

k et

al.3

0

Soci

al C

ogni

tive

The

ory

RC

T w

ith 4

19 e

mpl

oyee

s of

a h

uman

res

ourc

es

com

pany

; web

-bas

ed c

ondi

tion

(n =

209

) ve

rsus

co

mpa

riso

n co

nditi

on (

n =

201

) th

at p

rovi

ded

prin

t m

ater

ials

on

the

sam

e to

pics

. All

subj

ects

w

ere

asse

ssed

at

pre-

test

and

pos

t-te

st t

hrou

gh

an o

nlin

e qu

estio

nnai

re c

onta

inin

g m

ultip

le

mea

sure

s of

hea

lth b

ehav

ior

and

attit

udes

.

Wor

kpla

ceT

he w

eb-b

ased

pro

gram

was

mor

e ef

fect

ive

than

pri

nt m

ater

ials

in p

rodu

cing

im

prov

emen

ts in

the

are

as o

f die

t an

d nu

triti

on b

ut w

as n

ot m

ore

effe

ctiv

e in

re

duci

ng s

tres

s or

incr

easi

ng P

A. T

he

web

-bas

ed g

roup

gav

e si

gnifi

cant

ly h

ighe

r ra

tings

to

the

prog

ram

mat

eria

ls t

han

the

prin

t gr

oup

on a

ll he

alth

top

ics

and

in t

heir

ov

eral

l eva

luat

ion.

Com

pute

r m

ultim

edia

ap

plica

tion—

Ger

ber

et a

l.31 —

A lo

w li

tera

cy

diab

etes

edu

catio

n co

mpu

ter

mul

timed

ia

appl

icat

ion

in u

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cl

inic

env

iron

men

t

Gag

ne’s

The

ory

of L

earn

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C

ompo

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D

esig

n T

heor

y

RC

T w

ith 1

83 E

nglis

h- a

nd S

pani

sh-s

peak

ing

adul

t pa

tient

s (a

ged

18+

yea

rs)

with

typ

e 1

or

2 di

abet

es; u

se o

f mul

timed

ia v

ia c

ompu

ter

that

in

clud

ed a

udio

/vid

eo s

eque

nces

to

com

mun

icat

e in

form

atio

n, p

rovi

ded

psyc

holo

gica

l sup

port

, an

d pr

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self-

man

agem

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skill

s w

ithou

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text

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com

plex

nav

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vers

us s

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are

only

.

Out

patie

nt

clin

icIn

terv

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had

incr

ease

d in

pe

rcei

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susc

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es

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for

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with

hig

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liter

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N

o si

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diff

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in c

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A

1C, w

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, kno

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sel

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sel

f-rep

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and

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tinue

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eHea

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n ty

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desc

ript

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Sett

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es

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timed

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ning

m

odul

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olub

ar

et a

l.32 —

A m

ultim

edia

e-

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mod

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to

impr

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colo

n ca

ncer

lit

erac

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at c

an b

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liver

ed in

a v

arie

ty

of fo

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D-

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Befo

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sing

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onve

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sam

ple

of 2

3 ad

ults

, mea

n ag

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77.

2 ye

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recr

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a h

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catio

n fa

ir t

o de

term

ine

colo

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bef

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odul

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odul

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n a

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pre

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lust

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on

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pute

r w

ith a

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ser

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as a

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in t

heir

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. Out

of t

he 1

0 ite

ms,

3 s

how

ed

impr

ovem

ent,

2 di

d no

t ch

ange

, and

5

decr

ease

d in

sco

re. T

he in

terv

entio

n ap

pear

ed s

ucce

ssfu

l in

impr

ovin

g th

e co

mpr

ehen

sion

of s

ever

al s

peci

fic c

once

pts

(lym

phad

enec

tom

y an

d ra

diat

ion

ther

apy)

. H

owev

er, s

ever

al c

once

pts

rem

aine

d po

orly

un

ders

tood

des

pite

edu

catio

nal i

nter

vent

ion

(inva

sive

ness

, mal

igna

nt, a

nd m

etas

tatic

). W

hile

the

maj

ority

of r

espo

nden

ts

pref

erre

d to

lear

n ne

w h

ealth

info

rmat

ion

dire

ctly

from

doc

tors

or

nurs

es, t

hey

wer

e hi

ghly

sat

isfie

d w

ith t

he e

-lear

ning

mod

ule.

