Influence of health literacy on outcomes using telehomecare technology: A systematic review

Abstract

Objective:

To conduct a systematic review of the literature describing the interaction between the use of telehomecare technology and level of health literacy among chronic patients. The aim of the review was both to explore whether and how level of health literacy affects the ability to use telehomecare technology and, additionally, whether and how the use of telehomecare technology influences the level of health literacy.

Design:

Systematic literature review.

Method:

Four relevant studies, reported in five papers, were identified and evaluated according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The studies include a total of 1,120 participants in the telehomecare intervention groups and 617 participants in the control groups. The following data were extracted from the four included studies: author, year, country, number of patients, type of patients, time horizon, health literacy screening tool, nature of the intervention and description of the compared alternatives, for example, usual care.

Results:

The studies report conflicting observations, and a synthesis of their results therefore provides no clear picture of the interaction between health literacy and the use of telehomecare technology.

Conclusion:

Exploring the interaction between health literacy and the use of telehomecare was not a primary objective in any of the four included studies. Further research is needed to provide a better picture of the interaction between health literacy and the use of telehomecare technology.

Keywords

Chronic disease health literacy PRISMA guidelines REALM review telehomecare TOFHLA

Introduction

Since the late 1990s, health literacy has evolved into a vibrant area of research (Baker, 2006), and the healthcare system has become increasingly complex because of changing demographics, shifts in focus, significant advancement in science and technology and so on (Ratzan, 2001). This development encourages patients to play a more active role in the management of their own disease and setting higher requirements to their level of health literacy and self-management (Chiarelli, 2006; Ratzan, 2001).

There is no universally agreed conceptualisation or definition of health literacy despite growing interest in the concept in recent years (Sorensen et al., 2012). The definitions offered by the American Medical Association (AMA) (Parker et al., 1999), the Institute of Medicine (IOM) (Nielsen-Bohlman et al., 2004) and the World Health Organization (WHO) (Nutbeam, 2008) are among those most frequently cited in the existing literature (Sorensen et al., 2012). Although varying slightly in content, these definitions share a focus on the individual’s ability to access, understand, evaluate and use health information to make appropriate health decisions and maintain good health (Sorensen et al., 2012). The concept of health literacy includes multiple levels with different requirements to personal skills in relation to health care – making it a very broad and complex concept. In a widely used approach, Nutbeam (2000) frames the different levels of health literacy as follows:

A functional level of health literacy comprises the basic skills of numeracy, reading and writing that allow an individual to function effectively in a healthcare setting (e.g. by being able to navigate the healthcare system, take the right dose of medication, provide an accurate presentation of symptoms, etc.).

An interactive level of health literacy refers to a more advanced level of literacy, social and cognitive skills that allow an individual the capability to understand and retrieve health information. At this level, individuals are also able to engage actively in a dialogue about their disease and course of treatment with healthcare professionals.

The critical level of health literacy comprises an advanced set of skills that allow the capability to critically analyse health-related information retrieved from the healthcare system or independently, and also the ability to act on this information.

A shared feature of all three levels of health literacy is that basic literacy skills, defined as basic numeracy, reading and writing skills, constitute the foundation of health literacy; it is not possible to understand and critically analyse health-related information without the ability to read and write (Nutbeam, 2000).

Health literacy is essential in the management of chronic diseases in modern healthcare systems that set high requirements to patients’ level of self-management and empowerment. The ability of chronic patients to take care of themselves and their disease should ideally be based on knowledge about their disease and course of treatment to support the capability of self-management and empowerment (Chiarelli, 2006; Ratzan, 2001). Advances in technology offer educational opportunities that allow patients to become more involved in their own course of treatment and health decisions and, as a possible result, help them to become more health literate and more empowered (Ratzan, 2001).

