Prospective fully longitudinal mixed methods evaluation of health literacy improvement among older adults with chronic conditions through home-monitoring-based telenursing in Japan

Abstract

Objective: While improving health literacy can enhance health among older adults, surmountable barriers preclude full utilization. The purpose of this study was to prospectively measure health literacy changes in older adults with chronic conditions exposed to home monitoring-based telenursing (HMBTN) by examining its link with their experiences of HMBTN, self-care, symptoms, and health status.

Methods: In this study, a prospective fully longitudinal mixed methods design was employed. Eighteen older adults with chronic conditions, such as diabetes, congestive heart failure, chronic obstructive pulmonary disease, amyotrophic lateral sclerosis, and non-small cell lung cancer were included in a 12-week HMBTN intervention. Health literacy, self-care, and symptoms were assessed quantitatively, interviews were conducted to understand experiences with HMBTN, and healthcare/telenursing care records were reviewed to collect health status at baseline, mid-term, and after HMBTN. The findings were converged twice to facilitate the drawing of interpretations and super-meta-inferences throughout the study.

Results: Sixteen participants completed the 12-week HMBTN intervention program. Their scores for applying (p = .031) and understanding health literacy (p =.039), and self-care activities (p =.002) significantly improved. Qualitatively, their ambivalent feelings about and expectations for HMBTN at baseline changed as they made positive lifestyle adjustments through usage. Increased motivation, sense of confidence, and better understanding of symptoms involving self-management were linked to improvements in health literacy.

Conclusions: Improvements in the applying and understanding domains of health literacy among older adults with chronic conditions were linked to their proficiency in utilizing new technologies to make appropriate lifestyle changes. Furthermore, they developed a sense of confidence through their daily HMBTN.

Introduction

Background about telehealth/telenursing for older adults with chronic conditions

In the context of nursing, diagnostic and monitoring functions have dramatically increased in significance (Benner, 1984/1992, p. 68-77). Nursing practice involves both physical and qualitative psychosocial assessments to make clinical inferences and to improve patients’ self-care abilities. Collecting these multiple clinical perspectives is conducive to mixed methods evaluation. Though people continue uninterrupted in their life course, people in later life sometimes suffer from chronic diseases. Therefore, it is important to consider prospective longitudinal lifelong nursing care.

Chronic diseases are characterized by long duration and slow progression (World Health Organization [WHO], 2021b). The prevalence of these conditions is increasing, representing 71% of all causes of death worldwide and killing 41 million people every year (WHO, 2021b). The Ministry of Health, Labor and Welfare (MHLW) of Japan recently reported that by 2035, considering the baby boom generation being in the over-75 age bracket, the quality, value, safety, and performance of healthcare, such as telehealth, must be improved by utilizing information and communications technology (ICT) (MHLW, 2015). As the population ages rapidly in most developed countries, the percentage of older adults (over 75 years old), a demographic group associated with multiple chronic conditions, frailty, and thus a higher demand for care, will also increase (Cabinet Office, 2021; MHLW, 2021; Weiss, 2010). Chesser et al. (2016) reported that health outcomes in older adults are associated with their health literacy (HL), which can help reduce medication use and improve health self-management. Wolf et al. (2010) suggested that HL is related to cognitive health and mortality in older adults. Therefore, lifelong maintenance of HL in older adults living with chronic conditions is crucial.

Telehealth/telenursing/telehealth nursing (hereafter “telehealth”) is designed around specific needs to improve self-care, health outcomes, and satisfaction by sharing health-related data with healthcare providers and remotely delivering cost-effective care; multiple authorities consider it a solution for providing care to people with chronic conditions (American Academy of Ambulatory Care Nursing, 2021; American Telemedicine Association, 2018; Mudiyanselage et al., 2018; Lu et al., 2017; Yilmaz et al., 2018). Telenursing is a cost-effective way to longitudinally monitor people’s chronic health status and also facilitates consultations from a safe distance, including in cases of a state of emergency such as the coronavirus disease 2019 pandemic.

