Design of a personalized e-coaching module on physical activity and nutrition for people with chronic diseases and low health literacy

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Design of a personalized e- coaching module on physical activity and nutrition for people with chronic diseases and low health literacy

Julia Borgman

Creative Technology – University of Twente

Supervisor: Wendy Oude Nijeweme - d’Hollosy Critical Observer: Laura Schrijver

July 2^nd 2020

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Abstract

Low health literacy is an often overlooked problem for many patients and health care providers. Especially low health literate patients with chronic diseases, that require continuous self-monitoring, may experience a decrease in the understandability of health related information and, simultaneously, in overall health condition. E-coaching applications enable personalized

coaching and guidance to improve the health of patients with chronic

diseases, such as diabetes type 2. However, these e-coaching applications are often difficult to understand for low health literate users, decreasing the overall efficiency of these applications.

This research studies different strategies that can be implemented into eHealth applications, such as e-coaching applications, to improve the

understandability and efficiency for low health literate users. This research studies and evaluates several strategies on a variety of design methods, such as formulation, visual aids and interface design. A guideline was created, in two different versions, that helps application developers to adjust or improve their applications and contents for low health literate users. This guideline was applied to reformulate and redesign messages on physical activity and nutrition from an e-coaching application for patients with diabetes type 2.

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Acknowledgements

First, I would like to thank my supervisor Wendy Oude Nijeweme - d’Hollosy and my critical observer Laura Schrijver, for their amazing help and guidance during this research, especially during the situation regarding COVID-19.

Furthermore, I would like to thank Eline Heemskerk from the Dutch foundation “Pharos” for her important advice and expertise on the topic of low health literacy. Additionally, I would like to thank both health care professionals for their participations in the interviews and for sharing their experiences regarding low health literacy in their work fields. Lastly, I would like to thank all participants, who participated in the first and second

evaluations of my research.

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List of figures

Figure 1: Individual, external and socioeconomic influences of health literacy,

according to the framework by Paasche-Orlow and Wolf [12] ... 15

Figure 2: Three causal pathways that display the influence of health literacy on health outcomes from the framework of Paasche-Orlow and Wolf [12] .... 16

Figure 3: The Creative Technology Design Process [35] ... 26

Figure 4: Implementation of CTDP ... 28

Figure 5: Larger widgets and consistent layout, with error recovery mechanism ... 32

Figure 6: Small widgets and consistent layout, including scrollbar and error recovery mechanism ... 32

Figure 7: Different input methods: selection box, radio button and interactive icon ... 32

Figure 8: No caption ... 35

Figure 9: Share your progress with others to increase your motivation. ... 35

Figure 10: Contrast difference in the same drawing: a) no colour, b) no contour lines and low contrasting colours, c) low contrasting colours with contour, d) high contrasting colours with contour ... 36

Figure 11: Colour wheel ... 36

Figure 12: Process of creating the questionnaire for low health literacy. ... 37

Figure 13: Multiple choice question about physical activity ... 38

Figure 14: Multiple choice question exploring different input methods. ... 38

Figure 15: Multiple choice question about different choice of colours. ... 39

Figure 16: Pie chart indicating participant preference between audio, sentences and visual aids. The visual aids include captions. ... 40

Figure 17: Visualization indicating differences between phases. ... 41

Figure 18: Original message about nutrition ... 44

Figure 19: Reformulated message on nutrition. ... 44

Figure 20: A percentage of created visual aids with captions. ... 45

Figure 21: One of the questions from the second questionnaire ... 46

Figure 22: Visualization of the results from the second questionnaire. ... 48

Figure 23: Internal and external stakeholders ... 57

Figure 24: Affective and cognitive components of internal stakeholders [43] 57 Figure 25: Fundamental canons of engineers [50] ... 61

Figure 26: Possible misuse of identified for this project ... 62

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8 Figure 27: Schematic of intentionality and severity of possible misuse ... 63 Figure 28: Page 1 of the paper guideline. ... 65 Figure 29: Page 2 of the paper guideline ... 66 Figure 30: Screenshot of the Excel sheet containing messages on nutrition and physical activity. ... 72 Figure 31: Screenshot of a small percentage of the visual aid database on Google Drive... 73

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List of tables

Table 1: Health literacy levels ... 14

Table 2: Summary of design methods targeted at low literacy and low health literacy. The following sources were used: research papers on mobile interface design for low-literate populations and visual aids [31] [32], factsheets and checklists from Dutch literacy and health foundations [28][33][34], as well as the Patient Education Materials Assessment Tool (PEMAT) [29] ... 21