The development of information and communication technologies has created new health communication channels and made health information available on many different types of technological platforms, such as the Internet. This availability of health information does not only require traditional literacy or health literacy skills to understand and evaluate information but also raises the need for other types of literacies. In order to access the health information available on the Internet, an individual needs to know how to operate a computer and similar technologies (tablets, smartphones, etc.) that have access to the Internet – referred to as computer literacy (Norman and Skinner, 2006). An individual also has to know what resources on the Internet to consult in order to find and extract relevant information on a desired topic – referred to as information literacy (Norman and Skinner, 2006). The link between health information and communication technologies and health literacy has been explored prior to this current review. A 2010 study, for example, found that individuals with higher health literacy skills were more likely to use technology in terms of email, use search engines, browse the Internet and search for health information on the Internet (Jensen et al., 2010) – all being skills that require the computer and information literacy mentioned above.

Telehomecare technology is a branch of technology that differs from other health information and communication technologies in that it does not require the ability to search for health information on the Internet and extract relevant information (i.e. it does not require computer and information literacy to operate as other health information and communication technologies). Telehomecare technology includes the use of sensor-based technology to measure a patient’s different vital signs (such as blood pressure, oxygen saturation, weight) and afterwards transmit these measurements to healthcare providers (Glascock, 2013). According to Richard Wootton (2012), one of the main functions of telehomecare is to provide education to patients to enhance their knowledge. On the basis of this statement, it would be interesting to elucidate the interaction between the use of telehomecare technology and the level of health literacy – and to explore the nature of this interaction if it exists.

To the authors’ knowledge, the literature on the use of telehomecare technology and level of health literacy has so far not been systematically reviewed. The aim of the present review is, accordingly, to explore the interaction between telehomecare technology and health literacy. In particular, we seek to examine whether the use of telehomecare technology influences the level of health literacy and also whether the level of health literacy affects the ability to use telehomecare technology.

Methods

A systematic literature search was conducted to identify relevant studies of the interaction between levels of health literacy and the use of telehomecare technology. Our systematic review conformed to the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement (Moher et al., 2009), which consists of a 27-item checklist that will not be reported here in detail.

Inclusion criteria

The studies considered for the present review had to address the concept of telehomecare defined as ‘a system of care delivery based upon the acquisition and use of information obtained by a sensor based technology located in the residence and transmitted to a remote location for dispatch to care provider’ (Glascock, 2013: 33). This definition of telehomecare which includes sensor-based technology and the above-mentioned description of health literacy gave rise to another inclusion criterion: namely, that the telehomecare interventions should include an interactive home-monitoring component that demands an active involvement from the patient to conduct measurements (e.g. measuring blood pressure, weight, lung function and so on, once a week) and also a certain level of understanding of their disease. No requirements were set as to the duration of which these measurements were carried out in the studies up for consideration of inclusion.

The intervention in the studies considered for the present review needed to focus on the level of health literacy among patients and not on the level of health literacy among healthcare professionals. Furthermore, the studies had to access the level of health literacy using the Test of Functional Health Literacy in Adults (TOFHLA) (Parker et al., 1995) or the Rapid Estimate of Adult Literacy in Medicine (REALM) (Davis et al., 1991). The TOFHLA and the REALM are objective, standardised and acknowledged screening tools widely used in the existing literature.

Studies were qualified for inclusion if designed in either of the two ways:

Studies that investigated whether and how the level of health literacy (as measured with a standardised screening tool) influences the benefits of using telehomecare technology among study participants divided into subgroups according to their level of health literacy. The primary outcome was knowledge about health/disease and various clinical outcomes such as mortality, hospitalisations, blood pressure and so on.

Studies that explored whether the use of telehomecare technology influences the level of health literacy over time, with at least two measurements of health literacy (as measured with a standardised screening tool) during the study period; the purpose should be to investigate whether the use of telehomecare technology has the ability to enhance the level of health literacy among patients.

Due to the novelty of the research area, no attempt was made to identify a common outcome from all relevant studies as would otherwise be required for a conventional systematic review.

Exclusion criteria

Studies were excluded if the telehomecare intervention (1) was not defined as described above (thereby excluding all other types of health information and communication technologies), (2) did not comprise an interactive home-monitoring component and (3) was not targeted at adult patients (age <18 years). Studies were also excluded if the level of health literacy (1) was assessed with a subjective self-reporting screening tool (e.g. if patients were asked to evaluate how difficult it is to use the Internet, to find information on the Internet) and (2) was assessed among healthcare professionals rather than patients. Finally, study protocols and pilot studies were excluded.