Recent studies have indicated that noninvasive telemonitoring can improve care from a distance and positively impact older adults’ health and well-being (Lu et al., 2017; Vegesna et al., 2017; Gokalp et al., 2018; Shany et al., 2017). Moreover, Schlachta-Fairchild et al. (2008) and Kamei et al. (2013) reported that home monitoring-based telenursing (HMBTN) improves health outcomes, self-management, sense of safety, and quality of life (QOL) in people with chronic conditions. It prevents chronic obstructive pulmonary disease (COPD) exacerbations compared with usual hospital visits (Kamei et al., 2011) and reduces hospital admissions (Shany et al., 2017), length of hospital stay, emergency department visits, and other disease exacerbations (Shany et al., 2017; Kamei et al., 2013). HMBTN has the potential to detect early stage changes in people with chronic conditions, such as COPD, amyotrophic lateral sclerosis (ALS), and diabetes mellitus (DM) (Kamei et al., 2018), improve QOL and chemotherapy regimen adherence, and reduce emergency hospital visits in people with cancer (Basch et al., 2016). This series of findings have influenced the Japanese healthcare system. In 2018, home monitoring-based oxygen therapy for COPD provided health insurance coverage (MHLW, 2017). Home monitoring and telenursing have been known to improve symptom management strategies in chronic conditions (Shankel & Wofford, 2016) and satisfaction with lung cancer treatment (Yount et al., 2014); however, whether HMBTN can improve HL in older adults with chronic conditions has not been demonstrated.

HL and enforcing self-management via telenursing

HL is defined as “competencies that relate to accessing, understanding, appraising, and applying health information” in healthcare, disease prevention, and health promotion, where people play an active role in improving their health (Sørensen et al., 2012, p.8-9; Nutbeam, 2015, p.450-456; Nutbeam, 2020, p.259-267; WHO, 2021a, p.4). HL is essential for controlling and managing health as well as improving the QOL of people with chronic conditions (McDonald & Shenkman, 2018). Adequate knowledge and literacy regarding one’s condition and treatments, specifically in the four domains of accessing, understanding, appraising, and applying health information mentioned above, are significant for developing self-management skills and a sense of cohesion, all of which are essential for managing a lifelong condition. To enforce self-management among older adults with chronic conditions, the authors developed an HMBTN using ICT technology. Hæsum et al. (2017) reported greater functional HL in a tele-homecare user with COPD but concluded that the causes of increased HL and the relationships among the four domains were unknown. Therefore, further research exploring these aspects in the context of HL improvement in older adults is required.

The overarching goal of this study was to identify, using a mixed methods approach, whether and why HL among older adults improves through the use of HMBTN. The mixed methods approach emerged as a third research paradigm, along with quantitative and qualitative approaches, in the late 1980s (Tashakkori & Teddlie, 2010; Creswell, 2015). Mixed methods research combines quantitative and qualitative approaches to maximize the understanding of a phenomenon of interest (Teddlie & Tashakkori, 2009; Tashakkori & Teddlie, 2010; Creswell, 2015; Plano-Clark & Ivankova, 2016b; Kakai, 2015). State-of-the-art procedures involve creating joint displays and drawing meta-inferences by integrating quantitative and qualitative data collection and analysis (Creswell, 2015; Fetters et al., 2013). Some HMBTN users with age-related chronic conditions are suspected of having difficulty using new technologies. Thus, the authors sought to illustrate multiple longitudinal meta-inference scaffolding to understand the experiences of these individuals. This included their challenges with the HMBTN given their low HL and the requirement of using the Internet and technical knowledge to benefit from the advanced new home care technology.

Purpose and Research Questions

The purpose of this study was to identify whether and why HL in older adults with chronic conditions such as DM, congestive heart failure (CHF), COPD, ALS, and non-small cell lung cancer (NSCLC) improves during a 12-week HMBTN prospective longitudinal intervention. Furthermore, the authors prospectively examined how this is linked to self-care activities, daily symptoms, experience of home monitoring, perceived health status, and disease stability.

Our mixed methods research question was as follows:

• •Whether and why does HL improve for/among older adults with chronic conditions who have their daily symptoms measured quantitatively, and how is this linked with their longitudinal experience, perceived health status, and disease stability as explored qualitatively over a 12-week HMBTN intervention?

Methods

Design

The authors adopted a prospective, fully longitudinal mixed methods design to maximize the synthesis of multiple sources of HMBTN data. This facilitated a comprehensive understanding of the intervention period for older adults’ self-care, daily symptoms, experience of telenursing, perceived health status, and disease stability in real life. Mixed methods research essentially consists of quantitative and qualitative data collection and analysis phases in response to the research questions (Creswell, 2015). Here, the authors adopted a longitudinal mixed methods design (Van Ness et al., 2011; Plano-Clark et al., 2015; Schumacher et al., 2021). This study utilized two of the three longitudinal designs distinguished based on the timing of data collection during clinical biomedical research: prospective, retrospective, and fully longitudinal. A prospective and fully longitudinal mixed methods approach was implemented based on its utility in investigating phenomena that change over time, such as developmental processes, responses to interventions, and societal trends (Plano-Clark, 2015; Plano-Clark et al., 2015). This study attempted to integrate “prospective,” which means moving forward at a point in one’s real life, and “fully,” which means that the individual participant continuously provides both quantitative and qualitative components. Furthermore, Greene (2007, 2008) explained that in paradigmatic assumptions, as well as context and theory, mixed methods address the complexity of society. Our research design was based on mixed methods dialectical assumptions to obtain a better understanding of older adults’ experiences of HMBTN. Since older adults with chronic conditions using HMBTN showed a dynamic illness trajectory (Kamei et al., 2021), our aim in this study was to ascertain whether the results of quantitative health literacy surveys and those of qualitative interviews (daily physical and mental conditions) are the same or not in their perceptions of the daily state, including psychosomatic state, perceived health status, and experience of receiving HMBTN, affecting HL.

