Exploring health literacy and self-management after kidney transplantation: A prospective cohort study

The effectiveness of remote interventions based on digital health technology in kidney transplant recipients: a systematic review

PURPOSE

To evaluate the application effect of remote interventions based on digital health technology in kidney transplant patients through a systematic review.

DESIGN

Systematic review.

METHODS

The databases of PubMed, Embase, Cochrane Library, CINAHL, and Web of Science were systematically searched for randomized controlled trials and quasi - experimental studies on remote interventions based on digital health technology in kidney transplant recipients. The search time limit ranged from the establishment of the databases to September 2024.

RESULTS

A total of 10 articles were included, involving 535 patients. A total of 21 clinical outcomes were identified in this study and they were classified into three categories, namely: ① Health-related conditions: Number of steps (n = 1), heart rate (n = 1), self-burden score (n = 1), self-management ability (n = 1), quality of life score (n = 2), Self-rating Anxiety Scale (SAS) and Self-rating Depression Scale (SDS) (n = 1), psychological distress (n = 1). ② Medication adherence and average tacrolimus concentration: Medication adherence (n = 5), number of missed doses (n = 1), medication errors (n = 1), rejection reactions (n = 1), average creatinine level (n = 1), tacrolimus blood concentration level (n = 2), within-patient variability of tacrolimus (n = 1), coefficient of variation (CV) of tacrolimus (n = 1). ③ Medical economic status: Nursing satisfaction (n = 1), incidence of adverse events (n = 1), rate of unplanned hospitalization (n = 3), duration of unplanned hospitalization (n = 1), one-year medical cost (n = 2), nursing cost (n = 1).

CONCLUSION

Remote interventions based on digital health technology can improve the health - related conditions, medication adherence and medical economic status of kidney transplant recipients. However, its impact on tacrolimus concentration remains unclear. Clinical medical staff should fully recognize its positive effects.

Associations Between Social Support, Health Literacy and Psychological Resilience to Self-Management Behaviours in Liver Transplant Recipients-A Structural Equation Model

AIMS

This study aimed to develop a structural model to elucidate the contributions of social support, health literacy and psychological resilience to self-management behaviours in liver transplant recipients after surgery.

DESIGN

Cross-sectional study.

METHODS

This study included 215 Chinese patients who returned to the outpatient department after liver transplantation between June 2023 and March 2024. Data were collected via a general demographic questionnaire, a self-management questionnaire for liver transplant recipients, a chronic disease resource questionnaire, the Connor-Davidson resilience scale and the health literacy scale for chronic patients. Correlation analysis and structural equation modelling were utilised to analyse the relationships among social support, health literacy, psychological resilience and self-management ability.

RESULTS

The final model showed good fit (χ2/df = 1.690, GFI = 0.919, IFI = 0.951, TLI = 0.938, CFI = 0.950 and RMSEA = 0.057). The direct effect coefficient of social support on self-management ability is 0.293. The indirect effect value of health literacy on the relationship between social support and self-management ability was 0.312, whereas the indirect effect value of psychological resilience in this context was 0.096. Furthermore, the chain-mediating effect involving both health literacy and psychological resilience between social support and self-management ability was 0.109.

CONCLUSION

The revised model, grounded in social cognitive theory, demonstrated a strong fit for predicting self-management behaviours among liver transplant recipients. Furthermore, social support, health literacy and psychological resilience exerted both direct and indirect influences on the self-management behaviours of these recipients.

REPORTING METHOD

Strengthening the Reporting of Observational Studies in Epidemiology (STROBE).

PATIENT OR PUBLIC CONTRIBUTION

In public or patient involvement in this study.

Two-Year Follow-Up of a Communication Intervention on Medication Adherence and Health Literacy in Kidney Transplanted Recipients-A Randomised Controlled Study

BACKGROUND

Patients with chronic conditions, including kidney transplanted recipients, are required to actively participate in their continuous care and maintain motivation to adhere consistently to treatment.

