Construction and effectiveness assessment of the health education system for outpatient chronic respiratory diseases based on visualized intelligent healthcare

Introduction

Chronic respiratory diseases, such as pneumonia, bronchitis, asthma, and bronchiectasis, markedly impacted patient quality of life and contribute significantly to the global burden of disease (1). Managing these conditions often required continuous and comprehensive patient education to ensure effective self-care, adherence to treatment regimens, and timely recognition of exacerbations (2,3). Despite advancements in medical therapy, many patients continue to struggle with the complexities of disease management, often due to inadequate health literacy (4). Health literacy, which referred to the capability to acquire, process, and comprehend basic health information and services required for making informed health decisions, is an important factor influencing health outcomes (5).

Domestic health education methods have often struggled to address the needs of patients with low health literacy (6), underscoring the necessity for innovative approaches that can bridge the gap between medical knowledge and patient comprehension. This gap necessitates the development and implementation of innovative educational strategies that enhance patients’ understanding and engagement (7). Visualized intelligent healthcare, which leveraged technology to present health information through visual and interactive formats, presents a promising solution (8). By simplifying complex medical information and making it more accessible, visualized intelligent healthcare can improve comprehension and retention, thereby facilitating better disease self-management (9).

Given the potential benefits of visualized intelligent healthcare, our study aimed to construct and evaluate the effectiveness of a health education system specifically designed for outpatient chronic respiratory diseases. The system integrates visualized intelligent tools to deliver patient-centric educational content tailored to individual needs. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2024-2053/rc).

Methods

Case selection

Inclusion criteria: (I) Individuals aged between 40 and 70 years, with no previous mental health issues, normal cognitive abilities, and capable of cooperating with various treatments and assessments. (II) Diagnosed with one or more of the following chronic respiratory conditions, based on clinical guidelines: chronic obstructive pulmonary disease (COPD, defined by GOLD 2023 criteria) (10); chronic bronchitis (without airflow limitation); bronchial asthma; bronchiectasis; or chronic pneumonia (defined as persistent inflammation >3 months, confirmed by chest CT) (11). (III) Exhibiting stable vital signs.

Exclusion criteria: (I) Patients suffering from other serious progressive diseases. (II) Individuals with neurological disorders or cognitive impairments. (III) Patients who, for various reasons, are unable to complete the survey during the study.

A single-center retrospective case-control study was conducted including 139 patients aged 40–70 years with stable chronic respiratory diseases. All patients were recruited from the outpatient department of The First Affiliated Hospital of Guangzhou Medical University between January and December 2023. Participants were non-randomly divided into two groups based on the health education model received in clinical practice: the routine health education (RHE) group (n=68) and the visual intelligent medical health education (VIMHE) group (n=71). Patient demographic information, including general data, health literacy scores, pulmonary function test results, and quality of life scores, was collected through the case system. The management methods were determined by the attending physician’s judgment and the availability of the VIMHE system at the time of enrollment, which may introduce selection bias. To mitigate this, multivariate logistic regression was used to adjust for confounding factors (age, gender, disease duration) in statistical analyses. All assessments were conducted by trained research staff following standardized protocols, and follow-up reminders were scheduled to ensure data completeness. No missing data were observed for the primary outcomes, as the study design prioritized participant engagement and protocol adherence. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of The First Affiliated Hospital of Guangzhou Medical University (No. ES-2024-K178-02) and individual consent for this retrospective analysis was waived.

Intervention approaches

RHE group

The RHE group received conventional health education, including face-to-face oral briefings by nurses on disease management, medication protocols, and self-care practices (15 minutes/session, twice monthly for 3 months). Patients were provided printed educational booklets with text-based content on pathology, medication side effects, and symptom tracking, supplemented by basic illustrations. Inhaler technique was demonstrated once in person without visual aids, and follow-ups relied on phone/text reminders for medication and appointments, lacking interactive features.

VIMHE group

Unlike the RHE group, the VIMHE intervention integrated digital tools and visual aids into a structured education system. Delivered via a hospital-developed mobile app, it featured animated videos illustrating inhaler usage, 3D anatomical models explaining disease mechanisms, and interactive modules for medication scheduling and symptom tracking. Monthly 30-minute face-to-face sessions included hands-on practice with visual demonstration tools and role-playing for emergency response—extending the RHE’s basic demonstration into immersive training.