As illustrated in the procedural diagram (Figure 1), our study prospectively converged both quantitative and qualitative data across time points to obtain a realistic interpretation across all meta-inferences, that is, a “super” meta-inference. The quantitative longitudinal strand examined older adults’ HL status at baseline (T2) and 12 weeks post HMBTN intervention (T3), based on a survey. Other quantitative outcomes included self-care activities and daily symptoms, which were recorded to identify possible effects on the outcomes.

Qualitative data were collected through semi-structured interviews at three time points: baseline, mid-term, and post intervention (T2, T2’, and T3). Data were collected to understand the contextual factors and processes that occurred during the intervention. Data on disease stability were collected qualitatively from the healthcare and telenursing session records over 36 weeks (T1–T4).

Study framework

The assumptions, outcomes, and variables that guided the study framework are shown in Figure 2. The framework also shows the intervention process, the study concept, and the timeframe. A 12-week HMBTN (T2–T3) intervention can affect older adults’ HL through 1) daily consideration of vital signs, 2) answering questionnaires with healthcare providers’ feedback about their self-care and disease symptom management (measured quantitatively), and 3) their HMBTN experiences such as perceived health status and disease stability (measured qualitatively).

HL assessment was primarily used to supplement quantitative HL improvement. We subsequently added value to the participants’ qualitative experiences and states to understand the complex dialectical situation in a prospective, fully longitudinal strand.

HMBTN intervention

Kamei et al. (2007) and Kamei et al. (2018) developed a patented (Japanese patent No. 5276806, 5352193) personal computer-type tablet 19-item HMBTN system comprising nine physical states (oxygen saturation, pulse rate, blood pressure, body temperature, peak flow, body weight, defecation, urine output, and sputum parameters), five activities of daily living (steps, sleep, appetite, activity, and home oxygen use), five symptoms (breathlessness, edema, physical pain, symptoms, and overall condition), and medication adherence to self-assess their health (Figure 3). Complete details of the system have been previously provided (Kamei et al., 2007; Kamei et al., 2018). The older adults conducted their health assessments every morning and sent their data to the monitoring center. They were provided with feedback and triage services in case of any concerning change in their health status.

Setting

Four geographically convenient institutions (one clinic and three hospitals) in Tokyo and Kawasaki City, Japan, participated in this study. The researchers asked the primary physician to distribute recruitment flyers to the patients based on the inclusion criteria from May 2016 to December 2021.

Participants

Patients who voluntarily chose to participate in the study were directly referred to the researchers. Nineteen outpatients were willing to participate in this study.

Inclusion criteria

Participant eligibility criteria were as follows:1) visit to a physician on a monthly or bi-monthly basis; 2) age ≥ 60 years; 3) no diagnosis of dementia; 4) ability to read/write Japanese; 5) basic skills to take prescribed medication or undergo treatment; and 6) one of the five chronic disease diagnoses: DM, CHF, COPD, ALS, or NSCLC receiving chemotherapy.

Sampling strategy

The sampling for a mixed methods study must respond to the research question, and it depends on whether both qualitative and quantitative data are to be collected from the same or different individuals (Ivankova, 2015, p.181-217). The sample size required to rationalize the use of a mixed methods design is not yet clear. In this study, we prospectively collected both types of data from each participant and performed multiple time point convergences to draw super meta-inferences regarding whether and why HL improves/does not improve, the link to their experiences of HMBTN, and whether the acceptance or contradiction of their daily state and perceived health status of receiving HMBTN affects HL. Therefore, all consenting individuals who received HMBTN during the study period were included in the sample. Since the clinical application of telenursing in Japan is still limited, there were few cases in each clinic willing to participate in the study.

Data collection

Quantitative data collection

Per the study procedures, primary outcomes (HL) and other outcomes (self-care and daily symptoms) were measured using self-administered questionnaires (Table 1).

HL.