OBJECTIVES

Our study aimed to test long-term effectiveness of a new health communication intervention designed to improve on medication adherence and health literacy in kidney transplant recipients 2 years following transplantation.

DESIGN

A randomised controlled non-blinded study was conducted between March 2020 and August 2023.

PARTICIPANTS

One hundred and ninety-five kidney transplant recipients were included.

MEASUREMENTS

Primary outcomes were self-reported medication adherence, measured by the BAASIS questionnaire, and health literacy, measured by the Health Literacy Questionnaire. The response rate was 87% (170 of 195 patients).

RESULTS

This study showed a significant difference between groups in favour of the intervention group for medication adherence (p < 0.02) and two essential Health Literacy Questionnaire domains-'navigating the health care system' (p < 0.02) and 'having social support for health' (p > 0.03)-2 years after transplantation. Regarding health literacy, three Health Literacy Questionnaire domains showed a significant correlation with adherence: 'having sufficient information to manage health' (p < 0.04), 'having social support for health' (p < 0.04), and 'ability to understand health information well enough to know what to do' (p < 0.05).

CONCLUSION

The findings in the study highlight the pivotal role of health communication in enhancing medication adherence and supporting important health literacy aspects for kidney transplant recipients.

HELP-KIDNEY: Health Literacy and Patient Outcomes in Pediatric Kidney Transplant

BACKGROUND

Below adequate health literacy is common and linked to increased risk of adverse health outcomes. Supporting optimal health following kidney transplantation requires the capacity to understand health information and make decisions about care. The impact of low health literacy in the context of pediatric kidney transplant has not previously been studied.

METHODS

This retrospective cohort study sought to determine the relationship between caregiver or patient health literacy and healthcare utilization (outpatient hospital visits, days in hospital) and to explore relationships between health literacy and adherence to tacrolimus (trough level coefficient of variation) and allograft function post-transplant.

RESULTS

Forty patients were included in the analysis. 60% were identified as having adequate literacy using the Newest Vital Sign (NVS). Lower health literacy was significantly correlated with increased healthcare utilization in the first 3 months post-transplant (rs = -0.36, p = 0.024) and in the first year post-transplant (rs = -0.35, p = 0.029). No association was demonstrated between health literacy level and number of days admitted to the hospital (rs = -0.16, p = 0.321), adherence to tacrolimus 6-12 months post-transplant (rs = 0.078, p = 0.68), or change in allograft function 2 years post-transplant (rs = -0.13, p = 0.43).

CONCLUSION

Limited health literacy is common in pediatric kidney transplant recipients and families and is associated with increased frequency of hospital and outpatient clinic department visits early post-transplant. In this small-sized cohort, we did not identify a relationship between health literacy level and hospitalization days, allograft function, or tacrolimus adherence. Larger studies are needed to evaluate the relationship between health literacy and transplant outcomes in children and test interventions that may improve communication and optimize care.

Associations between dialysis modality and adherence to immunosuppression after kidney transplantation-A single-center study

BACKGROUND

Patients with end-stage kidney disease often prefer home-based dialysis due to higher self-efficacy, which relates to improved medical treatment adherence. Kidney transplantation (KT) success depends on adhering to immunosuppressive medication post-transplant.

OBJECTIVES

To investigate whether adherence post-kidney transplantation (KT) and patients' attitudes toward immunosuppression were influenced by their prior dialysis type modality. Additionally, the study examined if adherence and patient's attitudes towards immunosuppression are associated with kidney graft survival.

METHODS

This cross-sectional single-center study included 201 KT patients. Adherence was assessed using BAASIS and the coefficient of variation of calcineurin inhibitors (COV-CNI). Patient attitudes towards medication were evaluated using the Q-method. Pill burden, comorbidity score and HRQoL and medication complexity, were scored. Cox regression was applied to determine KT survival outcomes over a 14-year follow-up period (until Dec 2021).