The studies should preferably take the form of randomised controlled trials (RCTs), but due to the novelty of this topic, no specific requirements were made as to type of study or the number of participants included. The broad range in criteria for the systematic search is due to the novelty of research area. Specific study characteristics in terms of participants, interventions, comparisons, outcomes and study design (PICOS) are shown in Table 1.

Table 1.

PICOS criteria for inclusion and exclusion of studies.

Parameter	Inclusion criteria	Exclusion criteria
Participants/patients in included studies	Both chronic and acute patients ≥18 years	Patients <18 years of age
Intervention	Telehomecare that includes sensor-based technology and an interactive home-monitoring component that demands an active involvement from the patient to conduct measurements of vital signs.	Other types of health information and communication technologies that do not comprise a sensor-based technology that obtain and transmit information to a remote location for dispatch to care provider.
	The studies should include an assessment of ‘health literacy’ measured with an objective standardised, acknowledged screening tool.	Telehomecare that does not include an interactive home-monitoring component.
		Self-reported health literacy assessment.
Comparison	Usual care	None
Outcome	Due to the novelty of the research area, no attempt was made to extract a common outcome from all relevant studies
Study design	• Randomised controlled trials	• Pilot studies
	• Non-randomised controlled trials	• Editorials and opinion pieces
	• Cohort, retrospective or prospective studies.	• Study protocols
	• Cross-sectional studies

PICOS: participants, interventions, comparisons, outcomes and study design.

Literature search

The literature search was conducted using the following electronic databases: PubMed (MEDLINE), Embase, The Cochrane Library (Cochrane Central Register of Controlled Trials), Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO. Databases were searched between 1 January 2000 and 1 May 2014.

The search was based on the following search words: [telemedicine OR telehomecare OR telehealthcare OR telehealth OR telemonitor OR ‘home telehealth’ OR ‘home healthcare’ OR ‘home-monitoring’ OR ‘remote monitoring’] AND [‘health literacy’ OR literacy].

Publication bias is a concern when conducting a systematic literature search, so our systematic database search was supplemented by a secondary search using Google and the Google Scholar search engine. Reference lists in articles selected for inclusion were also scanned to identify further articles relevant for inclusion.

Data extraction

A total of 302 articles were identified to be evaluated based on their titles and abstracts. An overview of the databases searched and the results of the searches are provided in Table 2.

Table 2.

Databases searched and the results of the different searches.

Database	Number of identified articles	Number of articles selected for inclusion
PubMed (MEDLINE)	88	2
Embase	174	3
The Cochrane Library	11	0
CINAHL	27	0
PsycINFO	2	0
Total	302	5

CINAHL: Cumulative Index to Nursing and Allied Health Literature.

All abstracts were read for relevance based on the inclusion and exclusion criteria. On this basis, 269 articles were excluded since they did not meet the inclusion criteria of there being a telehomecare intervention, did not include health literacy, or because the intervention was aimed at healthcare professionals. A total of 33 relevant articles were left for full-text screening and an examination of their reference lists. Of these 33 articles, 28 were excluded since they did not meet the inclusion criteria, the most prominent reason being that they did not measure health literacy. Two of the articles reported results from the same study, but with a different time horizon – 4 weeks and 12 months, respectively, which left four studies reported in five articles for inclusion in this review. The study selection process is illustrated in Figure 1.

Figure 1.

Study selection process.

The following data were extracted from the four included studies: author, year, country, number of patients, type of patients, time horizon, health literacy screening tool, nature of the intervention and description of the compared alternatives, for example, usual care. The four included studies were critically reviewed in line with the 2009 PRISMA statement (Moher et al., 2009).

Results

The results of one study were reported in two different articles, the first article (study 4.a) reporting short-term effects after 4 weeks and the second article (study 4.b) reporting long-term effects after 12 months. As seen in Table 3, three of four studies were carried out in the USA; the last one was conducted in Mexico and Honduras.

Table 3.

Overview of the five articles and various characteristics of the four included studies.

