A longitudinal qualitative study to explore and optimize self-management in mild to end stage chronic kidney disease patients with limited health literacy: Perspectives of patients and health care professionals

Health literacy and hypertension-related multimorbidity: unravelling the mediating role of self-management - insights from the lifelines cohort study

BACKGROUND

People with limited health literacy and hypertension may lack the self-management skills needed to manage their illness, contributing to the onset and progression of important adverse health outcomes (e.g., multimorbidity). This study aimed to assess the association between health literacy and the onset and progression of hypertension-related multimorbidity among people with hypertension and whether this association is mediated by components of self-management (i.e., motivation, self-efficacy beliefs and problem-solving).

METHODS

The study sample included data from 21,725 adult participants with hypertension who were followed in the Lifelines Cohort Study. Using causal mediation analysis with natural effect models, the total and direct effect of health literacy on hypertension-related multimorbidity and the indirect effects of motivation, self-efficacy beliefs and problem-solving were studied.

RESULTS

First, after controlling for age, sex, smoking status, education level and monthly income, the total and direct effects of health literacy on the onset of hypertension-related multimorbidity were null (OR: 1.00, 95% CI: 0.99-1.01); however, an increase in problem-solving scores had an indirect effect on the onset of hypertension-related multimorbidity (OR: 0.99, 95% CI: 0.98-0.99). Second, a change from limited health literacy to adequate health literacy (OR: 0.99, 95% CI: 0.98-0.99) and an increase in motivation (OR: 0.99; 95% CI: 0.99-1.00), self-efficacy beliefs (OR: 0.99; 95% CI: 0.98-0.99) and problem-solving (OR: 0.99; 95% CI: 0.98-0.99) scores had direct and indirect effects, respectively, on the progression of hypertension-related multimorbidity.

CONCLUSIONS

A change from limited health literacy to adequate health literacy had no direct effect on the onset of hypertension-related multimorbidity but did decrease the likelihood of its progression. Problem-solving indirectly mediated only the onset; meanwhile, motivation, self-efficacy beliefs and problem-solving mediated the progression of hypertension-related multimorbidity. Improving health literacy and self-management skills can play a crucial role in preventing or delaying the onset or progression of hypertension-related multimorbidity. These improvements can significantly reduce the disease burden for individuals with limited health literacy and those living with hypertension-related multimorbidity.

Designing qualitative research with value in the clinical and epidemiological context: what, why and how

Clinical and epidemiological research is indispensable for improvements in evidence-based healthcare and health outcomes, but it also leaves important gaps in our understanding of health and illness. Qualitative research has been increasingly recognized as a key to addressing some of these gaps, using both exploratory (to gain a more complete and in-depth understanding of problems) and explanatory (to explain quantitative results) approaches. By finding out 'what's going on' and bringing people's stories to light, qualitative research is widely advocated as crucial in enhancing patient-centered research and healthcare. To date, most clinicians, clinical researchers and epidemiologists are relatively unfamiliar with and untrained in qualitative research-a type of research that, compared with quantitative research, requires different research skills and uses a different jargon, type of reasoning, and methods. This article aims to equip them with the basic knowledge necessary to appraise and design qualitative research. Specifically, we provide a comprehensive overview of (i) what qualitative research is, including various examples of qualitative research questions and explanations of the contrasting properties of quantitative and qualitative research; (ii) what constitutes the added value of qualitative research in the clinical and epidemiological context, illustrated using numerous research studies conducted within nephrology; and (iii) practical guidelines for designing qualitative research within this context, including a self-developed checklist containing essential information to include in qualitative research protocols. In doing so, we hope to enrich clinical and epidemiological research with complementary qualitative evidence-amongst others, invaluable insights into patients' lived experiences and perceptions-and thereby greatly enhance patient-centered research and evidence-based healthcare.

The effectiveness of a health literacy enhancement program on knowledge, self-management behaviors, and clinical outcomes in people with chronic kidney disease: A quasi-experimental study in Thailand

Background

Chronic kidney disease (CKD) is a leading cause of death, with a rising incidence worldwide. Effective disease management requires health literacy (HL) interventions to optimize patients' self-management. However, difficulties in communication between patients and healthcare providers often impede improvements in HL. While HL interventions should prioritize enhancing communication quality, current evidence supporting this approach remains limited.

Objective

This study aimed to investigate the effectiveness of a Health Literacy Enhancement (HLE) program on CKD knowledge, self-management behaviors, and clinical outcomes in people with CKD.