Inte

rnet

-bas

ed p

erso

nal

com

pute

r—K

irop

oulo

s et

al.3

3 —M

ultil

ingu

al

depr

essi

on-s

peci

fic

info

rmat

ion

reso

urce

on

dep

ress

ion

liter

acy,

de

pres

sion

stig

ma,

and

de

pres

sive

sym

ptom

s in

Gre

ek-b

orn

and

Ital

ian-

born

imm

igra

nts

to A

ustr

alia

Non

e no

ted

RC

T w

ith 2

02 G

reek

- and

Ital

ian-

born

imm

igra

nts

aged

48–

88 y

ears

ran

dom

ly a

lloca

ted

to a

n on

line

depr

essi

on in

form

atio

n in

terv

entio

n (n

=

110)

or

a de

pres

sion

inte

rvie

w c

ontr

ol g

roup

(n

= 9

2); s

ingl

e-ce

nter

, cro

ss-s

ectio

nal,

para

llel

grou

p, R

CT

(A

ustr

alia

). In

terv

entio

n (M

IDon

line)

w

ebsi

te p

rovi

des

onlin

e m

ultil

ingu

al in

form

atio

n ab

out

depr

essi

on d

esig

ned

for

mid

dle-

to

olde

r-ag

ed c

onsu

mer

s fr

om a

non

–Eng

lish-

spea

king

ba

ckgr

ound

in G

reek

, Ita

lian,

and

Eng

lish;

con

tent

in

corp

orat

es in

form

atio

n, h

ow d

epre

ssio

n is

di

agno

sed,

rel

ated

dis

orde

rs, c

ause

s, t

reat

men

t op

tions

, etc

. The

con

trol

con

sist

ed o

f a s

emi-

stru

ctur

ed in

terv

iew

with

inte

rvie

wer

rel

atin

g to

th

e pa

rtic

ipan

t’s b

elie

fs a

bout

dep

ress

ion.

Com

mun

ity-

base

dT

he p

rim

ary

outc

ome

mea

sure

s w

ere

depr

essi

on li

tera

cy (

depr

essi

on

know

ledg

e), p

erso

nal s

tigm

a (p

erso

nal

stig

ma

tow

ard

peop

le w

ith a

men

tal

illne

ss),

perc

eive

d st

igm

a, a

nd d

epre

ssiv

e sy

mpt

oms.

For

dep

ress

ion

liter

acy,

the

re

was

a s

igni

fican

t di

ffere

nce

betw

een

the

“MID

onlin

e” in

terv

entio

n an

d th

e co

ntro

l gr

oup,

with

tho

se in

the

MID

onlin

e in

terv

entio

n di

spla

ying

hig

her

depr

essi

on

liter

acy

scor

es p

ost-

asse

ssm

ent

and

at t

he

follo

w-u

p as

sess

men

t.

Tab

le 1

. (C

ontin

ued)