Author, year and country	Number and type of patients	Design and time horizon	Intervention	Health literacy screening tool	Study conclusions
Study 1: DeWalt et al. (2006), in USA	123 patients diagnosed with heart failure: 59 in the intervention group and 64 in the control group.Aged 30–80 years.Objective: A comparison of efficacy of a heart failure self-management programme that included an educational booklet designed for patients with low literacy (written below sixth grade level).	RCT, over 12 months	A heart failure self-management programme with education on self-care emphasising daily weight measurement, diuretic dose self-adjustment, and symptom recognition and response.Scheduled follow-up phone calls (days 3, 7, 14, 21, 28, 56) and monthly during months 3–6).	S-TOFHLA	‘In conclusion, our heart failure self-management programme designed for patients of all literacy levels appears to reduce rates of hospitalisations and death. Patients with low literacy and other vulnerable patients may stand to benefit most from these programmes’.
Study 2: Bosworth et al. (2009), in USA	636 hypertensive patients randomly assigned to four different groups:Usual care (n = 159)Behavioural intervention (n = 160)Home monitoring (n = 158)Home monitoring + behavioural intervention (n = 159)Mean age: 61 ± 12 yearsObjective: A comparison of two different self-management interventions for improving blood pressure among hypertensive patients.	RCT, over 24 months	Behavioural intervention Behavioural self-management intervention delivered by nurse during phone calls (bimonthly).Home monitoring Home monitoring of blood pressure (3 times weekly and mail their logs every 2 months).Participants not divided according to level of health literacy, but 27%–28% were characterised as having low health literacy in each of the four groups.	REALM	‘Combined home blood pressure monitoring and tailored behavioural telephone intervention improved blood pressure control, systolic blood pressure and diastolic blood pressure at 24 months relative to usual care’.No difference reported between patients with low health literacy and those with adequate health literacy.
Study 3: Piette et al. (2012), in Honduras and Mexico	181 hypertensive patients: 89 in the intervention group and 92 in the control group.Mean age: 57.6 ± 0.8 yearsObjective: An evaluation of automated telephone-monitoring and behaviour-change calls plus home blood pressure monitoring among hypertensive patients in Honduras and Mexico. Primary outcome defined as systolic blood pressure. Pre-planned subgroup analysis in terms of patients with low health literacy.	RCT, over 6 weeks	Weekly automated monitoring and behaviour-change calls.Home blood pressure monitoring several times a week.It should be noted that 117 of 181 patients had low literacy in this study.	Health literacy screening questions and S-TOFHLA	‘Among patients with low literacy or significant needs for hypertension-related communication, the intervention led to a clinically significant improvement in systolic blood pressure’.
Study 4.a: Baker et al. (2011), in USA	605 patients diagnosed with heart failure (NYHA class II–IV):; 303 in the intervention group (TTG) and 302 in a brief single-session education control group (BEI).All participants received an initial 40 minutes education sessionMean age: 60.7 ± 13.1 yearsObjective: An investigation of the effect of two different levels of self-care training: a single educational session delivered by a health educator versus a combination of a single educational and a series of follow-up phone calls to reinforce education.It was also examined whether the benefits of the interventions differed by literacy level.	RCT, over 4 weeks	Multisession intensive education and self-care training with specific instructions to guide diuretic self-adjustment.5–8 follow-up phone calls during the first 4 weeks of the trial to reinforce education.Daily weighing to guide self-adjustment.The TTG intervention was designed to overcome factors that can impede behaviour and learning for those with low health literacy.	S-TOFHLA	‘The TTG programme was equally efficacious for patients with inadequate/marginal literacy as for those with adequate literacy. Both subgroups showed improvement in knowledge, self-care behaviours, self-efficacy, and heart failure symptom scores, and the TTG intervention was better than the BEI intervention for both subgroups’.Improvement in HF-related quality of life (HFQOL) in the TTG group. Patients with marginal/inadequate health literacy in the TTG group had a somewhat higher improvement in HFQOL.
Study 4.b: DeWalt et al. (2012), in USA	Same as in study 4.a, as this article is based on the same study.	RCT, over 12 months.Follow-up to study 4.a (Baker et al., 2011).	Multisession intensive education and self-care training with specific instructions to guide diuretic self-adjustment.5–8 follow-up phone calls during the first 4 weeks of the trial to reinforce education.Daily weighing to guide self-adjustment.After the first 4 weeks, the number of follow-up phone calls was reduced to one call every second week and eventually to one monthly call.	S-TOFHLA	‘People with low health literacy appear to benefit more from multisession (TTG) intervention than people with higher health literacy’.Overall, the improvement in HFQOL waned over time. The improvement in HFQOL appeared to be more sustained among patients with higher health literacy, but this was not statistically significant.