Methods

A quasi-experimental study using a two-group pretest-posttest design was conducted from December 2022 to March 2023. Fifty-two participants with stage 3 to 4 CKD, recruited from outpatient CKD clinics in two district hospitals in Central Thailand, were divided into two groups. Participants in the experimental group (n = 25) received the HLE Program based on Baker's HL concept, while the control group (n = 27) received usual care for 12 weeks. Data were collected twice before and after the 12-week program using a demographic form, CKD knowledge, CKD self-management behaviors (SMBs), and clinical outcomes, including blood pressure (BP), hemoglobin A1c (HbA1c), estimated glomerular rate (eGFR), body mass index (BMI), and waist circumference (WC). Data were analyzed using descriptive statistics, Chi-square, Paired t-test, and Independent t-test.

Results

Following the HLE Program, the experimental group had a significantly higher score in CKD knowledge (t = 8.79, p <0.001) and self-management behaviors (SMBs) (t = 7.70, p <0.001). They also achieved a better average estimated glomerular filtration rate (eGFR) (t = 3.14, p <0.01) and had lower systolic blood pressure (SBP) (t = -2.54, p <0.05) and diastolic blood pressure (DBP) (t = -2.05, p <0.05) compared to the control group and their baseline measures. The effect sizes (Cohen's d) were substantial, indicating large effects for CKD knowledge (2.44), self-management behaviors (2.14), and eGFR (0.87), while SBP (-0.71) and DBP (-0.55) indicated medium effects. However, no significant differences were observed in HbA1c, BMI, and WC.

Conclusion

The HLE program can enhance effective patient-provider communication using plain language, leading to significant improvements in CKD knowledge and SMBs, as well as clinical outcomes, including eGFR and BP. Nurses should implement this program to enhance HL in people with CKD, leading to effective self-management and helping slow the progression of the disease.

Trial Registry Number

Thai Clinical Trials Registry (TCTR20240920001).

Care of Adults with Advanced Chronic Kidney Disease

Chronic kidney disease (CKD) impacts over 10% of the global population. Adults with CKD face significant morbidity and mortality. As kidney disease progresses, the risk of adverse outcomes increases. Here, we present an overview of strategies to care for adults with advanced CKD (stage 4-5 CKD, not receiving kidney replacement therapy). We aim to guide clinicians through several aspects of CKD care, ranging from recommended laboratory assessments to interdisciplinary support for patients as they plan for kidney replacement therapy (dialysis, transplantation, or conservative management). We incorporate considerations of health equity and person-centered care, empowering clinicians to deliver high-quality care to people with CKD.

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.

User Evaluation of a Chat-Based Instant Messaging Support Health Education Program for Patients With Chronic Kidney Disease: Preliminary Findings of a Formative Study

BACKGROUND

Artificial intelligence-driven chatbots are increasingly being used in health care, but few chat-based instant messaging support health education programs are designed for patients with chronic kidney disease (CKD) to evaluate their effectiveness. In addition, limited research exists on the usage of chat-based programs among patients with CKD, particularly those that integrate a chatbot aimed at enhancing the communication ability and disease-specific knowledge of patients.

OBJECTIVE

The objective of this formative study is to gather the data necessary to develop an intervention program of chat-based instant messaging support health education for patients with CKD. Participants' user experiences will form the basis for program design improvements.

METHODS

Data were collected from April to November 2020 using a structured questionnaire. A pre-post design was used, and a total of 60 patients consented to join the 3-month program. Among them, 55 successfully completed the study measurements. The System Usability Scale was used for participant evaluations of the usability of the chat-based program.

RESULTS

Paired t tests revealed significant differences before and after intervention for communicative literacy (t54=3.99; P<.001) and CKD-specific disease knowledge (t54=7.54; P<.001). Within disease knowledge, significant differences were observed in the aspects of CKD basic knowledge (t54=3.46; P=.001), lifestyle (t54=3.83; P=.001), dietary intake (t54=5.51; P<.001), and medication (t54=4.17; P=.001). However, no significant difference was found in the aspect of disease prevention. Subgroup analysis revealed that while the findings among male participants were similar to those of the main sample, this was not the case among female participants.

CONCLUSIONS

The findings reveal that a chat-based instant messaging support health education program may be effective for middle-aged and older patients with CKD. The use of a chat-based program with multiple promoting approaches is promising, and users' evaluation is satisfactory.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05665517; https://clinicaltrials.gov/study/NCT05665517.