Jacobs et al. 9

eHea

lth in

terv

entio

n ty

peT

heor

ySt

udy

desc

ript

ion

Sett

ing

Out

com

es

Touc

h-se

nsiti

ve ta

blet

/pe

rson

al c

ompu

ter—

Nea

fsey

et

al.34

—A

to

uchs

cree

n-en

able

d “P

erso

nal E

duca

tion

Prog

ram

” an

alyz

es

patie

nt-e

nter

ed

info

rmat

ion

and

deliv

ers

inte

ract

ive

educ

atio

nal c

onte

nt

tailo

red

to t

he

repo

rted

beh

avio

rs

of a

dults

with

hy

pert

ensi

on; s

enio

r ho

usin

g, a

nd s

enio

r ce

nter

s

Non

e no

ted

3-m

onth

(fou

r vi

sits)

bet

a te

st o

f 11

fem

ale

part

icip

ants

. Of t

hese

, 10

part

icip

ants

com

plet

ed

all f

our

visit

s. 11

wom

en a

ged

60+

year

s w

ith a

he

alth

lite

racy

sco

re o

f at l

east

44

(six

th g

rade

) an

d w

ho w

ere

taki

ng p

resc

ribed

ant

ihyp

erte

nsiv

e m

edic

atio

n w

ith in

depe

nden

t phy

sical

and

cog

nitiv

e fu

nctio

ning

who

wer

e at

incr

ease

d ris

k of

pot

entia

l ad

vers

e dr

ug in

tera

ctio

ns (P

AD

I) pa

rtic

ipat

ed. T

he

spec

ific

aim

s of

the

beta

test

wer

e fo

r ol

der

adul

t pa

rtic

ipan

ts to

(1) a

chie

ve ta

rget

BP

read

ings

, (2)

in

crea

se k

now

ledg

e/un

ders

tand

ing

of p

oten

tial

drug

inte

ract

ions

aris

ing

from

sel

f-med

icat

ion

prac

tices

, (3)

incr

ease

sel

f-effi

cacy

for

avoi

ding

po

tent

ial d

rug

inte

ract

ions

ste

mm

ing

from

sel

f-m

edic

atio

n pr

actic

es, (

4) r

educ

e se

lf-re

port

ed

adve

rse

beha

vior

s as

soci

ated

with

pot

entia

l dru

g in

tera

ctio

ns, (

5) im

prov

e m

edic

atio

n ad

here

nce,

(6

) dem

onst

rate

sat

isfac

tion

with

the

APR

N

prov

ider

rel

atio

nshi

p, a

nd (7

) dem

onst

rate

sa

tisfa

ctio

n us

ing

the

PEP-

NG

.

Com

mun

ity-

base

dFi

ndin

gs fr

om t

he b

eta

test

sug

gest

tha

t ol

der

adul

t us

er s

atis

fact

ion

was

hig

h. B

P de

clin

ed o

ver

the

four

vis

its fo

r 82

% o

f th

e pa

rtic

ipan

ts. T

he P

erso

nal E

duca

tion

Prog

ram

had

a la

rge

effe

ct s

ize

in

incr

easi

ng k

now

ledg

e an

d se

lf-ef

ficac

y fo

r av

oidi

ng a

dver

se s

elf-m

edic

atio

n be

havi

ors.

Be

havi

or r

isk

scor

e di

d no

t ch

ange

si

gnifi

cant

ly b

ut w

as s

igni

fican

tly c

orre

late

d w

ith s

ysto

lic B

P on

the

four

th v

isit.

Res

ults

of

thi

s pi

lot

stud

y su

gges

t th

at t

he P

EP-N

G

is a

n ef

fect

ive

syst

em t

o ca

ptur

e pa

tient

se

lf-m

edic

atio

n be

havi

ors

on a

tou

ch-

sens

itive

tab

let

PC in

stea

d of

usi

ng p

enci

l an

d pa

per

met

hods

.