RCT: randomised controlled trial; S-TOFHLA: Short-Test of Functional Health Literacy in Adults; REALM: Rapid Estimate of Adult Literacy in Medicine; NYHA: New York Heart Association; TTG: Teach to Goal; BEI: Baroreflex Effectiveness Index; HF: heart failure.

The selected studies included a total of 1,120 participants in the intervention groups and 617 participants in control groups. The number of participants ranged from 123 (DeWalt et al., 2006) to 636 (Bosworth et al., 2009), and all the studies took the form of RCTs. The included studies evaluated quite similar telehomecare interventions, which all included a home-monitoring component in which patients had to measure either blood pressure or weight to guide self-adjustment of diuretic dose. The frequency of measurements varied between the studies from daily to once a week. All four studies also included an educational component: in study 2 (Bosworth et al., 2009), the education was delivered over the phone by a nurse; in study 3 (Piette et al., 2012), education was delivered as automated phone calls giving self-care information; and in studies 1, 4.a and 4.b (Baker et al., 2011; DeWalt et al., 2006, 2012), the educational component consisted of an initial face-to-face educational session with follow-up phone calls during the trial period.

All identified studies investigated whether the level of health literacy affected the benefits of telehomecare technology. Studies 1 and 3 (DeWalt et al., 2006, 2012; Piette et al., 2012) found that their intervention seemed to be most beneficial for patients with a low level of health literacy or for other vulnerable groups. It should be noted that study 1 (DeWalt et al., 2006) included an educational booklet designed for and aimed at patients with low health literacy (written proficiency below sixth grade level). Study 2 (Bosworth et al., 2009) found no difference between patients with low health literacy and those with adequate health literacy in relation to the observed improvement in blood pressure. Reporting both short-term effects (study 4.a) and long-term effects (study 4.b), the last study came to different conclusions. In study 4.a (Baker et al., 2011) reporting the short-term effects, the intervention was seemingly equally efficacious in patients with low health literacy and in those with adequate health literacy, as both subgroups showed improvement in knowledge, self-care behaviours, self-efficacy and heart failure symptom scores. Reporting the long-term effects after 12 months in study 4.b (DeWalt et al., 2012), the authors found that their intervention may hold greater benefits for people with low health literacy compared to those with higher health literacy. Furthermore, the improvement observed in heart failure–related quality of life (HFQOL) observed in study 4.a (Baker et al., 2011) waned over time when assessed again after 12 months in study 4.b (DeWalt et al., 2012).

The risk of bias in each of the four included studies was assessed following the Cochrane Collaboration guidance for assessing risk of bias (Higgins and Green, 2005). Overall, the risk of bias was low in all four studies; a detailed overview of the risk assessment for each of the four studies is shown in Table 4.

Table 4.

Risk of bias in each of the included studies.

Domain	Description	Review authors’ judgement
Allocation sequence	Was the allocation sequence in the included studies performed adequately?	Study 1	Low risk
		Study 2	Low risk
		Study 3	Low risk
		Studies 4.a and 4.b	Low risk
Allocation concealment	Was the allocation of participants in the included studies properly concealed?	Study 1	Low risk
		Study 2	Low risk
		Study 3	Low risk
		Studies 4.a and 4.b	Low risk
Baseline characteristics	Were the baseline characteristics (including level of health literacy) of participants in the included studies similar?	Study 1	Low risk
		Study 2	Low risk
		Study 3	Low risk
		Studies 4.a and 4.b	Low risk
Incomplete outcome data	Were incomplete outcome data of the included studies assessed in a satisfactory manner?	Study 1	Low risk
		Study 2	Low risk
		Study 3	Low risk
		Studies 4.a and 4.b	Low risk
Selective outcome reporting	Were the included studies free of selective outcome reporting?	Study 1	Low risk
		Study 2	Low risk
		Study 3	Low risk
		Studies 4.a and 4.b	Low risk
Other sources of bias	Were the included studies free of other problems (contamination) that could put them at a high risk of bias?	Study 1	Low risk
		Study 2	Low risk
		Study 3	Low risk
		Studies 4.a and 4.b	Low risk