Based on Sørensen et al. (2012), the authors defined the four domains of older adults’ telemonitoring and telenursing-related HL as accessing, understanding, appraising, and applying the HMBTN. The research team discussed and constructed an original 15-item HL questionnaire to measure HL, with telemonitoring as the primary outcome. The survey content included one item on accessing literacy (collecting disease information), six items on understanding literacy (understanding how to use telemonitoring and other related materials), three items on appraising literacy (incorporation of home monitoring equipment), and five items on applying literacy (asking healthcare providers about telenursing and illness, and managing and transmitting data at a certain time). The baseline questionnaire had a Cronbach’s α of .89, and the exploratory factor analysis confirmed three domains of HL: accessing and applying (factor 1, contribution rate 41.3%), understanding (factor 2, 20.7%), and appraising (factor 3, 12.5%) HL (cumulative contribution rate 74.5%).

Self-care.

Fifteen self-care activities, such as cooking, walking, clothing, bathing, home rehabilitation, and medication (range 0-15), and 20 items on self-care awareness, such as maintaining food/intake, respiratory rehabilitation, and family relations (range 0-20) were measured using an original checklist. Depression was measured using the Japanese version of the Geriatric Depression Scale-5 (Toba, 2003) (range 0-5) at T2 and T3.

Daily symptoms: breathlessness, self-rating overall symptoms.

Breathlessness was measured using the modified Borg scale (Borg, 1982) (range 0-10). The overall symptoms were self-rated using a visual analog scale (range 0-10). These data were collected daily using the HMBTN system.

Qualitative data collection

Semi-structured interviews were performed at baseline (T2), mid-term at eight weeks after the intervention (T2’), and after 12 weeks of intervention (T3) to explore each participant’s perceptions, experiences, and perceived health status (Table 1). All interviews were conducted in Japanese, transcribed verbatim, and analyzed in Japanese. They were subsequently translated into English and back-translated into Japanese to confirm translation accuracy.

Baseline conditions and perception of HMBTN.

At baseline (T2), participants were interviewed about their current condition and perceptions of the HMBTN.

Experience of HMBTN and perceived health status.

At T2, T2’, and T3, semi-structured interviews were conducted to understand participants’ experiences of HMBTN and perceived health status as primary outcomes. Telenursing records also reflected these outcomes.

Disease stability.

Healthcare records were reviewed to evaluate disease stability by assessing the treatment course, prescription, and number of exacerbations before and after the 12-week intervention for a total period of 36 weeks (T1–T4).

Analyses

Quantitative data analysis

Quantitative data were analyzed using the Wilcoxon matched-pairs signed-rank test with median variables. The significance level was set at p < 0.05 using the Japanese version of SPSS® Statistics (version 24.0; IBM SPSS, 2016).

Qualitative data analysis

The interview records were analyzed using text mining techniques for qualitative content analysis using the Japanese version of Text Analytics for Surveys version 4.0.1 (IBM SPSS Text Analytics for Surveys, 2015). In the Japanese text, we relied on morphological analyses to identify the effects of participants’ experiences on HMBTN and HL improvement. The text was morphologically analyzed at each time point. The research team categorized frequently appearing phrases using extracted nouns and verbs (Yu et al., 2011). In the analysis, the researchers discussed each category until a consensus was reached.

Prospective fully longitudinal mixed data analysis

The current study involved older adults’ responses to the HMBTN intervention. After completing the quantitative and qualitative data analyses independently, comprehensive prospective integration of the data was conducted using joint display analysis. The joint display is a method of integrating quantitative and qualitative results (Tashakkori & Teddlie, 2010; Creswell, 2015), extracting meta-inferences (Plano-Clark & Ivankova, 2016a), and juxtaposing related quantitative and qualitative data to draw further interpretations (Fetters, 2020). Fetters (2020, p.194) defines joint display analysis as “the process of discovering linkages between the qualitative and quantitative constructs, organizing and recognizing the findings into a matrix or figure to optimize the presentation as a finalized joint display,” and interpreting the mixed findings.

As the team extracted two prospective meta-inferences to expand the understanding of older adults’ experiences with HMBTN at multiple time points, for the prospective assessment of HL changes, the authors performed an overarching interpretation of the multiple meta-inferences from the longitudinally collected data from all time points. This was done to draw a realistic conclusion regarding the overall integrative interpretations, labeled “super meta-inferences.” The authors believe that this type of prospective, fully longitudinal analysis promotes a dialectical understanding of older adults’ perspectives as well as HMBTN practices that can be effective in the future.

Ethical considerations

The participants were given an explanation of the study’s purpose and methods. They were also informed that they could withdraw at any time without a penalty. Enrollment commenced after the recruited individuals provided written informed consent. The institutional ethics committee of the first author approved this study (Approval No.16-A079 and 20-A013).