Com

pute

r-med

iate

d in

terv

entio

n—D

i Noi

a et

al.3

5 —C

ompu

ter-

med

iate

d in

terv

entio

n w

ith C

D-R

OM

con

tent

to

incr

ease

frui

t an

d ve

geta

ble

cons

umpt

ion

amon

g ec

onom

ical

ly

disa

dvan

tage

d A

fric

an-

Am

eric

an a

dole

scen

ts

in y

outh

ser

vice

s ag

enci

es

TT

MPr

e-te

st–p

ost-

test

qua

si-e

xper

imen

tal s

tudy

with

50

7 A

fric

an-A

mer

ican

ado

lesc

ents

age

d 11

–14

year

s. A

genc

ies

wer

e as

sign

ed t

o C

IN a

nd

noni

nter

vent

ion

cont

rol s

tudy

arm

s to

exa

min

e th

e ef

ficac

y of

an

inte

rven

tion

for

incr

easi

ng fr

uit

and

vege

tabl

e co

nsum

ptio

n am

ong

econ

omic

ally

di

sadv

anta

ged

Afr

ican

-Am

eric

an a

dole

scen

ts.

Four

30-

min

ses

sion

s of

CD

-RO

M-m

edia

ted

inte

rven

tion

cont

ent.

Com

mun

ity-

base

dA

fter

adju

stm

ent

by c

ovar

iate

s, pr

os (p

<

0.02

5) a

nd fr

uit

and

vege

tabl

e co

nsum

ptio

n (p

< 0

.001

) var

ied

signi

fican

tly w

ith s

tudy

ar

m. Y

outh

s in

the

CIN

arm

had

hig

her

pro

scor

es a

nd fr

uit

and

vege

tabl

e co

nsum

ptio

n th

an c

ontr

ols.

Mor

e yo

uths

in t

he C

IN a

rm

than

in t

he c

ontr

ol a

rm p

rogr

esse

d to

late

r st

ages

and

mai

ntai

ned

reco

mm

ende

d in

take

le

vels

(p <

0.0

5). A

TT

M-b

ased

inte

rven

tion

can

incr

ease

frui

t an

d ve

geta

ble

inta

ke a

nd

effe

ct p

ositi

ve c

hang

es in

TT

M v

aria

bles

re

late

d to

inta

ke a

mon

g ec

onom

ical

ly

disa

dvan

tage

d A

fric

an-A

mer

ican

ado

lesc

ents

.

Tab

le 1

. (C

ontin

ued)

(Con

tinue

d)




eHea

lth in

terv

entio

n ty

peT

heor

ySt

udy

desc

ript

ion

Sett

ing

Out

com

es

Inte

rnet

-del

ivere

d,

com

pute

r-tai

lore

d lif

esty

le in

terv

entio

n w

ith

tailo

red

info

rmat

ion

mod

ules

—O

enem

a et

al.3

6 —W

ebsi

te w

ith

tailo

red

info

rmat

ion

mod

ules

on

satu

rate

d fa

t in

take

, PA

, and

sm

okin

g ce

ssat

ion

in

The

Net

herl

ands

The

Pre

caut

ion

Ado

ptio

n Pr

oces

s M

odel

(P

APM

)

A R

CT

(de

liver

ed in

Dut

ch)

with

an

inte

rven

tion

grou

p an

d a

no in

terv

entio

n w

aitin

g-lis

t co

ntro

l gr

oup;

sel

f-rep

orte

d be

havi

or a

nd d

eter

min

ants

w

ere

asse

ssed

at

base

line

and

1 m

onth

follo

w-

up. E

xpos

ure

to t

he in

terv

entio

n w

as m

onito

red

thro

ugh

serv

er r

egis

trat

ions

; res

pond

ents

wer

e 21

59 D

utch

adu

lts a

ged

30 y

ears

or

over

with

ri

sk b

ehav

ior;

108

0 in

the

inte

rven

tion

arm

and

10

79 in

the

con

trol

arm

. Out

com

e m

easu

res

wer

e sa

tura

ted

fat

inta

ke, c

ompl

ianc

e w

ith t

he

PA g

uide

line

and

smok

ing

stat

us b

ased

on

self-

repo

rted

beh

avio

r, a

s w

ell a

s se

lect

ed b

ehav

iora

l de

term

inan

ts, t

hat

is, s

elf-r

ated

beh

avio

r an

d in

tent

ion

to c

hang

e sa

tura

ted

fat

inta

ke a

nd P

A,

and

stag

es o

f cha

nge

tow

ard

smok

ing

cess

atio

n.