While both groups covered core topics like medication management and lifestyle modification, VIMHE enhanced engagement through real-time feedback (e.g., self-assessment quizzes with visual results) and personalized reminders synced to peak flow meter data—functions absent in RHE’s paper-based tracking. The VIMHE app also enabled continuous patient-provider interaction between sessions, whereas RHE relied on intermittent verbal briefings. Despite identical intervention durations, VIMHE’s visual-intelligent approach aimed to bridge the literacy gap through technology-driven, interactive learning.

Newest Vital Sign (NVS)

The NVS was an efficient screening tool designed to gauge functional health literacy. This score assesses an individual’s comprehension and interpretation skills, specifically by examining their ability to understand nutrition labels. The assessment typically involves a straightforward graphic, such as a label from an ice cream container, from which the participant must answer several questions. These tasks might include making calculations, comparisons, or interpreting nutritional elements. A key benefit of the NVS is its simplicity and speed, enabling quick application in clinical environments without the need for extensive training. Scores range from 0 to 6 points, with higher values indicating greater health literacy. By using the NVS, healthcare professionals can identify patients facing challenges in managing their health due to limited health literacy and can subsequently provide them with targeted education and assistance. The Cronbach’s alpha for NVS is reported to be 0.74, indicating an acceptable level of internal consistency (12).

Test of Functional Health Literacy in Adults (TOFHLA)

The TOFHLA is a standardized assessment designed to measure adults’ capacity to read and understand health-related information. It is comprised of two sections: reading comprehension and numeracy skills. The primary objective of the TOFHLA is to help healthcare practitioners identify patients who may struggle with managing their healthcare due to inadequate health literacy. Patients with low health literacy may encounter difficulties in following medical instructions, understanding educational materials, and completing essential medical forms, which can adversely impact the effectiveness of treatments and overall health outcomes. TOFHLA scores enable healthcare providers to tailor educational and support interventions to enhance patients’ comprehension and management of their health conditions and treatment plans. The results inform medical professionals on how to modify their communication strategies, employing clearer language and more comprehensible resources to bolster patients’ health management and self-care capabilities. The reliability of TOFHLA is evidenced by a Cronbach’s alpha of 0.943, indicating a high level of internal consistency (13).

Health Literacy Survey-European Union (HLS-EU) Score

The HLS-EU-Q is a standardized instrument specifically designed to assess individuals’ skills and confidence in managing health information within the European context. The HLS-EU score evaluates a person’s confidence and practical abilities in dealing with health-related information through a series of questions that span multiple dimensions of everyday health scenarios. Higher scores indicate greater health literacy, while lower scores suggest the need for improved understanding. This assessment is vital for policymakers, researchers, and healthcare professionals as it helps pinpoint populations with lower health literacy levels. Such insights enable the creation and implementation of targeted interventions aimed at enhancing overall public health literacy and addressing health disparities. The reliability of the HLS-EU-Q is demonstrated by a Cronbach’s alpha of 0.84, indicating good internal consistency (14).

Electronic Health Literacy Scale (eHEALS)

The eHEALS is a quantitative measure designed to assess an individual’s ability to locate, comprehend, and utilize health information available on the Internet. The eHEALS score is derived from responses to a questionnaire consisting of 21 statements that evaluate essential competencies, such as navigating online platforms, assessing information quality, understanding health information, and applying this knowledge. Participants rate each statement using a Likert scale, which ranges from ‘completely disagree’ to ‘completely agree’, often on a five-point or seven-point scale. The total eHEALS score is the cumulative sum of these individual ratings, spanning from 21 to 147 points when using a seven-point scale. Higher scores signify improved electronic health literacy. The reliability of eHEALS is supported by a Cronbach’s alpha of 0.94, indicating a high degree of internal consistency (15).