Designing family-based interventions in kidney failure: The perspectives of the triad 'patients on haemodialysis/family caregivers/healthcare professionals

OBJECTIVES

This study explored the perspectives of people undergoing in-centre haemodialysis, family caregivers, and healthcare professionals about the development and implementation of family-based interventions in renal care settings.

DESIGN

A qualitative exploratory study was carried out combining purposive and snowball sampling techniques.

METHODS

Semi-structured interviews were submitted to thematic analysis.

RESULTS

A total of 82 individuals (27 adults on haemodialysis, 32 family caregivers, and 23 healthcare professionals) participated in this study. Five major themes were identified: (i) educational needs (improve disease and treatment-related knowledge; acquire better clarification on dialysis-related health behaviours); (ii) support needs (easier access to available community resources and professional psychological support; additional emotional and instrumental support from family members); (iii) expected barriers (concerns about participating in a group format; availability of the person on haemodialysis/family caregiver dyad; travel to the intervention site and associated costs); (iv) expected benefits (mutual emotional validation and support; improve family coping skills and involvement); and (v) preferences for content and format (interdisciplinary and moderated by health psychologists) and timing of the intervention (weekends and/or non-dialysis days).

CONCLUSIONS

Findings suggested that interventions focused on the family system in kidney failure need to follow an interdisciplinary approach, combining psychosocial support with an educational component. Future research is needed to minimize barriers to the conjoint participation of the person on haemodialysis/caregiver dyad. This study identifies important intervention goals to inform the design of family-based interventions for people receiving haemodialysis and their family caregivers.

Healthcare providers' support and outcomes in hemodialysis patients: The mediating effect of health literacy

OBJECTIVE

This study aimed to identify the mediating effect of health literacy (HL) on the relationship between healthcare providers' support and outcomes in patients on hemodialysis.

METHODS

A convenience sample of 149 hemodialysis patients participated in a cross-sectional survey. Mediation analysis with the percentile bootstrap method was used to identify the mediating effect of HL on the relationship between healthcare providers' support and patient outcomes.

RESULTS

Healthcare providers' support and HL were significant predictors of patient outcomes. HL mediated the relationship between healthcare providers' support and patient outcomes.

CONCLUSION

The HL of hemodialysis patients is essential in the relationship between healthcare providers' support and patient outcomes. Patient educators should implement a multifaceted HL-tailored intervention strategy to improve the HL of hemodialysis patients.

PRACTICE IMPLICATIONS

Hemodialysis patients' HL is a crucial mediating factor in the relationship between healthcare providers' support and patient outcomes. A multifaceted HL-tailored intervention strategy is needed to improve HL and, thus, health outcomes among hemodialysis patients.

Treatment Adherence in CKD and Support From Health care Providers: A Qualitative Study

Rationale & Objective

Adherence to recommended medical treatment is critical in chronic kidney disease (CKD) to prevent complications and progression to kidney failure. Overall adherence to treatment is low in CKD, and as few as 40% of patients with kidney failure receive any documented CKD-related care. The purpose of this study was to explore the experiences of patients with CKD and their adherence to CKD treatment plans, and the role their health care providers played in supporting their adherence.

Study Design

One-on-one interviews were conducted in 2019-2020 using a semi-structured interview guide. Participants described experiences with adherence to treatment plans and what they did when experiencing difficulty.

Setting & Participants

Participants were recruited from the Chronic Renal Insufficiency Cohort (CRIC) study. All CRIC participants were older than 21 years with CKD stages 2-4; this sample consisted of participants from the University of Pennsylvania CRIC site.

Analytical Approach

Interviews were recorded, transcribed, and coded using conventional content analysis. Data were organized into themes using NVivo 12.

Results

The sample (n = 32) had a mean age of 67 years, 53% were women, 59% were non-White, with a mean estimated glomerular filtration rate of 56.6 mL/min/1.73 m2. From analysis of factors relevant to treatment planning and adherence, following 4 major themes emerged: patient factors (multiple chronic conditions, motivation, outlook), provider factors (attentiveness, availability/accessibility, communication), treatment planning factors (lack of plan, proactive research, provider-focused treatment goals, and shared decision making), and treatment plan responses (disagreeing with treatment, perceived capability deficit, lack of information, and positive feedback).

Limitations

The sample was drawn from the CRIC study, which may not be representative of the general population with CKD.

Conclusions

These themes align with Behavioral Learning Theory, which includes concepts of internal antecedents (patient factors), external antecedents (provider factors), behavior (treatment planning factors), and consequences (treatment plan responses). In particular, the treatment plan responses point to innovative potential intervention approaches to support treatment adherence in CKD.

