Patient Safety / Quality

Providing effective patient teaching on the Internet

Today, people can Google their way to an overload of information on any healthcare topic. But does the information make a difference? What kind of information and what type of presentation actually lead to better health?
As a doctoral student, nursing faculty member, and cardiology nurse practitioner with an interest in using technology to help patients with self-management, I designed and implemented a study to address these questions. The study compared two approaches to helping participants lower their cholesterol levels through dietary change.

Research and development
My initial steps included refining the research question and study design, using available resources. To identify a gap in the research or an area needing further research, I started by reviewing published articles on three topics: dietary management of cholesterol levels, efficacy of self-management, and Internet use for healthcare interventions.
Using the guidelines of the Expert Panel on the Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (ATP III) and information on the websites of the American Heart Association, the Mayo Clinic, and the National Heart Lung and Blood Institute of the National Institutes of Health, I developed two websites for the study: an education group website and a self-efficacy group website.
Both websites presented the same information in six sessions. But the self-efficacy group website also provided self-efficacy building activities, including goal setting, evaluation, and online interaction with me and other study participants. Participants in this group used e-mail to send their goals and goal evaluations to me, and I used e-mail to send individual feedback and reinforcement to each participant. For each session, I posted discussion questions on a discussion board. (See Topics for discussion in pdf format by clicking on the download now button.)
Participants were randomly assigned to the two groups. At the beginning and end of the study, I obtained fasting lipid profiles from all participants, and they filled out surveys that measured dietary knowledge, adherence, and self-efficacy.

Approval and pilot study
To protect the rights of study participants, a researcher must submit a detailed description of the study, using an institutional review board (IRB) application. A study can’t begin until the IRB approves it.
For this study, I also needed to obtain approval from the university where I was a doctoral candidate, the hospital where I would pilot the websites to identify and correct problems, and the college where the study would take place. After several months, I had all the approvals I needed, and I implemented my pilot study.
Fifteen people took part in this two-week pilot study. They completed the study questionnaires online and participated in the six sessions. After the pilot study, I met with the participants in small focus groups to get feedback on the self-efficacy website. Based on this feedback, I added a pictorial navigation guide to the home page to make navigation easier.

Implementing the study
After participants provided informed consent, they had blood drawn for their fasting lipid profiles, and their heights and weights were measured. They completed baseline study questionnaires on the Internet.
Weekly e-mail reminders went to participants who hadn’t logged on to the study website during the past week. For those in the education group, this was the only communication sent. For those in the self-efficacy group, I provided e-mail feedback on their goals and goal evaluation each session, using e-mail and the discussion board.
The discussion board also allowed self-efficacy group participants to share strategies, provide positive feedback, and otherwise support self-efficacy. They posted recipes, recommended restaurants with heart-healthy menus, and shared their thoughts and feelings on new foods, activities, and information on heart-healthy diets.
Ten days after the sixth and final session, participants again had blood drawn for fasting lipid profiles, were weighed, and completed a questionnaire. A data manager and statistician helped with the data setup and analysis.

Study findings
The study questions asked if the following variables would improve after participation:
•    low-density lipoprotein (LDL) cholesterol levels
•    dietary adherence
•    dietary knowledge
•    dietary self-efficacy.
I used analysis of variance (ANOVA), a statistical method that controls the effect of one variable while another is analyzed. Analysis revealed no significant differences between the groups in dietary adherence, knowledge, or self-efficacy. But when baseline LDL cholesterol was statistically controlled using ANOVA, there was a significant difference between the groups in LDL cholesterol levels (F = 4.52, P = .04). (See Making a difference in lipid levels in pdf format by clicking on the download now button.)
The other significant difference was in the frequency of website use. Participants in the self-efficacy group logged in an average of 119 times compared with only 19 times for the education group (P < .000).
Limitations of the study included the small sample size and the fact that the researcher was also the person who administered the intervention. Another limitation was the participants’ high dietary self-efficacy before the study, which limited the amount of change in cholesterol levels during the study.
The study results certainly provide support for more study of Internet-based interventions to achieve healthier living. Suggested topics include self-management of diabetes mellitus, asthma, and metabolic syndrome. The challenge for future researchers is to develop strategies to recruit those participants most in need of the intervention.

Selected references 
Brunzell JD. Lipoprotein management in patients with cardiometabolic risk: consensus statement from the American Diabetes Association and the American College of Cardiology Foundation. Diabetes Care. 2008;31(4):811-822.
Burke LE, Dunbar-Jacob J, Orchard TJ, Sereika SM. Improving adherence to a cholesterol-lowering diet: a behavioral intervention study. Patient Educ Couns. 2005;57(1):134-142.
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA. 2001;285(19):2486-2497.
Ghandehari H, Kamal-Bahl S, Wong ND. Prevalence and extent of dyslipidemia and recommended lipid levels in US adults with and without cardiovascular comorbidities: The National Health and Nutrition Examination Survey 2003-2004. Am Heart J. 2008;156(1):112-119.
Libby P. The forgotten majority: unfinished business in cardiovascular risk reduction. J Am Coll Cardiol. 2005;46(7):1225-1228.
Visit for a complete list of selected references.

Claire P. Donaghy is an associate professor of nursing at William Paterson University in Wayne, New Jersey, as well as a nurse practitioner for the Morris Anesthesia Group and a nurse in the postanesthesia care unit at St. Clare’s Hospital in Denville, New Jersey. Ms. Donaghy’s  research was supported by a dissertation fellowship from Rutgers, The State University of New Jersey, and a scholarship from Region 1 New Jersey State Nurses Association.

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