Table 3: Mobile interface design strategies ... 31

Table 4: Formulation strategies ... 33

Table 5: Selection of audio(visual) aids ... 34

Table 6: Visual aid design strategies ... 35

Table 7: Response frequencies for messages on physical activity and nutrition ... 40

Table 8: Answer frequencies of 25 participants ... 42

Table 9: Response frequencies of the second questionnaire, where Q stands for “question” ... 47

Table 10: Possible risks ... 54

Table 11: Paradigm cases with ethical failure and successes. The (+) indicates a successful case. ... 60

Table 12: Current value statement (the statement can be supplemented during the project process) ... 64

Table 13: Response frequencies for the awareness phase ... 82

Table 14: Response frequencies for the motivation phase ... 82

Table 15: Response frequencies for the action phase ... 82

Table 16: Response frequencies for the behaviour phase ... 83

Table 17: Response frequencies for messages on physical activity ... 83

Table 18: Response frequencies for messages on nutrition ... 83

Table 19: Response frequencies of question 1 ... 93

Table 20: Response frequencies of question 2 (for this question no participants selected the reformulated message) ... 93

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1. Introduction

1.1 Background

Developments within the fields of health care and technology result in the emergence of e-health [1]. E-health refers to “health services and information delivered or enhanced through the Internet and related technologies” [2]. As a result, a large amount of health related information is accessible to a

substantial part of society. This opportunity represents many benefits for caregivers and recipients, such as quality enhancement and cost containment [3].

Especially people with chronic diseases, that require continuous monitoring and attention, can benefit from this innovation. According to the World Health Organization, chronic diseases form the leading causes of death and disability around the globe [4]. Prominent chronic diseases are cancer, type 2 diabetes, cardiovascular diseases and chronic obstructive pulmonary disease.

Multiple preventable risk factors have a high influence on the course of these diseases, such as overweight, high blood pressure and high cholesterol levels.

In turn, these risk factors are related to behaviour patterns, such as unhealthy eating behaviour and physical inactivity. Therefore, the prevention and control of chronic diseases, by influencing the risk factors and related behaviours, is an important priority to improve global health [4].

Self-management through electronical applications, such as e-coaching, that are specifically designed for the needs of patients with chronic diseases, can influence these risk factors and behaviours [5]. Besides personal health benefits, e-health can relieve pressure on the health care system, due to remote assistance of health care professionals and the prevention of additional disease related complications [4].

Yet, not everyone experiences these benefits. A part of the population has difficulty with understanding and processing health related information.

In the Netherlands, 2,5 million people have low literacy and 36% of the adult population has limited health proficiency [6]. People with low literacy have difficulty understanding, processing and using (written) information, such as understanding numbers in certain contexts or reading daily newspapers [7].

Low literacy influences the level of health literacy. People with low health literacy have difficulty with understanding, processing and effectively using information that is related to their health.

As a consequence, some people with low health literacy might have difficulties during spoken conversations with health care professionals, while others may experience difficulty understanding leaflets about their health condition [8].

For low health literate people with a chronic disease, understanding and effectively implementing information with respect to their disease, can form a major obstacle [6]. In this situation, e-health applications may not be applicable to the person or they may not obtain the desired outcome. The design of an application that is understandable and helpful for low health literate people with a chronic disease poses a challenge for the developers.

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1.2 Aim of the research

The aim of this research is to (re-)design an existing e-coaching module in a way that people with low health literacy can understand, process and effectively use this application with respect to their chronic disease.

This e-coaching module, the ‘Diameter’, is developed by Roessingh Research and Development (RRD) in cooperation with the University of Twente and the Ziekenhuis Groep Twente (ZGT). The Diameter is an application that assists people with type 2 diabetes mellitus, to control their glucose levels. The app uses continuous measurements of blood glucose levels, heart rate, physical activity, nutrition and medication of the individual. These continuous measurements enable real-time personalized feedback based on an individually predicted model for glucose level control. The Diameter provides information and feedback on nutritional and physical behaviour in the form of motivational messages. The application aims to provide both short term benefits, such as personal well-being, as well as long term benefits in the form of risk prevention.

The Diameter is not specifically personalized for people with low health literacy. Consequently, people with low health literacy can have difficulty to understand and interact with the application, which can result in undesired outcomes.

The motivational messages on nutritional behaviour and physical activity that are incorporated within the Diameter may require reformulation to make them applicable for low health literate users leading to the need to redesign the application content, layout and the means of user interaction based on the needs of the target group.

The aim of this research is to reformulate and design e-coaching messages related to physical activity and nutrition for users with low health literacy. Additionally corresponding guidelines are constructed for the developers of this eHealth application, which may also be implemented for applications which involve other chronical diseases than type 2 diabetes.