Com

mun

ity-

base

dT

he In

tern

et-d

eliv

ered

, com

pute

r-ta

ilore

d lif

esty

le in

terv

entio

n w

as e

ffect

ive

in

redu

cing

sel

f-rep

orte

d sa

tura

ted

fat

inta

ke

and

in in

crea

sing

sel

f-rep

orte

d PA

am

ong

part

icip

ants

who

com

plet

ed t

he s

tudy

. No

sign

ifica

nt in

terv

entio

n ef

fect

s w

ere

foun

d fo

r se

lf-re

port

ed s

mok

ing

stat

us.

Elec

tron

ically

del

ivere

d ap

plica

tion

usin

g to

uchs

cree

n co

mpu

ter—

Ow

nby

et a

l.37 —

Elec

tron

ical

ly d

eliv

ered

in

terv

entio

n th

at

targ

eted

HIV

pat

ient

s’

heal

th li

tera

cy a

s a

way

of i

mpr

ovin

g th

eir

med

icat

ion

adhe

renc

e

IMB

skill

s m

odel

Befo

re-a

nd-a

fter

stu

dy o

f 118

pat

ient

s liv

ing

diag

nose

d w

ith H

IV; e

valu

ated

1 m

onth

be

fore

and

1 m

onth

aft

er t

hey

com

plet

ed t

he

inte

rven

tion.

Ass

esse

d in

terv

entio

n’s

cont

ent

to in

crea

se

HIV

-rel

ated

hea

lth li

tera

cy, u

sabi

lity,

and

ac

cept

abili

ty t

o lik

ely

user

s an

d ef

fect

of t

he

inte

rven

tion

on p

artic

ipan

ts’ i

nfor

mat

ion,

m

otiv

atio

n, a

nd b

ehav

iora

l ski

lls a

s w

ell a

s th

eir

HIV

med

icat

ion

adhe

renc

e.

Com

mun

ity-

base

dR

esul

ts s

how

tha

t al

thou

gh c

hang

es in

ad

here

nce

in t

he e

ntir

e sa

mpl

e on

ly

appr

oach

ed s

tatis

tical

sig

nific

ance

, in

divi

dual

s w

ith a

dher

ence

less

tha

n 95

%

show

ed s

igni

fican

t in

crea

se in

adh

eren

ce

over

tim

e.Pa

rtic

ipan

ts’ s

elf-r

epor

ted

know

ledg

e an

d be

havi

oral

ski

lls in

crea

sed

over

the

cou

rse

of t

he s

tudy

. The

ir c

hang

e in

info

rmat

ion

pred

icte

d th

eir

post

-inte

rven

tion

adhe

renc

e, s

ugge

stin

g a

link

betw

een

the

inte

rven

tion’

s ef

fect

s an

d ou

tcom

es.

Tab

le 1

. (C

ontin

ued)



Jacobs et al. 11

eHea

lth in

terv

entio

n ty

peT

heor

ySt

udy

desc

ript

ion

Sett

ing

Out

com

es

Com

pute

r-del

ivere

d ta

ilore

d in

terv

entio

n—R

awl e

t al

.38—

Com

pute

r-de

liver

ed

tailo

red

inte

rven

tion

to im

prov

e co

lon

canc

er s

cree

ning

kn

owle

dge

and

heal

th

belie

fs o

f Afr

ican

-A

mer

ican

s

Hea

lth B

elie

f M

odel

Befo

re-a

nd-a

fter

stu

dy o

f Afr

ican

-Am

eric

ans

51–

80 y

ears

of a

ge, E

nglis

h-sp

eaki

ng, a

nd c

urre

ntly

no

n-ad

here

nt t

o C

RC

scr

eeni

ng g

uide

lines

(w

ere

due

for

scre

enin

g). C

ompa

red

chan

ges

in C

RC

-rel

ated

kno

wle

dge

and

heal

th b

elie

fs

1 w

eek

post

-inte

rven

tion

deliv

ery

betw

een

patie

nts

who

use

d th

e co

mpu

ter-

deliv

ered

ta

ilore

d in

terv

entio

n an

d th

ose

who

rec

eive

d no

n-ta

ilore

d pr

int

mat

eria

l (an

Am

eric

an C

ance

r So

ciet

y br

ochu

re o

n C

RC

scr

eeni

ng).