Results

Participant attributes

Of the 19 individuals who voluntarily participated, one withdrew before providing consent because of hospitalization. Therefore, 18 older adults with a median age of 70.5 years (range 60-95) participated in this study (Table 2). The participants were mostly men (78%), lived with their families (78%), and had comorbidities (72%). Three patients were classified as stage 3 (irreversible diabetic nephropathy) type 2 DM based on the Kidney Disease Improving Global Outcomes (2013) staging system; six were classified as New York Heart Association class II (mild) or III (moderate) CHF (American Heart Association, 2017); two had stage IV (very severe) COPD according to the Global Obstructive Lung Disease Criteria for using home oxygen therapy (Global Initiative for Chronic Obstructive Lung Disease, 2022); five participants with ALS had scores greater than 21 out of 48 points on the Amyotrophic Lateral Sclerosis Functional Rating Scale (1996); two had the American Joint Committee on Cancer (2017) Tumor Lymph Node Metastasis staging system NSCLC ⅢA. Seven participants (39%) were regular computer users, and all were able to operate a tablet computer independently at enrollment. Primary disease exacerbation before (T1 to T2) and after (T3 to T4) the 12-week intervention period was not　observed, except in two participants (CHF and ALS) (Mr. C, 61 years old (y.o.) and Ms. O, 60 y.o.).

Sixteen participants completed the program, and the primary disease conditions of 13 participants remained stable during the intervention (T2 to T3). Three participants were diagnosed with exacerbation during the study; one participant with CHF (Mr. C) had a prescription change because of several episodes of acute disease progression, and two participants with ALS (Mr. A, 60 y.o. and Ms. O) were diagnosed with ALS progression. Ms. O was admitted and discharged from the hospital during the intervention. Despite no diagnosis of primary disease exacerbation, one participant with NSCLC who received regular chemotherapy (Mr. J, 72 y.o.) showed side effects and was hospitalized and discharged from the hospital during the study; all four provided data from T1 to T4. However, two participants (Mr. G, 69 y.o. and Mr. M, 87 y.o.) withdrew on days 16 and 6, respectively, because of undiagnosed cognitive decline identified after enrollment, which caused difficulty in self-monitoring (Table 3)

Telemonitoring and telenursing intervention

Six to 249 days (median, 100 days) were telemonitored with 26-100% (median, 99.5%) adherence. A total of 18.0% (median) of the monitoring days were triggered (suspected threshold).

A telenurse contacted the participants three to 48 times (median, 11.5 times) by videoconferencing or phone (Table 3).

HL improvement and other outcomes

The data of the 16 participants who completed the 12-week HMBTN intervention (three with DM, four with CHF, two with COPD, five with ALS, and two with NSCLC) were statistically analyzed (Table 4). Comparing the baseline (T2) and post intervention (T3), the total HL score (median) did not improve (p = .255); however, the subscales of understanding HL (Q 6: Understanding how to use telemonitoring and telenursing) (p = .039) and applying HL (Q 10: Can tap and manage screen well) (p = .031) showed statistically significant improvements. In the sub-group with increased HL (n = 9); the median baseline score went from 42.0 to 54.0 post intervention (p = .007), in the group with no change in the HL immutable group (n = 5); and in the group with declining HL (n = 2), the median baseline score went from 55.0 to 53.0 (p = .197) and from 60.0 to 47.0 post intervention (p = .180), respectively.

As for the other outcomes, self-care awareness and disease symptoms did not differ between the two time points. However, self-care activities improved significantly (p =.002).

Participants’ experiences with HMBTN

A total of 459 text segments were extracted into 39 sub-categories (T2 with 12, T2’ with 12, and T3 with 15 sub-categories), which were integrated into 14 categories (T2 with four, and T2’ and T3 with five categories). Examples of the participant narratives are presented in Table 5. The underlined text indicates the participants who were diagnosed with exacerbation of the primary disease from T2 to T3

Baseline (T2): Reflection on lifestyle and set goals despite some worries.

At the beginning of the intervention, the participants explained their self-care expriences such as diet and food intake, exercise, and/or weight control. All participants hoped to improve their physical condition and were interested in using telemonitoring to achieve better daily life and physical status, as exemplified by statements such as, “I am careful about my food, sodium, and water intake” (Participants I and M). Others indicated that they tried to use the HMBTN to live a better daily life through their own small goals, as exemplified by the statement, “I think telenursing helps me live a healthy routine life” (Participants J, P, and R). These were categorized into “reflection on lifestyle” and “set goals according to one’s lifestyle.” However, they also expressed ambivalent feelings of worry and expectations regarding managing the home monitoring equipment and self-monitoring: “I don’t know how HMBTN will help as of now” (Participants F, I, J N, and O). Conversely, one participant expressed, “It’s good to know the conditions of health and the progression of illness on a daily basis” (Participants E and K). These were categorized into “worries and expectations regarding HMBTN.” They expected that the HMBTN would simplify the process of asking their healthcare providers questions, seeking advice about their daily concerns, and feeling connected to healthcare providers, even at a distance. However, some participants stated, “I think it’s convenient as I can make video calls and ask questions easily” (Participants H and Q). These were categorized as “a sense of security that the healthcare provider is nearby.”