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1.3 Research questions

For this research, the main research question is:

“How to redesign a personalized e-coaching module on physical activity and nutrition for people with chronic diseases and taking into account low health literacy?”

To answer this research question, five sub-research questions were formulated:

1. “What is low (health) literacy?”

2. “How does low health literacy affect people with chronic diseases?”

3. “What is the behaviour pattern of people with low health literacy and a chronic disease with respect to a healthy behaviour pattern?”.

4. “How to make health related information understandable for people with low health literacy?”

5. “What are known effective methods to make information understandable for people with low health literacy?”

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2. State of the art

This chapter consists of literature research on the topic of this research. The state of the art is divided in various subchapters, following the line of the sub research questions from chapter 1.3. A section of the state of the art is based on the final literature review report from the academic writing course of Creative Technology.

2.1 The meaning of health literacy

Before a deeper understanding into the aspects of health literacy can be established, the term ‘Health Literacy’ must be defined. Health literacy is a relatively new term within the health promotion field. It is often defined as the ability to understand and to use health related resources [9]. This definition focuses on the functional aspects of health literacy from an individual’s perspective, but does not address the broader context. Besides personal benefits, health literacy can also provide social benefits and contribute to change within health education and communication methods [9].

The definition of health literacy, according to the World Health Organization (WHO), addresses this additional social aspect [9]. The WHO describes health literacy as the following: “Health literacy represents the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health.” [10, p. 357]. Health literacy is directly connected to and dependent on the literacy level of the individual. Following the definition of UNESCO, literacy is the “ability to identify, understand, interpret, create, communicate and compute using printed and written materials associated with varying contexts” [11]. A high literacy level can increase the autonomy and personal empowerment of an individual, however high literacy levels do not guarantee that an individual reacts to health related information or services in the intended way. This is caused by additional dependence on environmental aspects and personal responses, such as communication and social skills. Therefore, when addressing health literacy, not only cognitive skills of the individual should be addressed, but also the social, economic and environmental determinants of health [11].

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14 Table 1: Health literacy levels

These three levels provide more insight into the different classifications of health literacy and the corresponding benefits. As a result, different levels of health literacy can be applied for different purposes, that may range from creating flyers about chronical diseases to setting up community courses about health care applications.

The e-coaching application that is addressed within this research aims to enable personal autonomy towards the user and therefore focuses on interactive health literacy.

Health Literacy Level

Definition Effects Examples

Functional

health literacy Consists of the communication of information related to heath risks and how to handle the health care system

Focus on personal

benefits Promotion of

immunization programs, creation of accessible health information flyers Interactive

health literacy Consists of the communication of health related

information, as well as opportunities to develop personal skills in a supportive environment

Focus on the development of personal autonomy

Offering health education courses at public schools and creating social support groups

Critical health

literacy Consists of all of the above, as well as the provision of information about the social and economic determinants of health and the

opportunity for policy or organizational change

Contributes to personal and social actions

Facilitation of health resources within a

community and enabling communication between

community leaders

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2.2 Low health literacy and health outcomes

In this chapter, a frameworks is addressed that describes the relationship between health literacy and health outcomes. Paasche-Orlow and Wolf proposed a framework, which describes systematic, interactional, and self- care mechanisms by which low health literacy is likely to lead to worse health outcomes [12]. This framework gives more insight into the promising areas for the development of health-care intervention, as well as health care related behaviours that are associated with low health literacy [12].

2.2.1 The influential factors of health literacy

Health literacy is influenced by multiple factors, that can be partially

differentiated based on individual and external components [13]. According to Paasche-Orlow and Wolf, low health literacy is additionally strongly

associated with socioeconomic indicators, such as educational attainment, ethnicity and age [12]. These indicators can be interrelated with the individual and external components of health literacy.

Based on the definition of health literacy from section 2.1, it can be concluded that health literacy partially depends on the cognitive and social skills of an individual in relation to a certain task. The context of the task and its properties, such as the level of difficulty or the prerequisites, may affect the completion of this task.

Consequently, health literacy is not only dependent on the abilities and skills of a person, but also on the external factors that relate to the task that needs to be accomplished [12]. These socioeconomic, external and individual influences that contribute to the level of health literacy are displayed in figure 1.

Figure 1: Individual, external and socioeconomic influences of health literacy, according to the framework by Paasche-Orlow and Wolf [12]

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2.2.2 Causal pathways and associated behaviours

Health literacy influences health outcomes in multiple ways, which can be distinguished by characteristics that are closely related to the patient, these are called patient factors, and by factors that are more extrinsically orientated towards the system or the health care provider, which are called system factors [12]. Paasche-Orlow and Wolf address three different causal pathways that connect health literacy to health outcomes, which can be seen in figure 2 [12].