RESULTS

Prior dialysis modality was not associated with adherence to immunosuppression post-KT evaluated by BAASIS on average 4.7 years post-KT. Previous in-center hemodialysis patients had a higher CNI-COV (p = 0.011). The Q-sort analysis identified fully adherent patients linked to profile 1 (organized, resilient) whereas profile 2 patients were more careless. Patients linked to profile 3 (challenging, nervous) had higher education, a higher pill burden, and experienced more immunosuppression side effects. Death-censored graft loss increased by 7.6% with each additional pill, quadrupled if one dose of immunosuppression was missed, and increased by 2.9% for each point of COV-CNI rise.

CONCLUSIONS

Adherence to immunosuppression post-KT using BAASIS was not associated with prior dialysis type, despite in-center hemodialysis patients showing the highest COV-CNI. Taking COV-CNI into account, managing missed doses of immunosuppressants, and exploring patient attitudes could potentially enhance adherence and consequently improve KT survival.

Self-Management of Kidney Transplant Recipients Research: A Comprehensive Bibliometric Analysis

Objective

This study analyzes research trends in self-management among kidney transplant recipients to inform future directions.

Methods

Bibliometric analysis was performed on 444 English articles related to self-management of kidney transplant recipients in the Core Collection of Web of Science and Scopus databases using COOC 12.8, R software, Microsoft Excel 2019, VOSviewer, and CiteSpace, with a focus on citation ranking, publication year, journal, country, organization, author, impact factor, and keywords.

Results

Four hundred and forty-four English articles revealed the United States as the leading publisher on kidney transplant recipient self-management. Norway's University of Oslo was the most productive institution, with Mirjam Tielen as the most prolific author and SCHÄFER-KELLER as the most influential. Belgium's research was most cited. Emerging hotspots included medication adherence, quality of life, psychological aspects, telemedicine, and health literacy in self-management research.

Conclusion

This study has identified the most influential articles concerning the self-management of kidney transplant recipients, documented the pivotal journals in the field, and noted the most prolific countries, organizations, and authors contributing to the literature, as well as highlighted upcoming research trends. Going forward, the research in kidney transplant recipient self-management should explore the full potential of interdisciplinary integration, particularly by incorporating telemedicine into self-management education. Future efforts should also be directed towards refining the existing post-transplant follow-up management systems and enhancing lifelong care for kidney transplant recipients. Concurrently, there is a need to improve health literacy and self-management capabilities among these patients, with the ultimate goal of improving their prognosis.

Trying to understand the illness: A qualitative investigation of health literacy of patients undergoing maintenance hemodialysis

Limited health literacy is high among patients with chronic kidney disease, which can pose challenges in health care. Evidence of health literacy in Indonesia, particularly regarding patients undergoing hemodialysis, is lacking. In this study, we aimed to explore health literacy in adult patients undergoing maintenance hemodialysis. An inductive qualitative study was conducted. Individual semi-structured interviews were conducted with 10 adult patients undergoing hemodialysis, four family caregivers, and four healthcare professionals. Interviews were transcribed verbatim and analyzed thematically. Three themes emerged from the data: "Trying to understand the illness," "searching and obtaining health information," and "applying health information." Understanding and accepting the illness included raising awareness of the changes in their lives and accepting these changes. Participants actively sought information from healthcare professionals and other sources and used it carefully. Behavioral changes included patients' adherence to therapy, although participants often felt bored during the illness trajectory. Understanding the illness and being willing to seek and critically evaluate health information before implementing it are important. These aspects may affect patient outcomes and require further intervention and research.

Effectiveness of a health communication intervention on health literacy in the first year following kidney transplantation - A randomized controlled study

OBJECTIVE

This study aimed to evaluate the effect of a new health communication intervention focusing on knowledge management skills on health literacy and medication adherence during the first year following kidney transplantation.

METHODS

We randomized 195 patients during 2020-2021, to either intervention- or control group. Questionnaires were completed at baseline and at 12 months post-transplantation with a 12-month response rate of 84%. Health literacy was measured by the multidimensional Health Literacy Questionnaire (HLQ) instrument. Medication adherence was measured by the self-reported questionnaire (BAASIS©).

