Low technology use, electronic health literacy among veterans with COPD who smoke
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Key takeaways:
- Less than 40% of veterans with COPD who smoke reported reliable internet in their homes.
- Many patients found online security confusing and did not trust technology with their personal data.
Many veterans with COPD who smoke did not regularly use technology and had low electronic health literacy, suggesting the need for outreach outside of technology, according to results published in Annals of the American Thoracic Society.
“Our findings underscore how important it is that clinicians screen not only for access to technology but actual use of it,” Anne C. Melzer, MD, MS, of the Minneapolis VA Health Care System and the University of Minnesota Medical School, told Healio. “Many patients in our study had very low electronic health literacy. As health systems expand technology-based programs for delivering health care, they should invest in the education and infrastructure necessary for vulnerable patients to participate. Failure to do so is likely to perpetuate or even widen tobacco-related health disparities.”
In a single-center mixed-methods study, Melzer and colleagues surveyed 204 veterans (mean age, 65.8 years; 87.1% men; 76.4% white; 44.9% income less than $20,000) with COPD who currently smoked to understand how they accessed and used information and communication technology (ICT), such as the internet, email, text, and the VA secure patient portal, MyHealtheVet. They also sought to learn about the barriers veterans faced when using ICT.
When a patient did not have an internet-capable device and had less than monthly use of ICT, researchers classified them as having low technology use. Researchers further used eHEALS, the electronic health literacy scale, to capture the average score for this patient population; the lowest score possible was 8 and the highest score indicating high literacy was 40.
Additionally, researchers found variables that predicted low technology use and eHEALS scores through a Bayesian three-component joint model.
Findings
In this patient population, researchers observed an average pack-years smoked of 61.11.
Based on the researchers’ definition, 25.5% of veterans had low technology use.
Of the total cohort, dependable home internet was noted in just around one-third (36.3%) of veterans. A fair number of patients had an email (68.1%) and/or phone that could send texts (71.6%), but less than 60% reported using them on a weekly basis (email: 46.6%; text: 58.3%). Researchers also found low enrollment (27.5%) and monthly usage levels (13.2%) of MyHealtheVet. All of these findings were surprising, Melzer told Healio.
“Tobacco use is progressively concentrated in sub-populations, particularly among those with lower income and educational attainment,” Melzer said. “While we expected that use of ICT would be lower in our population of patients with COPD who smoke than the general population of older Americans, we were surprised at how many — one in four — used technology essentially not at all. Over a third did not have an e-mail address and over two thirds were not enrolled in the patient portal. These are all really large barriers to participation in health promoting interventions and health care delivery as currently practiced in the post-COVID era."
In terms of eHEALS, this patient population had “low to moderate” electronic health literacy, with a mean score of 24.6. Further, the average score of those classified as having low technology use was even worse at 17.
According to researchers, there was a relationship between a small score on eHEALS and low technology usage (slope estimate, –8.5; 95% CI, –12.13 to –4.81), whereas a high score on eHEALS was linked to having a college education (slope estimate, 3.83; 95% CI, 0.43-7.24). They found less obvious relationships between electronic health literacy and age, COPD assessment test score and health status, which could be a result of the uniform study population.
Of the 204 patients who took the survey, 18 participated in an interview.
When asked about obstacles when using ICT, these patients stated several: trouble with navigating account security, loss of login information, hesitancy when asked to input personal data and little knowledge on online processes. Notably, processes thought to be too much work and/or puzzling included setting up an account, resetting a password and multifactor authorization, according to patient responses.
Further, ICT was viewed as unnecessary by numerous patients, and several did not use means of technology despite having access to them.
If the patient had past experience with using ICT, such as in their job, they did not report concerns with using them.
Future studies
Although Melzer and colleagues observed low use of ICT in their study cohort, electronics have become a key part in smoking cessation programs over the years.
“Like the rest of health care, much of tobacco dependence treatment is now delivered virtually,” Melzer told Healio. “For example, groups are highly effective for cessation and many of these are being offered virtually due to COVID-19 impacts on care delivery. There are a number of apps and text messaging programs to support cessation, including ones offered by the VA specifically for veterans. At least as many veterans participate in these programs as the more traditional quit lines.”
The huge prevalence of virtual and electronic programs is helpful but only if the patients have access to technology/internet and want to use it, Melzer added.
“While there are many ways to access tobacco dependence treatment, lack of access to technology limits the available options and ease of participation,” she said.
Despite the benefits associated with technology to support health, these results demonstrate that those in charge of tobacco treatment programs need to include pathways for patients who do not have access to technology and patients who have low electronic health literacy in order to create an effective program that is widely accessible.
“We will incorporate these results into our future studies of proactive outreach for tobacco treatment,” Melzer told Healio. “We will need to balance the use of technology-facilitated outreach, which costs less to reach a larger number of patients, against these limitations in technology access. We plan to include multiple modes of communication including phone to reach the full population.”
For more information:
Anne C. Melzer, MD, MS, can be reached at acmelzer@umn.edu.
Perspective
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As a leader in a voluntary health agency that relies on getting trusted information to the public regarding all aspects of lung disease, I know that the information needs to be distributed in multiple channels that can take advantage of increasing technology but also needs to meet the patient where they are. This means meeting them on an educational, geographic and cultural level as well as taking into account financial resources and access hurdles. It also means that the message needs to be best delivered by a trusted messenger. Unfortunately, in the current climate, the trust in science and health authorities has been shaken.
This article is significant because it points out a factor that further leads to disparities in health and care access. The study points out the relatively low penetration of ICT in a specific population that needs their medical condition (COPD) and a behavior (smoking) addressed. This means that the other channels of delivering needed medical information need to be enhanced while at the same time the health care system should find means to provide the tools that increase the use of ICT for this population. The dividends of improving the use of ICT may be manifested in less hospitalizations and medical use in general as well as possible improved success in the smoking cessation efforts which also will return benefits to the patient and society. The use of ICT specifically for smoking cessation can also offer a means of providing a circle of trusted individuals with whom they could communicate.
The findings of this article, I think, provide evidence of the varied forms of accessing medical information by individuals who may get information from multiple sources such as acquaintances; from reading websites, blogs and/or personal stories; and from listening to the radio and watching TV public service announcements. Health care providers need to offer multiple means of getting medical information to their patients and not rely solely on ICT.
For this study to be generalizable it needs to broaden to a multiple center design with a broader population based on health or disease status, age, race, geography and resources.
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