Relationship Between Health Literacy Scores and Patient Use of the iPET for Patient Education

Relationship Between Health Literacy Scores

and Patient Use of the iPET for Patient Education

Submitted by

Melissa Ann Sorgeloos

A Direct Practice Improvement Project

Presented in Partial Fulfillment of the Requirements for the Degree

Doctor of Nursing Practice

Grand Canyon University

Phoenix, Arizona

May 29, 2019

Abstract

Health literacy (HL) can be used as a predictor of health outcomes. Negative health outcomes associated with lower HL levels include barriers to understanding of education materials presented to patients and diminished participation in self-care healthcare behaviors. Nurses, guided by Orem’s self-care deficit in nursing theory, can work in conjunction with patients to improve communication through HL assessment. The purpose of this quantitative correlational project was to determine to what degree a relationship existed between health literacy scores, measured with the REALM-SF tool, and patient use of the iPET system to view health education modules for telemetry patients at a 225-bed community hospital in the Southwestern United States. The population was comprised of adult patients ranging from ages 18–89 years old. The sample for this project included 21 adults (N=21) within the age range of 18–89 years old who had been admitted or placed on the telemetry unit as either an observation or inpatient status. Results supported the clinical question as patients that used the iPET for education did score higher on HL assessments by 1.03 points. The correlation between HL and use of the iPET was positive and moderate, r(19) = .417, p = .060, which sustained the project purpose. Routine HL assessments at the project site are not part of the nursing workflow. Based on HL levels, findings revealed that patients most apt to benefit from use of the iPET did not actually utilize it. Recommendations stemming from this project promote routine nurse assessment of patient HL scores to assure that education materials are presented to patients based upon patient HL levels.

Keywords: Health literacy, patient engagement, healthcare technology, patient education

Dedication

I dedicate this project to my mother and father, Karen and Kevin Sorgeloos, both of whom have strongly supported all of my educational endeavors throughout my lifetime. From preschool onwards, my parents have instilled the importance of obtaining an education, while challenging and supporting me to reach for the stars academically. It is not without my parents’ love and support that I am in the places I am at today, continually and constantly striving to be the best I can be. As I seek to fulfill my academic dreams, I can only hope my parents realize the impact that their love and support have had on my life. Thank you, Mom and Dad, for planting the seeds and allowing me to flourish.

I also dedicate this project to my wife, Amanda. I would not be at this point of my academic career without her constant love and support. Thank you for believing in me and being there for me—always, every day, and forever.

Acknowledgments

I wish to express my recognition and gratitude to those who have mentored and supported me throughout this journey to obtain my Doctor of Nursing Practice (DNP) Degree. I cannot express fully, in words, my appreciation and thanks to Dr. Frances Patmon, my content expert/committee member for my Direct Practice Improvement project, whose expertise and knowledge has helped me considerably along my journey. I have learned so much from Dr. Patmon and I greatly appreciate her time and supportive energy. A special thank you to Dr. Katherine Kenny for her support, guidance, and collaboration throughout the various stages of my project. Her time and assistance have had a tremendous impact on me during this wonderful learning experience. I would like to thank Dr. Rhonda Johnston, my committee chair, for all of her feedback and positive support throughout my academic journey. A special thanks to Dr. Herschel Knapp, my mentor from the beginning. I would like to thank Dr. Knapp for all of his time, energy, guidance, recommendations, and helpful advice.

I would like to send wishes of gratitude, thanks, and appreciation to my wife, Amanda, for all of her endless love and support. I could not have gotten through this program without her encouragement. Thank you.