RESULTS

Results showed that the intervention group had a significant increase in 2 HLQ domains compared to the control group capturing the "ability to appraise health information" Domain 5, (p-value = 0.002) and the "ability to navigate the healthcare system" Domain 7, (p-value <0.04). The effect sizes of SRM were 0.49 (Domain 5) and 0.33 (Domain 7). Medication adherence was comparable in the groups at any measure points.

CONCLUSIONS

This study contributes to important knowledge about how a health communication intervention focusing on knowledge translation using motivational interviewing techniques positively strengthens health literacy in kidney transplant recipients.

PRACTICAL IMPLICATIONS

Current patient education practice may benefit from focusing on knowledge translation in combination with motivational interview technique.

Assessment Tools for Measuring Health Literacy and Digital Health Literacy in a Hospital Setting: A Scoping Review

Assessment of (digital) health literacy in the hospital can raise staff awareness and facilitate tailored communication, leading to improved health outcomes. Assessment tools should ideally address multiple domains of health literacy, fit to the complex hospital context and have a short administration time, to enable routine assessment. This review aims to create an overview of tools for measuring (digital) health literacy in hospitals. A search in Scopus, PubMed, WoS and CINAHL, following PRISMA guidelines, generated 7252 hits; 251 studies were included in which 44 assessment tools were used. Most tools (57%) were self-reported and 27% reported an administration time of <5 min. Almost all tools addressed the domain 'understanding' (98%), followed by 'access' (52%), 'apply' (50%), 'appraise' (32%), 'numeracy' (18%), and 'digital' (18%). Only four tools were frequently used: the Newest Vital Sign (NVS), the Short Test of Functional Health Literacy for Adults ((S)TOFHLA), the Brief Health Literacy Screener (BHLS), and the Health Literacy Questionnaire (HLQ). While the NVS and BHLS have a low administration time, they cover only two domains. HLQ covers the most domains: access, understanding, appraise, and apply. None of these four most frequently used tools measured digital skills. This review can guide health professionals in choosing an instrument that is feasible in their daily practice, and measures the required domains.

Is Health Literacy Associated With Surgical Outcomes? A Systematic Review

INTRODUCTION

Low levels of health literacy have been shown to increase healthcare utilization and negatively affect health outcomes within medical specialties. However, the relationship of health literacy with clinical, patient-centered, and process-oriented surgical outcomes is not as well understood.

MATERIALS AND METHODS

We sought to systematically review the current evidence base regarding the relationship between health literacy and a range of outcomes in patients experiencing surgical care. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we searched six databases and then identified and extracted data from 25 cross-sectional or cohort studies deemed eligible for a systematic review.

RESULTS

Among included studies, strong evidence exists to support an association between low health literacy and worse patient-centered outcomes, as well as an association between low health literacy and poorer process-oriented surgical outcomes. However, the relationship between health literacy and clinical outcomes remains unclear.

CONCLUSIONS

Substantial opportunities remain to improve our understanding of the impact of health literacy on surgical outcomes. Future work should expand the range of institutional and specialized surgical settings studied, implement a standardized set of validated health literacy assessment tools, include more diverse patient populations, and investigate a comprehensive range of patient-reported outcomes.

A Cross-Sectional Analysis of Health Literacy and Compliance to Treatment in Organ Transplant Recipients

This study was conducted to determine the correlations between health literacy, transplant effects, and compliance to treatment in organ transplant recipients and to identify the factors influencing compliance to treatment. The participants (n = 130; males = 66.9%; mean age = 56.4 years) were organ transplant recipients visiting an organ transplantation center in Seoul, South Korea. The regression model explained 32% of the variance in participants' compliance to treatment. Among the health literacy variables, "Scale 3: Actively managing my health" (β = 0.38, p = 0.001) and "Scale 4: Social support for health" (β = 0.25, p = 0.019) had a significant effect on compliance to treatment. In this study, health literacy was identified as a key factor influencing compliance to treatment. Therefore, patients' health literacy should be assessed prior to transplantation to identify potential high-risk patients for treatment nonadherence. In addition, after transplantation surgery, patient-tailored interventions should be developed and provided for self-management that reflects the patient's health literacy level to ultimately enhance patient outcomes.

