Exploration of health information overload in consumers with chronic health conditions

Background: Health information overload (HIO) in patients has received growing attention in recent years. It generally refers to a state where the volume and complexity of health information exceeds an individual processing capacity. Patients with chronic health conditions are often faced with a large volume of health information. Lifelong management with a high risk of comorbidities or complications could encourage those patients to search for more health information. Additionally, patients with chronic health conditions often receive plurality of advice and counselling from multiple healthcare providers. Thus, exposure to a large amount of health information from online sources or several healthcare providers might contribute to HIO. Limited research has shown a potential association of HIO in patients with negative emotions, low medication adherence, and impaired decision making. As most of this research was focused on cancer information overload, these findings cannot be generalised to patients with other health conditions. Thus, more studies focusing on other chronic diseases are essential. Due to the small number of studies that have investigated HIO in patients, we first aimed to examine the breadth of evidence of HIO, to identify the areas that call for further exploration. Therefore, a scoping review was conducted to identify the chronic health conditions with a high possibility of experiencing HIO. Moreover, to understand patients' experiences with HIO and its potential reasons, consequences and solutions, we explored HIO perspectives in such patients qualitatively. Additionally, to measure the extent of HIO and its associated factors, we developed a questionnaire targeting patients with a chronic health condition. Objectives: The overall aim was to develop a comprehensive and clear understanding of HIO and its potential implications for patients with a chronic health condition with a high possibility of experiencing HIO. This thesis included three studies designed to address the following objectives collectively: ‚Äö Broadly examine and identify the scope of research addressing HIO in consumers of health information ‚Äö Explore patient-reported reasons for, consequences of, and proposed solutions for HIOin patients with diabetes and/or cardiovascular diseases ‚Äö Measure the extent of HIO in Australian patients with a chronic health condition(diabetes), and determine potential factors impacting or associated with HIO Results: To address objective 1, a scoping review was conducted to identify and summarise the available literature on HIO among consumers of health information. Of the 69 records included for final analysis, 22 studies specifically examined HIO, whereas the remainder discussed the concept of HIO alongside other concepts. The 22 studies focused on one or more of the following: (a) ways to measure HIO (multi-item/single-item scales); (b) predictors of HIO-these included low education level, health literacy, and socioeconomic status; and (c) interventions to address information overload, such as videotaped consultations or written materials. Cancer information overload was a popular topic amongst studies that focused on HIO. Based on the identified studies, there is a clear need for studies investigating HIO in patients with chronic health conditions other than cancer. This review was the initial step in facilitating future efforts to create health information that do not overload patients. Based on the gaps identified in the scoping review, an exploratory sequential mixed methodological design was adopted. The initial empirical phase was a qualitative study. Specifically, semi-structured interviews with open-ended questions were conducted to collect qualitative data. Interviews were performed with adults in Tasmania, diagnosed with type 2 diabetes and/or heart disease. Fourteen interviews were conducted and thematically analysed using the Framework Method. Low health literacy and sociodemographic factors, repeated or even contradicting information from multiple sources, and short consultation time with healthcare professionals, were reported as reasons for experiencing HIO. Feeling overloaded led to negative psychological implications and health information avoidance. Proposed solutions included providing consistent, small, and straightforward segments of health information at one time, and reducing exposure to unlimited health information sources. Simplifying information, receiving information from trusted healthcare professionals, and better communication with patients may reduce HIO in patients with these chronic medical conditions. For the quantitative component of the exploratory sequential mixed method, a questionnaire was devised to survey a national sample of adult Australians with a chronic health condition (diabetes). Items for this questionnaire were informed by themes identified in the previous qualitative study, findings from the scoping review, and from the literature. An online survey comprising two samples [sample 1 (n=455), and sample 2 (n=500)] was conducted among Australian adults with diabetes. Data were collected using an adapted Cancer Information Overload scale (5 items using 5 point-Likert scales) to measure levels of HIO. Sociodemographic factors, health characteristics, and measures of eHealth literacy, anxiety, depression, medication adherence, treatment burden, and problem-solving and decision-making preferences were also examined. Multiple linear regression was used to determine factors associated with the continuous dependent variable (i.e., all HIO scores, that ranged from 5 to 25). Binary logistic regression was conducted using a dichotomous dependent variable (low HIO vs high HIO) based on our selected cut-off value of 20, to identify factors specifically associated with high HIO (20 to 25). A total of 955 participants responded, with a median age of 59 years (IQR= 51 to 66). Participants had a mean (SD) score for HIO of 14.18 (4.2). Of 955 participants, 9.5% had relatively high HIO (score ‚Äöv¢‚Ä¢ 20). Multiple linear regression of the combined total sample identified significant associations between HIO and the following variables: shorter duration of diabetes (regression coefficients [b]: -.031, 95% confidence interval [CI]: -.053, -.009), lower eHealth literacy (b: -.132, CI: -.171, -.094) and lower medication adherence (b: -.114, CI: -.185, -.043), being female (b: .643, CI: .083, 1.204), lower education levels compared to tertiary or postgraduate (b: -.552, CI: -1.088, -.016), increasing level of treatment burden, such as high treatment burden (b: 2.409, CI: 1.314, 3.503), the presence of depression (b: .897, CI: .123, 1.671), and low frequency of using the internet to search for health information (b: 1.035, CI: .353, 1.171). Binary logistic regression showed that participants with lower eHealth literacy (adjusted odds ratio [aOR]: .956, 95% confidence interval [CI]: .925, .988), and lower adherence (aOR: .925, CI: .868, .986) were more likely to have relatively high HIO. Participants with depressive symptoms (aOR: 2.067, CI: 1.072, 3.986) were more likely to have high HIO. Identifying significant factors associated with high HIO provides a basis for futures studies that develop interventions targeting these factors to mitigate the issue of HIO. Conclusions and Recommendations: In conclusion, this thesis presents a series of sequential studies that thoroughly examined HIO in patients with one or more chronic health conditions (primarily diabetes, and CVD to a small extent). Generally, this thesis highlights that at least one in ten patients with a chronic health condition (diabetes) had high HIO, depending on the cut-off score used. Thus, identifying and addressing modifiable factors related to high HIO has a potential role in mitigating HIO in such patients. For example, interventions that improve patients' eHealth literacy and reduce their treatment burden should be incorporated in patient education programs and healthcare services for patients with a chronic health condition such as diabetes. Despite the variety of identified sources of health information, health professionals appeared to be the main source of health information for patients, as shown in both studies 2 and 3 of this research. This should be considered when designing strategies to address HIO. Healthcare professionals can play a crucial role in the context of HIO, and they should be encouraged to provide consistent health information that does not confuse patients, and to recommend reliable health information sources, such as official government health websites. The association between HIO and negative emotions and depressive symptoms in patients was also identified in both studies 2 and 3. Therefore, there is a need to screen and identify those patients by healthcare providers to give them the required management and support. Given the somewhat inconsistent reported outcomes regarding the association of anxiety, or age with HIO, further studies are recommended to deeply explore the relationship between these factors and HIO in patients with chronic health conditions. This research highlighted the significant role of healthcare providers in addressing HIO in patients. Therefore, future actions need to consider how health professionals could provide support for overwhelmed patients, so they can effectively manage their chronic health conditions.