Access and utilization of health care

The first pathway refers to how people utilize and access health care. Several behaviours are associated with this pathway [12]. Patients with low health literacy may not understand health related information and therefore they may not understand possible symptoms and prevention methods of certain diseases [14]. This may lead to a delay in seeking health care or to no health care actions at all. Moreover, patients with low health literacy may experience unease during medical consultations, due to the insecurities and shame that occur when their misunderstanding is exposed [14]. Low health literacy is further associated with an overall worse mental health state, such as depression [15].

Figure 2: Three causal pathways that display the influence of health literacy on health outcomes from the framework of Paasche-Orlow and Wolf [12]

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17 On a patient level, several factors may alter the way in how people utilize and access the health care system. Navigation, which consists of all the skills that are needed to go from one place to another in the pursuit of health care, can influence the self-efficacy of a patient, as well as the amount of perceived barriers that occur when seeking health care [12][16]. These factors are dependent on personal attributes, such as the level of health literacy and the corresponding influences as described in the previous paragraph.

Additionally externally oriented system factors influence the utilization and access of health care. An example of a system factor is the complexity of the available health care system. Due to many different health care providers, varying regulations and health plans, misunderstandings can occur easily. In addition, frequent rule changes and health insurance policies can create more complications and confusion [12].

The e-coaching application that is described within this research, has the ability to influence the complexity, by providing accessible health care and guidance, which is adapted towards low health literate patients. Therefore, the complexity of the system may decrease. Simultaneously, the less complex and accessible health care may increase the self-efficacy of the patients and may contribute to a decrease in perceived barriers when undertaking health actions.

Provider-Patient Interaction

The next pathway describes the interaction between the health care provider and the patient. This pathway is influenced by internally oriented factors, such as personal knowledge. Limited knowledge of patients with low health literacy about certain diseases may affect the interaction with health care providers in a negative way [12]. Besides knowledge, factors such as the patient’s beliefs and their participation in medical related decision influence their health outcomes. Low health literate patients may or may not have insights into their limited knowledge about their condition, therefore they may avoid asking questions and may generally display worse patient

activation [14]. As such, low literate patients may be less responsive towards providers and may avoid asking questions and admit confusion. As a result, an association is made between provider distrust and low literacy, as well as an overall worse assessment of health care quality [17][18]. Additionally, patients with low literacy may use medical descriptions that differentiate from the terms that are implemented by providers and they may provide less

accurate information about their own medical health history and medication, which can evolve into misunderstanding on the provider’s side of the

interaction [12].

In addition, provider oriented factors influence this pathway, such as the communication skills of the provider and their teaching ability. Providers tend to be unaware of the limited health literacy of their patients and even in case of awareness they might not possess the ability and knowledge to facilitate successful communication and teaching targeted at low literate patients [12] [19].

The e-coaching application that is adapted towards low health literate patients may improve the overall health related knowledge of the patient by providing understandable information. Simultaneously, patients may increase their participation in decision making. Moreover, the e-coaching application focuses on communication skills, in the form of messages, which are adapted for the target group. These adapted messages may positively influence the communication with the patient.

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18 Self-Care

The last pathway is defined as ‘Self-Care”. This pathway largely consists of self-management factors, which form an important part of personal health care, for example in the form of taking medication according to the pre- arranged instructions of the health care provider [20]. Self-management requires knowledge regarding the task that needs to be accomplished, but also individual motivation and capacity to follow a health care plan. Overall people with low health literacy have been found to have limited practical and

instrumental knowledge in relation to self-management [20]. In addition external factors, such as health education, influence the self-management process of a patient. A study has shown, that inadequate functional health literacy is associated with decreased medication knowledge and increased medication direction discrepancy [21]. Moreover, competing and changing information, which is provided by health care providers and public

communications, may contribute to increased misunderstanding among low health literate patients [12].

The e-coaching application assists patients by providing personal information and may therefore contribute to improved self-management and self-efficacy in relation to individual health care [20]. Health education adapted towards low health literacy, as well as supportive technologies, may additionally influence the self-care of a patient from an external perspective.

In conclusion, based on this causal pathway model, the e-coaching application may influence the connection between health literacy and health outcomes in multiple ways. As such, the application possesses the ability to impact the patient-provider interaction, the access and utilization of health care and the self-care of a patient. Furthermore, the application may influence the external system factors of these pathways, such as the complexity of health education, in a direct manner. As a result, the application may indirectly impact internal factors of the patient, such as personal knowledge and self-efficacy.