Out

patie

nt

clin

icPa

tient

s w

ho r

ecei

ved

the

com

pute

r-de

liver

ed t

ailo

red

inte

rven

tion

had

grea

ter

chan

ges

in C

RC

kno

wle

dge

scor

es,

perc

eive

d C

RC

ris

k sc

ores

, bar

rier

s sc

ores

, and

col

onos

copy

ben

efit

scor

es.

Web

-bas

ed p

ictor

ial

touc

hscr

een

kios

k—T

eolis

39—

The

ki

osk

prov

ides

ph

ysic

ian-

appr

oved

in

form

atio

n at

the

po

int

of c

are,

and

ba

sed

on r

espo

nses

of

the

ir e

xper

ienc

es

with

Med

lineP

lus,

pa

tient

s ha

ve a

bet

ter

unde

rsta

ndin

g of

the

ir

heal

th

Non

e no

ted

Des

crip

tive

stud

y us

ing

a sa

mpl

e of

809

un

insu

red

patie

nts

at a

maj

or u

nive

rsity

’s

hosp

ital’s

inte

rnal

med

icin

e cl

inic

.72

Pri

mar

y di

agno

ses

tuto

rial

s w

ere

crea

ted

for

a pa

ge la

yout

to

incl

ude

12 m

ajor

sub

ject

ca

tego

ries

inco

rpor

atin

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Jacobs et al. 13

the PowerPoint presentation to a Flash-based movie. This multimedia e-learning module (to improve colon cancer literacy) can be delivered in a variety of formats including an interactive CD-ROM, DVD, enhanced booklet, Podcast/iPod movie, or via the Internet. Another intervention used a computer-mediated intervention with CD-ROM content without the need for Internet to affect positive dietary behavior changes among economically disadvantaged African-American adolescents who may not have easy access to the Internet.35 Tailoring the type of delivery modality for different patient groups and subgroups was thought to be more beneficial than a one-size-fits-all approach.

Four of the interventions were not theoretically grounded.32–34,39 Interventions that were theo-retically grounded all used some type of decision-oriented health behavior theory. Due to the diver-sity of the interventions and the scope of this analysis, it is not feasible to comparatively assess whether having a theoretical foundation made a difference in outcomes.

Compared to control interventions (e.g. standard care without technology), the interventions using IT reported significant outcomes in both health literacy and/or at least one lifestyle behavior. These interventions varied in intensity from a onetime 2-min video to 24-h intervention (in 60-min intervals) delivered over 12 weeks. There were significant positive outcomes in increased HIV knowledge and HIV testing;29 fruit and vegetable consumption among adolescents;35 colorectal cancer knowledge scores, perceived risk scores, and colonoscopy benefit scores;38 and healthy body image and reduction in body dissatisfaction, disordered eating, and excessive exercise.40 A web-based pictorial touchscreen kiosk provided physician-approved information at the point of care, and based on responses of their experiences with MedlinePlus®, patients have a better under-standing of their health.39 A total of 72 primary diagnoses tutorials were created for a page layout to include 12 major subject categories incorporating the topics of greatest interests, allowing their patients to watch a tutorial based on their medical history.