Mid-term (T2’): Recognition of the effect of continuous monitoring with encouraging dialogue and adaptation, versus the difficulty of self-management.

Sixteen participants continued self-monitoring while two withdrew. These two groups’ experiences were different. In the continued group, daily monitoring led to noticing even small physical changes and daily confirmation of their disease condition. Numerical monitoring data made it easy to understand daily conditions: “I can be rest assured as the conditions are visible numerically” (Participants J, L, O, and R). These experiences improved daily conditions and were categorized into “recognition of one’s current state by visualizing daily physical conditions.” The participants stated that they understood that they were getting better by observing numeric values, that their walking steps had increased, and that they were better motivated to use the HMBTN. They hoped to get better and wished to continue: “I wake up at a regular time to manage the monitoring system; thus, my lifestyle has become regular” (Participants F, K, P, and R). These experiences enabled the development of a new positive lifestyle and were categorized into “understanding the positive effect of continuous monitoring.” Other participants stated, “My daughter/wife helps me with the telenursing console” (Participants F, K, and N). Their dialogue with family, friends, telenurses, and/or visiting home helpers about their health status increased and was categorized into “encouraging dialogue with others.” Furthermore, they reflected on their past self-care actions and began to set self-monitoring goals. At this time point, home monitoring had become manageable: “At the introduction stage, data transmission from the tablet was difficult; however, after understanding it, I have experienced no problem” (Participants L, N, and Q). These experiences were categorized into “adaptation to self-monitoring and self-management.” However, the two participants who withdrew had difficulty operating the equipment owing to cognitive decline: “The pulse oximeter was difficult to operate because I’m too old” (Participant M). Classified as “difficulty in self-management of HMBTN,” this category typically appeared only in the withdrawal group.

Post intervention (T3): Appropriate lifestyle and motivation, confidence, and a better understanding of one’s physical state, versus facing a worsening condition and seeking relief.

Sixteen participants completed the HMBTN intervention, including 13 who showed a stable pattern for 12 weeks and three who were diagnosed with acute exacerbations during T2 and T3. Their experiences showed greater variation. In the stable pattern group, “There was no basis for understanding my physical condition before HMBTN but now it can be seen from measurements regularly” (Participants E, F, J, Q, and R). They had “acquired the appropriate lifestyle from HMBTN” through self-checking and sending data to the monitoring center on a daily basis. They felt the effectiveness of continuing self-monitoring, their sense of security and motivation improved, they understood the advantages of maintaining an appropriate lifestyle, and hoped to continue with HMBTN. They were able to identify trends in their daily physical condition and link the monitoring data to their symptoms or lifestyles. They engaged with caregivers such as visiting services rather than their families: “It became easy to understand the swelling and changes in body weight after receiving telenursing” (Participants C, H, and L). These were categorized into “acceleration in appropriate lifestyle and motivation by sharing data.” They talked and exchanged information with family members to further improve their condition. They engaged with a broader range of people than just family members, and even if the monitoring data fluctuated, they could respond to symptoms: “I increased my walking speed” (Participant F) and “By graphing daily data, I could understand the changes in my body, which helped maintain my condition” (Participants K and Q). Such experiences were categorized into “being confident and better understanding of self-state and symptoms.” In contrast, the daily monitoring of the exacerbation group (n = 3) showed a worsening condition; the disease progression was clear: “The feeling of trying as much as I can against the reality of the illness progression that I face every day” (Participant O). These experiences were categorized into “facing the reality of disease progression.” In such circumstances, they wished to talk more with healthcare providers in person to get relief whenever their health declined: “There wasn’t much interaction with nurses, but there was always a sense of security” (Participant O and R). These experiences were categorized as “seeking a sense of relief through direct communication with healthcare providers.”

Discussion

In this section, the qualitative and quantitative prospective longitudinal components are converged to understand how they are linked to HL changes in older adults with chronic conditions using the HMBTN.

HL improvement and experiences over a 12-week HMBTN intervention

We integrated the quantitative and qualitative results, focusing on the quantitative changes in HL along with the qualitative experience of HMBTN among older adults with chronic conditions. We also examined how these factors were linked to self-care activities and daily symptoms. The quantitative and qualitative results at two time points (T2 and T3) were independently converged, jointly displayed, and meta-inferred (Table 6). These two meta-inferences were then integrated into a super-meta-inference model (Table 6).