Pulmonary function testing

Utilize a comprehensive lung function analyzer (Jaeger, Inc., Bodnegg, Germany) to assess various pulmonary function parameters. Compare these lung function indicators among the two patient groups both before and after treatment. Measurements include forced expiratory volume in the first second (FEV1), forced vital capacity (FVC), peak expiratory flow rate (PEFR), total lung capacity (TLC), among others. Pulmonary function tests (FEV1, FVC, etc.) were conducted at baseline and 3 months post-intervention using a Jaeger lung function analyzer. The interval between tests was standardized to ensure consistency in measurement.

Quality of life assessment

The primary outcome measure for evaluating the impact of the health education interventions on the quality of life among patients was the Short Form 36 (SF-36) Health Survey. This tool comprehensively assesses health-related quality of life across eight domains, including physical functioning, role limitations due to physical health, bodily pain, general health perceptions, vitality, social functioning, role limitations due to emotional health, and mental health.

Baseline SF-36 scores were recorded at the start of the study, and follow-up assessments were conducted at three-month intervals over a one-year period to monitor changes in quality of life. The SF-36 was administered by trained personnel to ensure accurate and consistent data collection. Higher scores on the SF-36 represent improved quality of life in the respective domains (16).

The reliability of the scale is demonstrated by a Cronbach’s alpha coefficient of 0.814, indicating its suitability for assessing the impact of health education interventions on patient-reported outcomes. Follow-up assessments at 3-month intervals were based on prior studies validating the SF-36’s sensitivity to short-term changes in chronic lung disease.

All health literacy scales (NVS, TOFHLA, HLS-EU, eHEALS) were administered by trained nurses at baseline and 3 months post-intervention in a quiet clinical setting to minimize measurement bias.

Statistical analysis

Measurement data are reported as mean ± standard deviation. Univariate and multivariate logistic regression analyses were performed to calculate the odds ratio (OR) and 95% confidence interval (CI), accounting for potential confounding factors (e.g., age, gender, disease duration, baseline pulmonary function) that may influence the results. Given the non-randomized retrospective design, this approach aimed to mitigate selection bias and enhance the validity of the findings. A two-sided P value <0.05 was considered statistically significant. Statistical analyses were conducted using SPSS version 19 (IBM Corp., Armonk, NY, USA) and R version 3.0.2 (R Core Team, Vienna, Austria).

Results

Baseline characteristics

Table 1 presents the baseline characteristics of participants in the RHE Group (n=68) and the VIMHE Group (n=71). There were no statistically significant differences between the groups in terms of these characteristics.

Health literacy scores

Table 2 shows the health literacy scores of participants in the RHE Group (n=68) and the VIMHE Group (n=71). The VIMHE Group demonstrated significantly higher scores across all assessed metrics. The NVS score was significantly improved in the VIMHE Group compared to the RHE Group (5.2±0.6 vs. 4.6±0.7; P<0.001). Similarly, the TOFHLA score was higher in the VIMHE Group (68.8±8.1 vs. 65.2±7.2; P=0.006). The HLS-EU score also showed a significant improvement in the VIMHE Group (33.1±4.7 vs. 30.5±4.3; P<0.001). Furthermore, the eHEALS score was significantly greater in the VIMHE Group (45.7±6.2 vs. 42.5±5.8; P=0.002).

Pre-intervention and post-intervention pulmonary function test results

Table 3 illustrates the pre-intervention and post-intervention pulmonary function test results of participants in the RHE Group (n=68) and the VIMHE Group (n=71). Pre-intervention results showed no statistically significant differences between the groups in terms of FEV1 (2.38±0.51 vs. 2.45±0.48 L; P=0.42), FVC (3.25±0.68 vs. 3.32±0.72 L; P=0.57), FEV1/FVC (73.58%±5.63% vs. 73.75%±5.41%; P=0.85), PEFR (320±50 vs. 328±52 L/min; P=0.35), and TLC (5.63±1.02 vs. 5.75±0.98 L; P=0.46). However, post-intervention results indicated significant improvements in all parameters for the VIMHE Group compared to the RHE Group. FEV1 was significantly higher in the VIMHE Group (2.71±0.46 vs. 2.52±0.49 L; P=0.01). Similarly, FVC (3.68±0.69 vs. 3.45±0.65 L; P=0.03) and FEV1/FVC (78.18%±4.96% vs. 75.42%±5.19%; P=0.002) were significantly improved. PEFR also increased significantly (365±50 vs. 345±48 L/min; P=0.01), as did TLC (6.32±0.92 vs. 5.78±0.96 L; P<0.001).