Interventions with mixed results

A diabetes education computer multimedia application delivered in an urban clinic environment found intervention groups increased perceived susceptibility to diabetes complications in the inter-vention group, especially among subjects with lower health literacy. Within the intervention group, time spent on the computer was greater for subjects with higher health literacy. However, no sig-nificant differences in change in A1C, weight, blood pressure, knowledge, self-efficacy, or self-reported medical care between intervention and control groups.31

Participants in an intervention with outcome measures of diet, stress, and physical activity reported significantly higher ratings for the web-based program materials than the print program on all health topics and in their overall evaluation. However, the e-intervention was not more effec-tive in reducing stress or increasing physical activity compared to the control intervention.30

A multilingual depression-specific information resource on depression literacy, depression stigma, and depressive symptoms in Greek-born and Italian-born immigrants in Australia showed that for depression literacy, there was a significant difference between the intervention and the control group, with those in the intervention displaying higher depression literacy scores post-assessment and at the follow-up assessment. However, there was no significant difference in stigma or depression levels between the intervention and the control group at pre-assessment, post- assessment, or at the follow-up assessment.33

A multimedia e-learning module to improve colon cancer literacy showed only a modest improvement in overall scores. Using Wilcoxon signed-rank test, this 3 percent improvement was not statistically significant. A total of 11 respondents improved, 7 did worse, and 4 showed no change in their scores. Out of the 10 items, 3 showed improvement, 2 did not change, and 5




decreased in score. The intervention appeared successful in improving the comprehension of several specific concepts (lymphadenectomy and radiation therapy). However, several concepts (i.e. invasiveness, malignant, metastatic) remained poorly understood despite educational intervention.32

Findings from the beta test of a touchscreen “Personal Education Program” that analyzed patient-entered information and delivered interactive educational content tailored to the reported behaviors of adults with hypertension showed blood pressure declined over the four visits for 82 percent of the participants. The Personal Education Program had a large effect size in increasing knowledge and self-efficacy for avoiding adverse self-medication behaviors. However, behavior risk score did not change significantly but was significantly correlated with systolic blood pressure on the fourth visit.34

The Netherlands-based randomized-controlled trial of an Internet-delivered, computer lifestyle intervention using tailored information modules on saturated fat intake, physical activity, and smoking cessation was effective in reducing self-reported saturated fat intake and in increasing self-reported physical activity among participants who completed the study, but no significant intervention effects were found for self-reported smoking status.36

The results from an Internet-delivered computer-based intervention that targeted HIV patients’ health literacy as a way of improving their medication adherence showed that although changes in adherence in the entire sample only approached statistical significance, individuals with adherence less than 95 percent showed significant increases in adherence over time. Participants’ self-reported knowledge and behavioral skills increased over the course of the study. Their change in informa-tion predicted their post-intervention adherence, suggesting a link between the intervention’s effects and outcomes.37

Four of the interventions34,36–38 utilized tailoring techniques. Expert recommendations for health literacy interventions include rejecting a “one-size-fits-all” approach41 and creating interventions that promote participant engagement and retention through interactivity, interesting multimedia elements, and ensure learning through an interactive teach-evaluate-reteach-when-needed algo-rithm.42 Ownby et al.37,43 reported that computer-delivered tailored information intervention focused on promoting HIV-related skills and knowledge was effective in improving knowledge and medication adherence and eliminating race-related knowledge disparities in persons treated for HIV.

Discussion

Overall, compared to control interventions, the interventions using technology reported signifi-cant outcomes or showed promise for future positive outcomes regarding health literacy in a variety of settings, for different diseases, and with diverse samples. Several employed a variety of modalities for delivering content. Interactive media delivered via eHealth interventions and applications provide opportunities for patients to act as engaged users instead of passive receiv-ers of information.44

Five of the interventions yielded mixed results.30,32,34,36 This may be due to the fact that some concepts are more difficult to understand or a lifestyle behavior is more difficult to change. For example, Holubar et al.32 multimedia intervention to promote colon cancer literacy was successful in improving the comprehension of some concepts (lymphadenectomy and radiation therapy), but several concepts remained poorly understood despite educational intervention (i.e. invasiveness, malignant, metastatic). Adjustments may be needed to accommodate different levels of difficulty in more complex concepts. Oenema et al.’s36 Internet-delivered, computer-tailored lifestyle inter-vention was effective in reducing self-reported saturated fat intake and in increasing self-reported



Jacobs et al. 15

physical activity, but no significant intervention effects were found for smoking. This may have more to do with the relatively low effectiveness of nonpharmacologic smoking cessation treat-ments in general.