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2.3 Health Outcomes associated with Low Health Literacy

The causal pathways that were addressed in the previous chapter and the associated determinants and behaviours can alter the course of someone’s health progress. When influencing the factors of this framework, as displayed in figure 2, in a positive way, the health outcomes that are associated with low health literacy can be improved. Several outcomes haves been associated with a low level of health literacy.

As such, low health literacy is associated with an overall decreased health status of senior citizen and the risk of mortality for seniors with low health literacy is clearly higher than for seniors with higher levels of health literacy [22]. According to Weiss, people with low health literacy tend to be more likely to make errors regarding medication and treatment [23]. Besides the personal burdens, these outcomes indicate an increase in overall health care costs and societal impacts. Rasu et al. found that people with lower levels of health literacy have an increased health care utilization and increased health care costs in comparison to people with higher levels of health literacy [24]. Besides these negative disease outcomes and behaviours, low health literacy is frequently associated a higher rate of chronic diseases [20]. This association is partially caused by poor self-management that is linked to low health literacy. In this chapter, chronic diseases and their relation to low health literacy will be further clarified.

2.3.1 Background on Chronic Diseases

The global disadvantages that people with low health literacy experience in relation to their health, are especially applicable for people that additionally have a chronic disease, such as cancer, cardiovascular diseases and diabetes [25].

The rates of chronical diseases among the global population is increasing, as well as the mortality rate of people with chronic diseases.

According to the World Health Organization, a total amount of 35 million deaths in the year 2005 were caused by chronic diseases [26]. There is large difference between the mortality rate that is associated in high income countries and low or middle in-come countries. The WHO states that 80% of deaths caused by chronic diseases occur in middle or low income countries, while 20% occur in high-income countries. In addition, the health care costs that are associated with chronic diseases have a large impact on the individual quality of life of those that are affected, but also on others in the form of economic effect through societal impact [27].

There exist various modifiable risk factors and behaviours that are associated with chronic diseases. The most influential risk factors consist of an unhealthy diet, physical inactivity and tobacco use [26]. In contrast, the most influential non-modifiable risk factors are age and heredity. These risk factors are influenced by underlying determinants that relate to the

socioeconomic, cultural political and environmental aspects of someone’s life, such as globalization urbanization and population ageing [26].

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20 In turn, the risk factors contribute to corresponding intermediate health outcomes. As an example, people with an unhealthy diet and little physical activity can be at a higher risk of becoming overweight. These intermediate health outcomes, such as obesity, raised blood pressure and raised glucose levels, may influence main chronic diseases [26].

2.3.2 The Relation between Chronic Diseases and Low Health Literacy

The consequences and influential factors of chronic diseases display similarities with aspects of low health literacy, such as the increased occurrence among certain population groups. The influences that health literacy has on the health-care of people with chronic diseases form an important aspect in making accessible health-care for people with low health literacy [20].

According to Poureslami et al., a higher level of health literacy is associated with reductions is risk behaviours that are related to chronic diseases [25]. As a result, people with low health literacy and chronic diseases are more likely to have a lower self-reported health status and an increase in hospitalizations.

Patients with chronic diseases commonly have the need to monitor and adjust their therapy based on their condition [25]. Therefore, the self- management aspect of health-care has a major influence on people with chronic diseases, which may pose a difficulty for patients with low health literacy. They are not only less likely to understand how to monitor their disease, understand their disease and symptoms, but may also experience difficulty interacting with monitor devices and interpreting the results [25].

As a result, the complexity of chronic diseases and the nature of the patients may contribute to a higher risk of misunderstanding chronic diagnoses, treatments and instructions that are related to self-care. These outcomes may in turn contribute to nonadherence to treatments and misuse of medications.

These factors may influence the access and utilization of health-care, the self-care and the overall health outcomes of patients with chronic diseases and low health literacy in a negative way.

Another health-care mechanisms that is influenced by low health literacy in combination with chronic diseases, is patient-provider interaction. This interaction, in turn, plays an important role for chronic disease management.

Due to the nature of patients with chronic diseases and low health literacy, the provider needs the requirements to develop certain skills and awareness, such as adapted communication methods and cultural competence, due to the variety of patients [25]. Additionally, patients with chronic diseases tend to have multiple conditions. Hence, the provider should help the patient to understand the interaction between his or her conditions and the adverse interactions between treatments. The risks of obtaining care from multiple different specialist can result in possible conflicting advice and confusion [25].