Pre-intervention and post-intervention quality of life scores

Table 4 presents the pre-intervention and post-intervention Quality of Life scores based on the SF-36 for participants in the RHE Group (n=68) and the VIMHE Group (n=71). Pre-intervention scores showed no statistically significant differences between the groups in physical functioning (65.74±7.83 vs. 66.32±7.41; P=0.657), social functioning (68.45±8.26 vs. 69.12±8.01; P=0.63), mental health (66.18±6.92 vs. 66.75±6.58; P=0.624), role limitations due to physical health (63.28±7.54 vs. 63.95±7.21; P=0.598), and role limitations due to emotional problems (64.75±6.87 vs. 65.32±6.52; P=0.618). Post-intervention scores indicated significant improvements in all parameters for the VIMHE Group compared to the RHE Group. Physical functioning scores were significantly higher in the VIMHE Group (73.68±6.95 vs. 70.32±7.21; P=0.006). Social functioning (74.75±7.68 vs. 71.25±7.92; P=0.009), mental health (69.74±6.18 vs. 66.63±6.34; P=0.004), role limitations due to physical health (68.65±6.98 vs. 65.38±7.32; P=0.008), and role limitations due to emotional problems (68.92±6.18 vs. 66.45±6.42; P=0.02) all showed significant improvement in the VIMHE group.

Discussion

The findings of our study on the development and efficacy evaluation of a VIMHE system for outpatients with chronic respiratory diseases demonstrated compelling evidence for its transformative potential in clinical practice and patient care. The substantial enhancements in health literacy, pulmonary function, and quality of life not only validate the theoretical framework guiding the use of visualized intelligent healthcare interventions but also substantiate their real-world impact. Our results suggested that the VIMHE system can serve as a powerful tool for empowering patients, enhancing their self-management capabilities, and ultimately leading to improved health outcomes and well-being.

The substantial enhancement in health literacy scores across all metrics, including NVS, TOFHLA, HLS-EU, and eHEALS, can be attributed to multiple facets of the visualized intelligent healthcare approach. Visual presentations of health information significantly enhanced comprehension by leveraging cognitive theories such as the dual coding theory, suggesting that learning is enhanced when information is showcased in both visual and verbal modes (17,18). Visual aids can simplify complex medical information, making it more accessible and easier to understand for patients, which is particularly important for those suffering from chronic respiratory diseases who need to grasp vital self-management skills (19).

The use of visual tools likely facilitated patients’ understanding of nutrition labels (as assessed by the NVS), enhanced their ability to navigate healthcare systems (as measured by TOFHLA), and improved their confidence in handling health-related information in daily life (reflected in HLS-EU scores). Moreover, the increase in eHEALS scores indicates that patients became more adept at using online resources to seek health information, a critical skill in managing chronic conditions (20). This improvement could be partly credited to the structured and interactive learning modules provided by the visualized intelligent health education system, which probably included simulations, interactive charts, videos, and infographics that make information more engaging and easier to retain (21,22).

Another remarkable finding is the significant improvement in pulmonary function parameters post-intervention in the VIMHE Group. This suggests a strong association between enhanced health literacy and better disease management outcomes. The significant improvements in pulmonary function (FEV1, FVC, FEV1/FVC) in the VIMHE Group can be attributed to multiple mechanism-driven pathways:

• Medication adherence and technique: the visual demonstration of inhaler use (e.g., correct hand-breath coordination) and personalized medication reminders likely reduced administration errors.
• Lifestyle modification compliance: visualized education on smoking cessation (e.g., animated depictions of lung damage) and exercise plans (e.g., step-by-step respiratory workout videos) may have facilitated behavior change. Smoking cessation alone has been linked to a 10–15% improvement in FEV1 within 6 months (23).
• Early exacerbation detection: the VIMHE training on symptom monitoring (e.g., using peak flow meters with visual reference charts) enabled timely medical intervention, preventing lung function decline. A study (24) show that early exacerbation management reduces FEV1 decline by 2–3% annually.
• Pulmonary rehabilitation adherence: interactive modules on breathing exercises (e.g., pursed-lip breathing animations) may have enhanced compliance with home-based rehabilitation, which is associated with a 12–15% improvement in FVC (25).