The likelihood of interventions being effective did not appear to be related to the modality (touchscreen versus traditional computer) or the length/intensity of the intervention. A few studies that evaluated lower intensity interventions (such as the use of the 2-min video on HIV testing and prevention) were effective in changing behavioral outcomes. This finding is significant in that it will influence decisions about benefits versus costs of eHealth interventions to be adopted and sup-ported. Applications that promote health literacy do not necessarily have the need to be extensive and expensive or require huge commitment in the way of training by providers who implement them. However, it is difficult to ascertain whether accessing eHealth interventions alone was suc-cessful or whether some of the improvements may have been, at least partly, due to the wider sources of information available on the Internet.

Considerations for future research

Interventions delivered via technology should provide culturally relevant health information and decision support to consumers with low literacy. Only two interventions31,33 were linguistically and culturally adapted. Two other studies35,38 recruited participants on the basis of racial characteristics (African-Americans). Studies suggest that race and ethnicity have some association with commu-nication processes because of the ways that race can act as a proxy for cultural factors.45 Nonetheless, few studies have explicitly assessed the significance of race, ethnicity, or culture on participants’ interaction with and response to health ITs.

Tailoring content to make eHealth interventions more personally relevant promotes patient engagement and is related to post-intervention behavior change, including among those from minority populations and with low levels of education and computer experience.46–48 Tailoring interventions to enhance their racial and ethnic relevance enhance their effects for blacks49,50 and Hispanics.51 Computer-based algorithms that take a person’s specific goals or needs into account in addition to characteristics such as language, age, gender, ethnicity, reading ability, and health literacy level might prove more efficacious.

Although tailoring and cultural/linguistic adaptation can be effective, it may require substantial effort if the assessment of both individual characteristics and related tailoring is required. This has led researchers to investigate the effectiveness of computer-based culturally appropriate automated tailoring applications since computer-based tailoring can require much less effort and thus be con-siderably more cost-effective. Achieving robust, comparable samples to measure the efficacy of tailored eHealth interventions can be challenging. Methodological complications surface when evaluating the effectiveness of tailored messaging programs because, by definition, participants do not receive exactly the same intervention. More advanced analysis strategies need to be applied in order to adequately address this challenge.

Conclusion

Understanding and measuring patients’ health literacy in relation to behavioral risk factors is an important goal in the prevention, detection, and management of chronic diseases. A concern is the fact that overall health literacy rates are poor and even poorer for individuals from lower socioeco-nomic and/or ethnic minority backgrounds. Implementation of eHealth and health ITs is being considered as an effective alternative in addressing current concerns about the health status and quality and safety of the US health care consumer population. Thus, it is imperative that we




ascertain best practices for delivering health literacy interventions using IT that is accessible and cost-effective. There is also a risk that eHealth and use of new technologies in health care might widen health inequalities. This review has indicated that it is possible to deliver eHealth interven-tions specifically designed to improve health literacy skills for people with different health condi-tions and risk factors. There is also evidence to suggest eHealth interventions may be more effective particularly for individuals with very low literacy. What remains less clear is the extent to which patients will feel comfortable using a computer or handheld electronic device or will have access to interactive eHealth programs using these modalities. It is also likely that understanding how the health care system works in addition to eHealth interventions is an important aspect of health lit-eracy. Before eHealth interventions can be hailed as a behavior change intervention of the future, the effective components and mechanisms need to be identified, rigorously tested, and its cost-effectiveness established in different contexts.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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a systematic review of ehealth interventions to improve health literacy

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