Table of Contents

List of Tables

List of Figures

Chapter 1: Introduction to the Project

Background of the Project

Problem Statement

Purpose of the Project

Clinical Question

Advancing Scientific Knowledge

Significance of the Project

Rationale for Methodology

Nature of the Project Design

Definition of Terms

Assumptions, Limitations, Delimitations

Summary and Organization of the Remainder of the Project

Chapter 2: Literature Review

Theoretical Foundations

Review of the Literature

Health literacy

Patient education

HIT

iPET

Summary

Chapter 3: Methodology

Statement of the Problem

Clinical Question

Project Methodology

Project Design

Population and Sample Selection

Instrumentation

Validity

Reliability

Data Collection Procedures

Data Analysis Procedures

Ethical Considerations

Limitations

Summary

Chapter 4: Data Analysis and Results

Descriptive Data

Data Analysis Procedures

Results

Summary

Chapter 5: Summary, Conclusions, and Recommendations

Summary of the Project

Summary of Findings and Conclusion

Implications

Theoretical implications

Practical implications

Future implications

Recommendations

Recommendations for future projects

Recommendations for practice

References

Appendix A. IRB Approval Letter

Appendix B. REALM-SF Scoresheet – Assessor Version

Appendix C. REALM-SF Tool – Patient Version

Appendix D. REALM-SF Use Approval

Appendix E. iPET Guide for Patients

Appendix F. Script for Patient Participation

List of Tables

Table 1. Demographic Variable Means

Table 2. t-test for Health Literacy Scores by iPET Groups

Table 3. Pearson Correlation Matrix of HL Scores and iPET Use

Table 4. Pearson Correlation Between HL Scores and Gender (N=21)

List of Figures

Figure 1. Represented Estimated Age Groups in the Sample by Percentage

Chapter 1:

Introduction to the Project

Health literacy (HL), within the individual, is defined as the maximum ability that a person has to acquire, comprehend, understand, and utilize necessary health information and services to make healthcare decisions that determine the best individual health outcomes (Centers for Disease Control and Prevention [CDC], 2016). Reaching the attainment of adequate HL and health equity are often impeded by a variety of barriers, which can lead to low HL rates and poor patient health outcomes. Wickham and Carbone (2013) identify low HL as a strong predictor for poor health and negative health outcomes when compared to other demographics such as age, income level, education level, employment status, or race. Negative patient outcomes stemming from lower health literacy levels include improper health maintenance, lack of health prevention interventions, decreased success rates in patient self-management care related to chronic illnesses, and lack of an adequate understanding when following medication prescriptions through adherence or proper use (Wickham & Carbone, 2013). HL levels are noted to be an identifiable risk factor for all-cause mortality rates after making adjustments for age, race, gender, income, education, and health status, causing national concern for the health of the nation (Sudore et al., 2006). HL influences patient understanding of health information, therefore emphasizing the importance placed on the methods for disseminating health education and health information.

Health information is currently presented to patients in a manner that is not easily understood or comprehended by the average person (US Department of Health and Human Services, Office of Disease Prevention and Health Promotion [USODPHP], (2010). Approximately 90% of adults have difficulties utilizing health information that is available via many outlets on an everyday basis (USODPHP, 2010). Additionally, 88% of American adults have some limitation surrounding health literacy, and approximately one-third of Americans have difficulty understanding and comprehending routine health-care-management directions such as following prescription or medication instructions for either themselves or for their family members (Loan et al., 2018). Nursing interventions and nurse participation play an integral role in helping to identify the methods to increase patient participation in their care, through patient engagement, especially when seeking to extract the benefits associated with Health Information Technology (HIT) systems (Patmon et al., 2016). Nurses must account for healthcare technologies when developing patient healthcare plans and health interventions.

It is imperative that nurses adapt to emerging healthcare HIT and integrate workflows to include patient involvement in healthcare technologies, in particular, focusing on the areas involving patient education and patient engagement (Huston, 2013). Low literacy can prohibit proper patient understanding and follow through of behaviors when it comes to nursing educational interventions or uses of technology within an acute setting (Wickham & Carbone, 2013). This DPI project examined the correlation between patient health literacy scores and patient use of healthcare technologies such as the Interactive Patient Engagement Technology (iPET) system. It is important, as nurses, to understand the dynamics between patient health literacy scores and forms of education delivery, so as to better understand and select the best methods available to provide health education to patients, based on varying patient health literacy levels. Delivering healthcare education to patients based on their comprehension capability provides patients with the best opportunity to understand the education material being presented. This aligns with patient engagement and patient inclusion in healthcare decisions, which provides patients the chance to achieve and attain the highest level of understanding and comprehension, while nurses promote positive outcomes and affirmative self-care behaviors for all patients.