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2.4 Design methods

There exist multiple methods for creating information and applications which are understandable and useful for people with low health literacy. In this chapter, multiple design aspects that are related to the development of an e- coaching application are discussed. Due to the dependence of health literacy on literacy skills and cognitive abilities of the individual, as discussed in chapter 2.2, the design methods consist of strategies that are targeted at low literacy as well as low health literacy. Various sources were studied in order to obtain a broad selection of design methods targeted at low health literacy and low literacy, as depicted in table 2.

The Dutch foundation “Pharos” was consulted, which is specialized in and aims to decrease healthcare differences among the Dutch population. An important source for this research consists of the checklist for creating accessible information [28]. This checklist is largely based on the “Patient Education Materials Assessment Tool” (PEMAT), which consists of a systematic method to evaluate and compare the understandability and actionability of patient education materials [29]. Another source consists of the Dutch foundation “Stichting Lezen en Schrijven”, which focuses on preventing and reducing low literacy among the Dutch population [30]. A guideline for creating understandable information was consulted to obtain various formulation strategies, which are included in table 2. Lastly, research papers on mobile interface design for low-literate population and visual aids were studied [31]. The combined collection of methods was differentiated based on mobile interface design, formulation, visual aids and audio or audio- visual aids.

Table 2: Summary of design methods targeted at low literacy and low health literacy. The following sources were used: research papers on mobile interface design for low-literate populations and visual aids [31] [32], factsheets and checklists from Dutch literacy and health foundations [28][33][34], as well as the Patient Education Materials Assessment Tool (PEMAT) [29]

Application Component Design strategy Mobile

Interface Design

Widgets - Use larger widget sizes [31]

- Position buttons in an accessible location [31]

Selection boxes - Use radio buttons, instead of checkboxes and

interactive icons [31]

Navigation - Use a combined structure, consisting of a linear navigation structure with a cross-linked navigation bar [31]

- Use a depth of no more than 5 pages and a breadth of less than 10 [31]

- Implement an error recovery mechanism (HOME or BACK buttons) [31]

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22 - Provide consistency within

the layout [31]

- In case a search option is integrated, use the ability to generate a maximum of 10 suggestions based on the user’s input [31]

Layout - Use not too much nor too little white space [31]

- Use a symmetrical arrangement with a

rhythmic composition [31]

Feedback - Incorporate a feedback mechanism that displays assistance and progress of the user [31]

Formulation Text structure - Write the main message of the paragraph at the beginning [33]

- Follow a logical sequence of paragraphs [29]

- Use short intermediate headings (max 3 words) [33]

- Use 10 or less words per sentence [33]

- Use not more than 5

paragraphs, each consisting of 2-10 sentences [33]

- For longer texts, add a summary at the end of the material [29]

Text content - Write in a personal manner, and use recognizable

situations/words [33]

- Repeat important information [29]

- Give clear contact information [28]

- In case user action is required, state at least one action using clear

manageable steps [33]

Sentence structure &

Grammar

- Use the Dutch A2 language level [33]

- Use the general Dutch sentence structure (subject – finite verb – direct object) [33]

- Write in an active voice [29]

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23 - Position verbs close to the

subject if possible [33]

- No discontinuous sentences and complex structures [33]

Font - Use larger font styles, with space in between letters (Verdana, size 12) [33]

- Use a consistent color scheme with high contrast [33]

- Emphasize important information with the bold style [33]

- Align sentences to the left [33]

- Use a minimum spacing of 1.5 between lines [33]

Words &

Numbers - Use common, everyday language [29]

- In case of abbreviations, use explanations (also on the meaning of the words) [29]

- Avoid calculations and numbers, in case numbers are used: use ‘1’ instead of

‘one’ [29]

- Frequencies are preferred over percentages [29]

- Avoid synonyms, words derived from foreign languages and sayings [33]

- Explain medical terms within the text [29]

Visual Aids - Use straightforward

symbols and photos [33][32]

- Avoid cultural symbols that can be perceived as

discriminating [32]

- Use colour schemes with contrasting colours, or colours that are frequently used in advertisements [32]

- Use line drawings or watercolours for illustrations [32]

- Create contrast difference between the subject and background [32]

- The meaning should reinforce written content [29]

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24 - It should not distract from

the meaning [29]

- Captions under images or illustrations should be used for assistance [32][29]

Audio(visual)

aids Audio - Use slow speech [34]

- Use clear pronunciation [34]

- Possibly repeat important information [34]

- Short sentences are preferred [34]

- Use the present tense [34]

- Avoid metaphors and difficult terms [34]

- Use a consistency in choice of words [34]

Audio-visual - If possible, integrate an instruction video about the e-health application [28]

Technical

aspects - Integrate a pause button [35]

- Integrate a possibility to repeat the audio [35]

- Integrate a possibility to alter the tempo of the audio [35]

- Extract background noise [35]

- If possible, provide an option to store own

recordings of the user [35]

- If needed, integrate

translation possibilities [35]

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2.5 Conclusion

In conclusion, the literature gave more insight into background information on low health literacy and health-care related behaviour of low health literate patients. These behaviours and related health outcomes, emphasize the importance of adjusting e-health applications for low health literate users.