At baseline (T2), older adult participants showed little (1.5 of 20 points) awareness and no depression [Geriatric Depression Scale-5:1.5 of 5 points]. However, during the interview at the introduction stage, they all reflected on their past lifestyle and expressed not only their expectations from telenursing but also their worries about introducing HMBTN. These ambivalent emotions toward HMBTN could only be found through interviews. The meta- inferences showed that self-care activities and awareness would affect motivation toward HMBTN and have a positive effect on a better lifestyle. These emotions show a conflicting proposition between expectations and worries; in other words, a dialectical experience of new technology use in the challenges of older adults.

At mid-term, participants gained more confidence from visualizing their daily physical conditions and adapted their life to self-monitoring and self-management, which led to the expansion of self-care activities. After the HMBTN intervention, older participants showed a significant improvement in their application and understanding of HL. Older adults gained a sense of security with the use of telemonitoring and telenursing, and were better motivated and confident about improving their lifestyles, which led to the expansion of their activities. These results indicate that by maintaining physical functions and activities with continued self-monitoring and management, their HL in the application domain improved with data transmission from the tablet, and they developed skills to manage the tablet screen by themselves. While all the older adults had worries about HMBTN at the beginning, their experience with it helped them realize the benefits of visualizing their daily physical conditions. This experience was used to improve self-care by objectively monitoring their condition as part of their daily routine. They adapted to equipment management through daily experiences, which helped them visualize their physical status, thereby recognizing the positive effects of continuous telemonitoring. Particularly, the applying domain, “Can tap and manage screen well” (p = .031) and the understanding domain, “Understanding how to use telemonitoring and telenursing” (p = .039) significantly improved in the group that completed the intervention. These findings suggest that older adults can become proficient in utilizing new technologies and integrating them into their lifestyles through their daily use. For older adults, it can be said that acquiring such skills is HL itself. In this population, the application of telenursing greatly differs from that of the younger generation, and to understand how older adults are able to acquire this literacy, asking them about their experiences and quantitatively assessing literacy with a prospective fully longitudinal mixed methods methodology is advantageous. Moreover, regarding the management of chronic diseases, Mudiyanselage et al. (2018) reported that a 12-month home-based telehealth monitoring program improved anxiety and depression and spontaneously affected HL in the COPD group. In the current study, however, the relationship between HL and depression or other symptoms was not clarified owing to the small number of participants with depression. Their worries expressed in the baseline interview were not expressed in the mid-term interview, suggesting that the psychological state is somewhat linked to improved HL. Moreover, Halcomb et al. (2016) reported that although telemonitoring equipment initially seemed complicated for older adults with chronic conditions and no prior computer experience, more than half were able to use the system. In this study, 44% of participants in the completion group were regular computer users. These results suggest that the former computer experience has some advantages in improving older adults’ HL in telemonitoring.

At T3, post intervention, the accomplishment group showed HL improvement, accelerated adoption of an appropriate lifestyle, higher motivation, and a sense of confidence. They understood their conditions better than they did at the baseline. They gained a sense of security through the utilization of the HMBTN, and their motivation improved. Additionally, patients with NSCLC receiving chemotherapy discovered several symptoms related to medications during monitoring, although the telenurse had already detected skin and other symptoms via the videoconferencing strategy. Thus, overall management prevented the worsening of side effects and might have improved HL. The super-meta-inferences from this study showed that HL improvement in older adults through HMBTN was linked to the fact that they understood their daily state via monitoring, gained confidence in understanding their symptoms, improved their lifestyle to accelerate the gains achieved through HMBTN, and maintained their motivation. This has been suggested to positively affect self-care activities. As discussed above, older adults’ experience of HMBTN goes beyond their worries at baseline. They will be able to experience its benefits with the daily use of the system, the relief from which brings about a new lifestyle. These processes can only be understood via the prospective and fully longitudinal integration of qualitative and quantitative strands.

Disease exacerbation and experience during HMBTN

The participants with exacerbations of ALS (Mr. A and Ms. O) expressed painful experiences of disease progression through daily monitoring. They experienced rapid disease progression and received noninvasive ventilation and tube feeding. Another participant with CHF (Mr. C) experienced exacerbated primary chest symptoms and received intravenous medications. These participants showed no changes in HL, and understanding their daily conditions numerically and objectively through telemonitoring did not lead to feelings of self-management. Telemonitoring services for chronic conditions are rapidly spreading in several countries (Gokalp et al., 2018; Kamei et al., 2018; Al Rajeh et al., 2019), enabling early exacerbations. Although telenursing for people with progressive and incurable diseases cannot control their symptoms, better self-care leads to early detection and response to disease progression and may lower the risk of elevating pain. Those who dropped out early were contacted three or five times telephonically during a six- or 16-day intervention (Table 3), and they needed extensive mentoring. Nevertheless, it must be noted that some may not wish to know the seriousness of their condition, and it is necessary to pay particular attention to such feelings in people with progressive diseases. Additional in-person mentoring is required to mitigate such risks.