Discussion

Our systematic search for literature exploring the interaction between level of health literacy and use of telehomecare technology identified four studies reported in five articles meeting the inclusion criteria. A synthesis of the results of the four included studies provides no clear picture of the interaction between health literacy and the use of telehomecare because the conclusions conflict: in two studies (DeWalt et al., 2006; Piette et al., 2012), the telehomecare interventions seemed to benefit patients with low health literacy or other vulnerable groups the most, and one study (Bosworth et al., 2009) found improvement in blood pressure to be equally effective in patient groups regardless of their health literacy level. The last study, described in two articles (Baker et al., 2011; DeWalt et al., 2012), reports long-term effects different from those achieved in the short-term: in the short-term, the intervention seemed to afford equal benefits to patients with low and adequate health literacy, but the long-term effects suggest that patients with low health literacy benefit more from the intervention.

This review is based only on four studies, which reflects the fact that research in this area is still in its very early stages of development. It should be noted that all four studies were RCTs (Baker et al., 2011; Bosworth et al., 2009; DeWalt et al., 2006, 2012; Piette et al., 2012) with a low risk of bias (see Table 1). The studies included a large number of participants (range 123–636), and most of the studies had a follow-up of at least 12 months, with only one study reporting results after 6 weeks without follow-up (Piette et al., 2012). Furthermore, a great strength of the four included studies was that the level of health literacy was assessed with the most acknowledged and mostly used tools to measure health literacy in the existing literature: Short-TOFHLA or REALM in the four included studies (Baker et al., 2011; Bosworth et al., 2009; DeWalt et al., 2006, 2012; Piette et al., 2012).

The greatest limitation to the included studies is that they were not designed to determine the impact of health literacy on telehomecare technology utilisation directly. The included studies apply multiple intervention strategies (home-monitoring and different education strategies) making it difficult to differentiate effects that could be ascribed to the use of telehomecare technology from effects that could be ascribed to the educational component or to both parts. It would have required much larger sample sizes to evaluate the significance of each intervention component.

Additionally, it should be noted that assessment of health literacy was a primary outcome measure in none of the four studies. The design of the included studies also made it difficult to establish whether it was the interaction between level of health literacy and use of telehomecare technology that has been investigated, or whether it was the effect of education on the level of health literacy > Future studies should be designed with a clear distinction between the educational component(s) and the use of telehomecare technology.

Strength and limitations to this review

The strength of this review is its specific focus on health literacy measured by objective acknowledged, standardised tools and the interaction between health literacy and telehomecare technology. Clarity in the definition and conceptualisation of telehomecare, combined with clarity and equality in the objective assessment of health literacy, creates a high homogeneity in telehomecare interventions and consistency in assessing health literacy, which is important when comparing and synthesising the results of included studies in terms of their reliability. An additional strength is the quality of the identified studies: all four studies were RCTs with the lowest number of participants being 123.

A serious limitation to this review was the limited number of studies and the involvement of the same author in two of four identified studies. Furthermore, there is no guarantee that all relevant studies were identified through the systematic literature search conducted here; publication bias can be a concern as a number of unpublished studies may exist.

Conclusion

The systematic literature search identified only four studies that explored the interaction between health literacy and the use of telehomecare technology, which indicates that relatively little research has so far been conducted to elucidate the connection between these two concepts. Synthesising the results of the four included studies provides no clear picture of the interaction between health literacy and the use of telehomecare because observations are conflicting. Furthermore, none of the four studies explored the interaction between health literacy and use of telehomecare as its primary objective. Further research is needed to develop a clearer picture of the interaction between health literacy and use of telehomecare. Such studies should preferably have the interaction between health literacy and the use of telehomecare technology as their primary objective, and they should clearly distinguish between education and use of telehomecare technology in their intervention components.

Footnotes

Funding

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

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