Therefore, various design strategies should be taken into account during the (re-)design process.

During the re-formulation of motivational messages related to nutritional behaviour and physical activity, the formulation strategies from table 2 can benefit the understandability of health related messages for low health literate patients. Additionally, the integration of visual aids and speech based

assistance may benefit the clarification of these messages. Furthermore, adjustments could be made within the interface design of the application, to integrate the previously mentioned interface techniques that are preferred by low literate users.

Finally, more understanding is needed about the personal needs and wishes of the target group towards an e-coaching application design, as well as their preferences between different methods. The e-coaching application addresses four distinct phases: the awareness, motivational, action and behaviour phase. Therefore, the preferences of low health literate users between these phases should be studied. These evaluations will be further described in the following chapters.

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26 Figure 3: The Creative Technology Design Process [36]

3. Methods and techniques

3.1 Creative Technology Design Process

In this chapter, the process of this project is described according to the Creative Technology Design Process (CTDP). Two classical approaches provide key elements that form a base for this design process. The

“Divergence and Convergence Model” is one of the inspirations, which differentiates between a divergence and convergence phase [36]. During the divergence phase, the design space is opened and defined. During the

convergence phase, this space is reduced, based on gained requirements and knowledge, until a solution is reached. Another inspiration is the “Spiral Model”, which consists of steps that focus on problem understanding and definition [36]. In this model, each design problem unfolds a series of questions applicable to the starting problem and its context.

The Creative Technology Design Process consists of four distinct phases:

ideation, specification, realisation and evaluation. This process is displayed in figure 3.

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3.2 Integration of CTDP

Ideation

The first phase that was conducted during the design process of this research, is the ideation phase. During this phase, interviews were conducted with two health care professionals, with the aim to obtain more insight into the state of the art and the needs of the users. Furthermore, various design methods were selected from chapter 2, based on their relevancy towards the main research question. The possibilities for the integration of these design methods within the e-coaching application, were further elaborated and prepared for user evaluation, which formed the transition point towards the specification phase.

Specification

During the specification phase, various designs were created to explore the design space. These designs were evaluated with the target group by the use of an online questionnaire. As an outcome, design methods were selected based on their perceived understandability and the preferences of the target group.

These design methods form the basis for the redesign and reformulation of the e-coaching messages and the creation of guidelines during the next phase.

Realisation

The realisation phase is characterized by implementing the product

specifications into a final model [36]. At the start of this phase, a guideline for application developers was created, as a paper and app version. This guideline consists of several strategies and design methods that can increase the

understandability of applications for low health literate users. This guideline formed the basis for reformulating and redesigning existing daily and weekly messages on nutrition and physical activity from the e-coaching application the “Diameter”. Two possible routes were created, consisting of visual aids with captions or reformulated textual messages. As a result, the personal preference of users, in relation to one of the routes, can be integrated within the e-coaching application.

Evaluation

The evaluation is the last phase and addresses the functional testing of the results from the previous phase. This phase aimed to verify whether the reformulated messages and visual aids with captions satisfy the user

requirements and facilitate the desired user experience. To accomplish this, a second questionnaire was created. This questionnaire consisted of the original e-coaching messages, the reformulated messages and designed visual aids with captions. As a result, it could be evaluated whether the understandability increases for the reformulated messages and visual aids. This evaluation was similarly executed and distributed as the first evaluation, but consisted of considerably less questions.

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28 The implementation of the CTDP within the project process is visualized in figure 4.

It should be noted, that before the interviews from the ideation phase, the first evaluation and second evaluation were conducted, an ethical approval from the ethical committee of the faculty “Electrical Engineering, Mathematics and Computer Science” (EEMCS) from the University of Twente was requested and received.

Figure 4: Implementation of CTDP

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4. Ideation

The main research question from chapter 1.3 and the obtained background knowledge and insights into previous work from chapter 2, form the basis for the ideation phase which is implemented in this chapter. This phase begins by examining the experiences and views of health care professionals in

relation to low health literacy within the health care. Furthermore, a selection of design methods from chapter 2.4 was created and conceptualized.