Through better understanding of disease mechanisms, medication regimens, and lifestyle modifications, patients were likely better equipped to adhere to their treatment plans and make informed health decisions (26,27). For example, improved awareness and comprehension of the importance of medication adherence and physiotherapy could lead to more consistent and effective practice of respiratory exercises, inhaler techniques, and lifestyle adjustments such as smoking cessation and nutrition improvements (28-30).

Additionally, the visualized intelligent healthcare approach could have contributed to better self-monitoring and early detection of exacerbations, allowing for timely interventions that prevent deterioration in lung function (31,32). The interactive nature of the educational tools likely encouraged patients to participate actively in their healthcare by regularly checking their symptoms and lung function, fostering a proactive approach to disease management (33).

In terms of quality of life, the significantly higher post-intervention SF-36 scores in the VIMHE Group underscore the broader impact of improved health literacy on overall well-being. Chronic respiratory diseases severely affect several areas of life, including physical activities, social interactions, and mental health (34,35). By empowering patients with the know-how and skills to handle their conditions effectively, the visualized intelligent education system likely alleviates some of the physical and emotional burdens associated with these diseases (36,37). Improved physical functioning scores can be directly linked to better management of symptoms and exacerbations, as well as increased engagement in activities that were once limited by respiratory issues (38). The enhancement in SF-36 scores can be linked to multi-faceted mechanisms: visualized education on self-monitoring (e.g., peak flow meter charts) enabled early detection of exacerbations, minimizing physical limitations. A prior study showed that timely symptom management improves physical functioning scores by 12–15% (39). Interactive modules (e.g., 3D disease animations) reduced health-related anxiety, with mental health scores improving as patients gained confidence in self-care. Similar interventions have reported a 20% reduction in depression scores via visual education (40). Behavioral reinforcement strategies (e.g., role-playing for social interactions) addressed social isolation, with social functioning scores correlating with reduced fear of disease progression (41).

Similarly, enhancements in social functioning scores may be connected to reduced constraints on social interactions due to better symptom control and increased confidence stemming from a deeper understanding of the disease (42,43). This knowledge reduces anxiety related to uncertainty about the condition, thus improving mental health outcomes (44). Furthermore, well-informed patients are more likely to partake in support groups and communicate effectively with healthcare providers and their social network, fostering a supportive environment that is conducive to better health outcomes (45).

The role restrictions caused by physical and emotional problems also saw significant improvements, suggesting that patients experienced fewer restrictions in their daily lives and felt more capable of handling the psychosocial challenges of their condition. This can be attributed to the comprehensive nature of the visualized intelligent health education system, which likely included modules on stress management, coping strategies, and psychological support resources. By addressing the mental and emotional aspects of living with a chronic condition, the educational system provided a holistic approach to disease management.

This study has several limitations that should be considered. First, the retrospective design may introduce selection bias, as patient grouping was based on clinical practice rather than randomization, potentially affecting the generalizability of results. The sample size (n=139) may also limit statistical power to detect small-effect differences, particularly in subgroup analyses. Second, the single-center nature of the study (detailed in Methods) restricts external validity, as results may not apply to populations with different healthcare resources or demographics.

Conclusions

In conclusion, the implementation of a visualized intelligent health education system for outpatients with chronic respiratory diseases has proven highly effective in enhancing health literacy, improving pulmonary function, and elevating quality of life. This study not only supported the theoretical foundations of visualized intelligent healthcare but also demonstrated its practical efficacy in real-world settings. The observed improvements suggest that VIMHE can play a pivotal role in empowering patients to better manage their conditions, thereby reducing disease burden and improving patient outcomes. To the best of our knowledge, this is the first study to systematically evaluate the VIMHE model in outpatient chronic respiratory disease management.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2024-2053/rc

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2024-2053/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2024-2053/prf

Funding: This study was supported by the Guangzhou Municipal Bureau of Science and Technology (No. 202201020462).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2024-2053/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of The First Affiliated Hospital of Guangzhou Medical University (No. ES-2024-K178-02) and individual consent for this retrospective analysis was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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