Chao Sun

Chronic lung disease (CLD) poses a large health and economic burden worldwide and
is unevenly distributed across regions and populations. Moreover, research funding is
disproportionately concentrated in high- income countries (HICs). Given the burden of
CLD, promoting health education and behavior change is essential to increase
individuals’ understanding of CLD and support them in adopting healthy behaviors,
such as seeking timely healthcare and adhering to prescribed medications. Across
diverse global contexts, challenges such as limited awareness of CLD, prevalent and
difficult-to-change risk behaviors and inappropriate CLD-related behaviors among
individuals and healthcare professionals (HCPs), remain in translating health education
into effective and sustained behavior change. With the increasing integration of
information and communication technology in healthcare, eHealth seems to
demonstrate potential in promoting health education and behavior change by increasing
the accessibility and efficiency of healthcare delivery without time or geographical
barriers. However, the effectiveness of eHealth might vary between contexts and
individuals due to differences in healthcare systems, digital coverage, and individual
characteristics such as eHealth literacy (eHL) level, which refers to individuals’ abilities
to access, understand, appraise and apply online health information. Drawing on three
countries with distinct socioeconomic, geographic and healthcare contexts, this thesis
aimed to provide a global perspective on health education needs and behavioral
challenges related to CLD, and to examine the potential of eHealth for supporting CLD
health education and behavior change. Specifically, this thesis had the following three
aims:

1) to explore beliefs, perceptions and behaviors related to CLD;
2) to assess eHL and its associated factors;
3) to evaluate the potential of eHealth for CLD health education and behavior change.

Chapter 1 provided a general introduction about the global burden of CLD, importance
and challenges of health education and behavior change for CLD, the potential of
eHealth regarding CLD, and the three settings in which empirical studies were
performed.

Chapter 2 and Chapter 3 explored CLD-related beliefs, perceptions and behaviors
among community members (CMs) and HCPs in Kyrgyzstan. Using a brief textual
scene describing a typical CLD-like condition, and integrating data from questionnaires,
interviews and focus groups, these two chapters provided context-specific insights into
how local people perceived CLD and its causes, as well as how they responded to CLD-
like conditions. Findings showed that CMs usually perceived CLD symptoms as acute,
infectious conditions, and attributed them to cold and smoking. Despite awareness of
the health risks, smoking remained prevalent among CMs, along with the widespread
use of solid fuels for cooking and heating with limited ventilation due to resource
constraints. A delayed help-seeking pattern was observed, such as the preference for
traditional medicine, and self-medication before seeking formal care. CMs with longer
duration of education, being unemployed, and living in the lowlands tended to have
more negative illness perception scores, which meant that they perceived CLD as more
threatening and burdensome. Among HCPs, challenges were noticed in differentiating
CLD from other respiratory diseases, and HCPs provided restricted and experience-
based helping behaviors due to lack of resources. For example, HCPs referred patients
to better-equipped places, prescribed antibiotics (which reflected uncertainty in
recognizing CLD and might not be always appropriate for CLD treatment) and rarely
used guidelines. Physicians appeared to provide more helping behaviors for CLD than
nurses. These findings suggest that CLD-related beliefs, perceptions and behaviors
might vary in contexts, shaped by socio-economic, cultural, policy-related and health
system factors.

Chapter 4 investigated eHLand its associated factors in the Chinese general population.
Online and offline surveys were used to improve inclusiveness and representativeness.
The sample showed limited eHL and CLD knowledge on average, generally reported
positive expectations to eHealth, perceiving it as easy to use and useful. While digital
access was common overall, notable disparities were noticed between the elderly and
those with a low socioeconomic position, and other groups. Younger age, higher
education and income level, having digital access, more frequent eHealth use, and a
more positive attitude towards eHealth were associated with higher eHL. This chapter
highlights the need to improve eHL and CLD knowledge, as well as the digital access
among the vulnerable population. The identified determinants of eHL provide a basis
for designing tailored health education and eHealth interventions to meet the needs and
preferences of different population groups.

Chapter 5 provided an overview of existing literature on digital health education (DHE)
for CLD, and reported delivery mediums, educational content, intervention
mechanisms, and outcomes of DHE. The findings indicate an increasing publication
trend in this field, but mostly in HICs. Websites and mobile applications were the most
widely used mediums, mainly focusing on teaching people how to manage their health
by themselves, yet intervention mechanisms were rarely mentioned. Most studies found
that DHE helped improve patients’ understanding of CLD, health outcomes, lifestyle,
mental and social well-being, while also being practical to use, well accepted by
participants, and highly rated in terms of satisfaction. Only two studies reported cost-
effectiveness, but neither provided a clear comparison of costs before and after DHE.
This demonstrates the potential of eHealth in supporting CLD health education, while
also revealing important gaps in the literature. In particular, there is a need for greater
attention to low- and middle-income countries, intervention mechanisms and cost-
effectiveness outcomes.

Building on a cluster randomized trial in Dutch primary care, Chapter 6 examined
whether illness perceptions and eHL affected effectiveness of a digital inhaler program
among asthma patients, as well as how illness perceptions and eHL were related to
demographics. In this trial, the intervention group used a digital inhaler program with
self-monitoring and medication adherence reminders, while the control group used a
passively monitored inhaler without feedback. Previously, the program proved to be
effective in improving asthma control and medication adherence. Our study showed
that illness perceptions and eHL did not affect the effectiveness. This implies the user-
friendly program may achieve equivalent effectiveness across patients with different
illness perceptions and eHL. This result might also be partly because the sample had
generally high eHL levels. In addition, we found that people with younger age were
more likely to have better eHL. These findings provide guidance for evaluating other
factors to identify subgroups that benefit from eHealth interventions most or require
additional support to use them, and highlight the potential equitable effectiveness of
eHealth interventions in different groups.

Chapter 7 presents the general discussion of this thesis. By integrating findings across
diverse contexts and study designs, this thesis identified beliefs, perceptions and several
behavioral challenges regarding CLD among CMs and HCPs, assessed eHL and its
associated factors, and examined the potential for eHealth in supporting CLD health
education and behavior change. Despite the demonstrated benefits of eHealth, those
with limited digital access, low eHL and lower socioeconomic position might benefit
less. These findings underscore the importance of tailoring health education to local
needs and contexts, for example using existing resources and simple, locally easy-to-
understand language, engaging key stakeholders such as community members, leaders,
teachers, HCPs, policy-makers and designers, and applying behavior change techniques
to promote effective and sustained behavior change. To address the digital divide and
maximize the potential for eHealth, it is recommended to invest in digital infrastructure,
engage end users in the development and evaluation of eHealth, incorporate established
behavior change techniques, and provide technical support for populations with lower
digital skills.