This chapter reviews the background behind why this project was selected and presents rationale to back the importance in conducting HL level assessment on all patients. The implications surrounding HL, as it relates to patient use of technology to view health education modules, is presented within the clinical question that guided this project. Supporting information, which emphasizes the significance of the project as it relates to the purpose and pertinence to the advancement of the nursing profession, is presented. Emphases on the importance of nursing interventions as they relate to health education are discussed. The methodology and design used in this project are presented, as well as a definition for the common terms used. Any imperative assumptions, limitations, and delimitations of the project are explained.

Background of the Project

In the 1990s, there was an increased and heightened global awareness surrounding HL levels in patients, in particular as to how HL related to health education and patient health outcomes (Kutner et al., 2006). Investigators within the United States began to identify the links between patient reading comprehension levels and how it impacted health-related outcomes such as medication adherence, readmission rates, health education, and hospitalization rates (Kutner et al., 2006). In 1995, the United States created the National Health Education Standards to define important guidelines and considerations relative to HL goals on the patient level (IOM, 2004). Once standards were identified, studies surrounding HL sought answers to identify obstacles or issues pertaining to HL, which prevented patients from achieving an optimal understanding of the health information presented. Assessments and surveys were conducted on the national level, to determine the HL statuses of adults within the United States, since barriers and objectives could not be addressed if HL were not known (Kutner et al., 2006).

In 2003, the United States conducted the National Assessment of Adult Literacy. For the first time, the assessment included statistics regarding literacy rates among American adults as they pertained to health literacy (Kutner et al., 2006). The results of the survey revealed that only 12% of the nation was considered to be proficient in health literacy (Kutner et al., 2006). Concerns surrounding the low HL level findings of the 2003 survey, led to the creation of national measures, goals, and guidelines that focused on the best efforts to improve HL rates among adults (Kutner et al., 2006). There have not been any subsequent national HL surveys conducted since 2003 and those results did not account for all of the updates and advancements in health education as they pertain to healthcare technologies, leaving gaps in the measures and goals originally set forth 16 years prior (Kutner et al., 2006). The United States government addressed concerns involving HL and the lack of accounting for HIT. The most recent Healthy People initiatives lists one of the goals of Healthy People 2020 as to improve the utilization of health communication strategies with HIT to improve population health outcomes and overall healthcare quality while assuring that health equity is achieved and maintained (Office of Disease Prevention and Health Promotion [ODPHP], 2017a). This is important because HIT has the potential to increase patient participation, improve the quality of delivered healthcare, improve patient outcomes, influence patient safety, stabilize healthcare efficiency, and reduce the costs associated with healthcare (Ahlan & Ahmad, 2015). Healthcare clinicians can become more directly connected to patients through health technologies, especially interactive technology devices (Werder, 2015).

Interactive technology devices, such as the iPET system, provides nurses the opportunity to educate patients in the acute care setting through the delivery of health education modules tailored specifically to patients based on their illnesses or disease processes (Patmon et al., 2016). The iPET system provides patients an opportunity to increase their initiative and partake in their healthcare choices through self-directed behaviors such as viewing health education modules tailored to their health maintenance plan (Patmon et al., 2016). To assess patient understanding as it relates to iPET technology, nurses could greatly benefit from obtaining HL levels on every patient (Loan et al., 2018). This would allow for proper nurse assessment of the patient’s potential capacity for understanding as well as help nursing identify areas in which the patient may need additional educational intervention considerations (Loan et al., 2018). This DPI project focused on health literacy scores as they related to patient use of technology as a means to obtain educational information in an acute-care setting. Although the literature supports health literacy as it relates to patient outcomes, HIT, and patient education, there are gaps in the literature relative to iPET technologies as a means to view health education and correlations with HL scores.

Problem Statement

It was not known if health literacy scores, measured with the REALM-SF tool, correlated to adult telemetry inpatient use of the iPET to view health education modules when compared to a similar group that did not use the iPET, after both groups of patients were provided the same instructions on functionality and use of the iPET system. Low or inadequate HL is a topic of great concern, as low health literacy levels affect health outcomes on both the national and individual level (Kutner et al., 2006). Studies demonstrate that HL scores can be used to predict patient health outcomes (Rymer et al., 2018) and that health literacy is recognized as a social determinant of health based on patient health outcomes (Logan et al., 2015). There is