The Relationship Between Health Literacy and Outcomes Before and After Kidney Transplantation

Limited health literacy (HL) is associated with decreased kidney function and death in patients with chronic kidney disease. Less is known about the impact of HL on kidney transplant (KT) outcomes. The aim of this study was to examine the relationship between HL and KT outcomes, including rates of waitlisting, healthcare utilization, acute rejection, renal allograft function, renal allograft failure, and death.

Methods

We performed a retrospective review of HL data previously collected at our center. HL was assessed in a convenience sample of consecutive, English-speaking patients age ≥18 y who were evaluated for KT at Mayo Clinic in Minnesota between June 2015 and March 2017 as part of a practice improvement feasibility project (n = 690). HL was assessed using the 4-item Brief Health Literacy Screening Tool modified for the outpatient KT evaluation process. The 4 items assess confidence completing forms, reading comprehension, and oral literacy.

Results

Overall, 30.4% of patients had limited or marginal HL. Patients with limited or marginal HL were less likely than those with adequate HL to be waitlisted for KT (hazard ratio = 0.62 and 0.69, respectively), even after adjusting for age, marital status, body mass index, Charlson comorbidity index, or dialysis dependency. Patient HL was not associated with post-KT healthcare utilization, acute rejection, or renal allograft function. Patients with limited or marginal HL appeared to experience a higher risk of renal allograft failure and post-KT death, but the number of events was small, and the relationship was statistically significant only for marginal HL.

Conclusions

Inadequate HL is common in KT candidates and independently associated with decreased waitlisting for KT. We observed no statistically significant relationship between HL and posttransplant outcomes in our cohort. Further efforts to improve communication in patients with inadequate HL may improve access to KT.

Measuring Mobile Phone Application Usability for Anticoagulation from the Perspective of Patients, Caregivers, and Healthcare Professionals

Oral anticoagulants (OAC) are recommended for preventing stroke and systemic embolism in atrial fibrillation. Proper use is imperative for maximizing anticoagulation therapy's effectiveness and safety. In preparation for the implementation of a smartphone-based SmartMed app (application) aiming to promote patient self-management, medication adherence, and data collection for patients on anticoagulation therapy, its usability assessment can ensure the value of OAC app development and adoption. We evaluated the SmartMed app's usability using the System Usability Scale (SUS) and the app-specific domain of the Mobile App Rating Scale (MARS) for its perceived impact on taking OAC regularly. We recruited 25 OAC users and their home caregivers and 59 healthcare professionals, including pharmacists, nurses, and cardiac surgeons from one medical center and one regional hospital in Taiwan. All participants (n = 84) thought the SmartMed app was useful, with mean SUS and MARS scores of 81.49 (±14.42) and 4.65 (±0.49), respectively. Usability evaluation revealed that fewer experiences with smartphone apps and different healthcare professionals (pharmacists versus nurses or cardiac surgeons) were associated with lower SUS scores and perceived impact. Throughout the evaluation process, the SmartMed app's design was considered helpful from multiple stakeholders' perspectives. Further ongoing mobile technology supports are necessary to establish the SmartMed app's effectiveness.

Co-Creation of a Multi-Component Health Literacy Intervention Targeting Both Patients with Mild to Severe Chronic Kidney Disease and Health Care Professionals

Limited health literacy (LHL) is common in chronic kidney disease (CKD) patients and frequently associated with worse self-management. Multi-component interventions targeted at patients and healthcare professionals (HCPs) are recommended, but evidence is limited. Therefore, this study aims to determine the objectives and strategies of such an intervention, and to develop, produce and evaluate it. For this purpose, we included CKD patients with LHL (n = 19), HCPs (n = 15), educators (n = 3) and students (n = 4) from general practices, nephrology clinics and universities in an Intervention Mapping (IM) process. The determined intervention objectives especially address the patients’ competences in maintaining self-management in the long term, and communication competences of patients and HCPs. Patients preferred visual strategies and strategies supporting discussion of needs and barriers during consultations to written and digital strategies. Moreover, they preferred an individual approach to group meetings. We produced a four-component intervention, consisting of a visually attractive website and topic-based brochures, consultation cards for patients, and training on LHL for HCPs. Evaluation revealed that the intervention was useful, comprehensible and fitting for patients’ needs. Healthcare organizations need to use visual strategies more in patient education, be careful with digitalization and group meetings, and train HCPs to improve care for patients with LHL. Large-scale research on the effectiveness of similar HL interventions is needed.