4.1 Impression of health care professionals

To substantiate the state of the art, two interviews were conducted with health care professionals from different fields. These interviews aim to retrieve more insight into the perspective and experiences of health care professionals regarding low health literacy and associated effects. Before the interviews were conducted, information about the project and the interview were provided to the healthcare professionals by means of an information

brochure. Furthermore, a consent form was provided, which had to be signed prior to the interview. The consent form and information brochure are

displayed in Appendix B.1. The complete interviews, with answers, are displayed in Appendix B.2 and B.3.

Two health care professionals were interviewed with varying professions to gain different perspectives on this topic. One professional is specialized in the field of mental health and works as a psychologist and psychotherapist with a focus on trauma counselling. The other health care professional works as a district nurse, who issues health care indications, provides at-home health care to patients and carries out intakes with people who enter the health care system. Both health professionals indicate that they frequently encounter patients who experience difficulty with understanding health related information. For both professions, this mostly concerns elderly or patients with a mental or social disability.

Both professionals indicated that low health literacy frequently occurs among elderly patients and patients with lesser educated backgrounds or

environments. According to the nurse, chronic diseases are prominently occurrent among this last group, increasing the importance of personal guidance. Additionally, low health literacy occurs often among patients who experience a language or cultural barrier. According to the psychologist, low health literacy may also occur among patients with a post-traumatic stress disorder, as well as younger patients with social and emotional difficulties.

There exists a strong relation between literacy and health literacy, according to both health professionals. The nurse indicates that besides the literacy level, the level of motivation and understanding on how to implement information influences how people perceive and understand health related information. Some people are able to read information, but are not able to process and understand this information in the desired way.

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30 The interaction with low health literate patients differentiates from regular patient-provider interaction. The psychologist indicated that the memory and comprehension of the patient must be taken into account and as a result information must be given in various ways. This is in line with the objectives on patient-provider interaction from literature. Currently, protocols exists for patients with light mental handicaps, as well as protocols for dyslexia.

Furthermore, protocols are implemented in the health care and educational system to improve and teach people how to handle low literacy.

The nurse additionally indicated that pocket cards exists for diabetes patients. However, the frequency of encountering these cards decreases. It is important that the information, which is communicated towards the patients, does not enable any possibility for doubt and misunderstanding, due to the importance of medical information, especially medication. The nurse added, that the difficulty lies in how to create simple and understandable

information, without providing too much information. Therefore, information can be presented in smaller proportions.

The personal opinions of the professionals on which method of presenting information is the most effective for low health literate patients, concluded that clear visual aids may be the most effective. According to the psychologist, these visual aids have to contain meaning and relate to the personal

experiences and environment of the patient. The nurse additionally stated, that visual aids should not contain too many connections and remain simple, without creating childish feelings. Additional clear textual information should contain the tasks or actions that the patient is expected to accomplish in a simple manner. In order to achieve creating such understandable

information, the e-coaching developers must imagine or put themselves in the perspectives of the patients.

The findings from these interviews show close resemblance to the literature findings and strategies from table 2 in chapter 2.4. Conclusively, both health care providers indicated the importance of creating understandable

information targeted at low health literacy and the potential effectiveness of visual aids. This last possibility is further elaborated in the next chapter.

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4.2 Design method selection and conceptualization

During the state of the art and interviews, various design methods targeted at low health literacy and low literacy were summarized. These methods address distinct aspects, which are applicable for application design, such as sentence formulation and visual communication strategies. Table 2 from chapter 2.4 displays various design methods related to formulation, visual aids, audio- visual communication and interface design. These methods are relevant for application design targeted at low health literacy, however not all methods are essential for the reformulation of messages on physical activity and nutrition and able to be implemented within the e-coaching application and guidelines.

Therefore, a selection of design methods was created based on table 2, which is further studied and evaluated. In chapter 2, cognitive skills, such as literacy levels, were identified as primary influences on health literacy. As a result, the design methods are partially focused on low literacy and, therefore,

intermediately focused on low health literacy.

4.2.1 Mobile Interface Design

Aside from the formulation and visual design of application content, the overall mobile interface design of an application influences the user

interaction and understandability. The design of mobile interfaces concerns various aspects, such as the type of navigation, display and interaction. This realisation of this research does not require large interface changes within the existing application, but rather focuses on small adjustments that can be implemented within future application and design methods that can be applied for displaying messages. Therefore, the interface design selection is minimal in relation to the other design aspects. Various mobile interface design strategies were selected from table 2, which are displayed in table 3 .

Table 3: Mobile interface design strategies Design strategy

- Use large widgets [32]

- Use radio buttons [32]

- Provide consistency within the layout, such as a rhythmic composition [32]

- Implement an error recovery mechanism [32]

Design of a personalized e-coaching module on physical activity and nutrition for people with chronic diseases and low health literacy