Self-monitoring comprises awareness and observation/measurement (Wilde & Garvin, 2007). We found that participants were initially worried about self-monitoring, but their confidence in improving self-management led to an expanded capacity for daily measurements and objective data observation. HL is not just a personal resource but also a social benefit and public goal (Nutbeam, 2000; WHO, 2021a); and each health sector, including telenurses, should provide appropriate support in times of triggered situation and ensure significant health outcomes for older adults with chronic conditions by utilizing new healthcare technologies.

Contribution to mixed methods research

Regarding the methodological aspect, the primary focus of this study was to understand the positive changes that occurred among older adults concerning HL, through their experience of using new technologies at home. Such a study should involve both inductive and deductive, fully longitudinal prospective approaches to comprehensively understand what is common and what is different in older adults’ experiences in the context of the passage of time. Moreover, in the outcome measurement of prospective interventions with long durations, the range of approaches has evolved to add value through data integration to conduct mixed methods interventional evaluations (Fetters & Molina-Azorin, 2020). Thus, interviews and questionnaires were conducted. While converging the inductive and deductive approaches prospectively, quantitative and qualitative variables were integrated, and repeated meta-inferences were made longitudinally. This study adopted the perspective of an individual’s real life, continuously providing quantitative and qualitative data integrated at multiple points in time to gain a comprehensive understanding of the phenomenon. In the context of the interpretive consistency of quantitative and qualitative strands, Greene (2007) pointed out that “inference and interpretation are fundamentally human cognitive processes” (p.142). Therefore, our meta-inferences and super-meta-inferences are credible representations of the research results. This type of prospective, fully longitudinal mixed methods study contributes not only to clinical and home care nursing but also to other disciplines to elucidate both quantitative and qualitative perspectives.

Limitations of the study

The sample size was limited to five primary diseases within a specific geographical area in central Japan. The measure of HL with the HMBTN had a high Cronbach’s α and a three-domain component; however, this should be verified by increasing the number of participants. In the HL items from Q10 to Q14 post intervention, all participants had a perfect score, indicating a ceiling effect. This study included all new telenursing users in the study period without prior literacy screening, which involves a potential bias, as this group could have been more interested in improving their HL than general Japanese older adults with chronic conditions. Further studies with appropriate sample sizes are required to legitimize the prospective, fully longitudinal mixed methods data collection methodology, and a greater variety of chronic conditions must be used to explore older adults’ experiences and outcomes through HMBTN.

Implications of the study findings

When implementing telemonitoring with telenursing for older adults with chronic conditions, healthcare providers should assess whether the HMBTN is an appropriate approach in terms of HL improvement, disease stage and conditions, and psychological aspects. In the event of acute worsening of conditions or cognitive impairment, if the participant is unable to manage the equipment and/or self-monitoring becomes a burden, the telenurse should share their observations with healthcare providers and/or community care services to discuss other options for appropriate support, including in-person visiting care.

Conclusion

A 12-week HMBTN intervention among older adults with DM, CHF, COPD, ALS, and NSCLC led to improvements in accessing and understanding HL in terms of managing the equipment, specifically in the group that completed the intervention. The participants adapted well to equipment management, which helped them visualize their physical status and recognize the positive effects of continuous telemonitoring. Improvement in HL among older adults with chronic conditions is linked to their proficiency in utilizing new technologies with appropriate lifestyle changes and a sense of confidence gained through daily HMBTN. These findings suggest that older adults can become proficient in utilizing new technologies through daily use and integrating them into their lifestyles. Further research is required to assess the eligibility of older adults with chronic conditions to adopt self-telemonitoring.

Acknowledgments

The authors acknowledge all the participants, physicians, and nurse collaborators involved in data collection for this study. The authors also thank Yoshiko Fujimura, RN, CNS, Hachinohe City Hospital, Aomori, Japan, and Aki Kawada, RN, MSN, Former Assistant Professor, St. Luke’s International University, Tokyo, Japan.

IRB approval

This study was approved by The Ethics Committee of St. Luke’s International University (16-A079 and 20-A013).

Author Contributions

Tomoko Kamei, Yuko Yamamoto, Takuya Kanamori, and Yuki Nakayama designed the study and collected and analyzed the data; Tomoyo Harada collected the data; and Kazumi Nishio, Yasushi Nakano, and Michael D. Fetters supervised the data analysis. All authors prepared, critically reviewed, and approved the final manuscript.

Declaration of Conflicting Interests

The authors declare that there are no academic or financial conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclose receipt of the following financial support for the research of this article: This study was supported by the Japanese Grants-in-Aid for Scientific Research [Scientific Research (B) 16H05598 and (A) 19H01082].

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