Validation of the Chinese version of the kidney transplant understanding tool in Chinese patients

AIMS

To evaluate the reliability and validity of the Chinese version of the Kidney Transplant Understanding Tool (K-TUT) among patients in China.

DESIGN

Cross-sectional study.

METHODS

A convenience sample of 171 kidney transplant (KT) candidates and 272 KT recipients was recruited from two tertiary and Grade A hospitals in Hunan Province, China. The reliability was calculated by half-fold reliability, test-retest reliability and Cronbach's alpha. The validity was analysed by the content validity index.

RESULTS

For KT candidates, the Chinese version of K-TUT deleted items 4, 6, 7 and 8, Cronbach's α coefficient was 0.778, half-fold reliability values were 0.792, and test-retest reliability values were 0.902. For KT recipients, the tool deleted items 3, 4, 6, 7 and 8, Cronbach's α coefficient was 0.769, half-fold coefficient values were 0.701, and retest coefficient values were 0.888. The content validity index was 0.967.

CONCLUSIONS

The K-TUT is an acceptable and reliable measurement for evaluating the relevant knowledge of KT recipients and candidates.

IMPACT

It is anticipated that this new tool will help the nursing staff to identify specific areas of deficiency that could be targeted in health education to improve the KT knowledge of patients.

Validity and Reliability of the Parental Health Literacy Questionnaire for Caregivers of Children Aged 0 to 3 Years in China

Caregivers' health literacy plays a vital role in the quality of parenting and significantly impacts children's physical and psychological health. However, the instruments to assess the health literacy of caregivers of children aged 0 to 3 years are lacking. This study aimed to evaluate the reliability and validity of the Chinese Parental Health Literacy Questionnaire (CPHLQ) in China. We conducted a cross-sectional study. Six hundred and thirty-four caregivers of children aged 0 to 3 years were recruited from Shandong, Yunnan, and Shaanxi Provinces, representing the eastern, central, and western regions of China, between November 2020 and January 2021. The reliability was evaluated by internal consistency reliability and split-half reliability. The construct validity was determined by confirmatory factor analysis. Social determinants of parental health literacy were assessed by multivariate linear regression model. Results showed that CPHLQ had satisfactory reliability and acceptable construct validity. Mothers compared to other types of caregivers, higher education levels, and nuclear or extended families compared to other family compositions were significantly associated with higher parental health literacy. The study further demonstrated that CPHLQ is a reliable and valid instrument to measure the health literacy of caregivers of children aged 0 to 3 years in the Chinese population. It can be used as an evaluation tool for intervention research, to inform policy-making and future health education interventions of improving caregivers' health literacy.

Is simplification of immunosuppressive medication a way to promote medication adherence of kidney transplant recipients? Findings from a randomized controlled trial

After kidney transplantation, a strict immunosuppressive medication regimen is necessary for graft survival. However, nonadherence to medication has been shown to occur early after transplantation and to increase over time. Weaning the recipient off dual therapy onto monotherapy in order to reduce immunosuppressive burden may also be a way to promote adherence, although little is known about the impact of such a regimen on fear of rejection. We performed a cohort study on medication adherence and fear of rejection in a randomized, investigator‐driven, open‐label, single‐centre pilot study. Recipients were randomized at 6‐months post‐transplant to either continue Tacrolimus and Mycophenolate mofetil (TAC/MMF) or to taper MMF at 6 months and discontinue MMF at 9 months (TAC monotherapy). Recipients completed questionnaires about medication adherence and fear of rejection at 6 and 12‐months post‐transplantation. Medication adherence was significantly higher in the TAC monotherapy group compared to dual TAC/MMF therapy group (χ² (1) = 4.582; P = 0.032). We found no difference in fear of rejection between the two groups of recipients (P = 0.887). Simplification of the medication regimen is a potential tool for increasing adherence in clinical practice (Netherlands Trial Register – NL4672).