‘The paper brochure is worth its weight in gold’: a qualitative study of older adults’ experiences and preferences for information delivery prior to elective hospitalisation for transcatheter aortic valve implantation in Norway

Abstract

Objectives

Older adults can have difficulties understanding and recalling information prior to hospitalisation for elective treatment. Limited research exists regarding how older adults perceive the accessibility and comprehensibility of the information provided by the hospital prior to elective hospitalisation. This study aims to explore how older adults undergoing elective hospitalisation for transcatheter aortic valve implantation (TAVI) experience the information received from the hospital and their preferences for modes of information delivery.

Design

A qualitative design was used. Data were collected through individual semistructured interviews with older adults prior to hospital discharge following elective TAVI. The data were analysed using reflective thematic analysis.

Setting

All patients scheduled for elective hospitalisation for TAVI at a public university hospital in Norway were screened for eligibility.

Participants

18 older adults participated in the study. Their median age was 82 years (range 67–91), and two thirds were males.

Results

The data were categorised into four main themes: ‘The paper brochure is worth its weight in gold’, ‘Combination of different modes of information delivery increased understanding and recall’, ‘Trust reduced the need to access and understand information’ and ‘Family played a crucial role in accessing and interpreting health information’.

Conclusion

Older adults undergoing elective hospitalisation found the traditional brochure valuable, alone or in combination with the digital material, which included an animated film. The participants emphasised that support from family members was required to access the digital information.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• A systematic and transparent approach was applied, guided by the Consolidated Criteria for Reporting Qualitative Research, to ensure credibility, dependability, confirmability and transferability.

• The study’s methodological approach provides valuable insights into how to address the needs of older adults undergoing elective hospitalisation, highlighting the importance of information strategies that include both patients and their families.

• Limiting the study to elective transcatheter aortic valve implantation patients from a single university hospital may restrict the transferability of its findings to other clinical settings or patient populations.

Introduction

The global population is ageing, leading to an increase in non-communicable diseases, especially cardiovascular.¹ The incidence of aortic valve stenosis (AS) has more than doubled in the last century, affecting 2–5% of adults over 65 years.2,4 Many older adults with AS face complex health issues, often associated with a high symptom burden and disability. To manage the symptom burden, invasive procedures—such as transcatheter aortic valve implantation (TAVI)—are a viable treatment option.^{3 4} TAVI is a safe and effective treatment recommended for older patients (≥70 years), and those with high risk or assessed as being unsuitable for surgical aortic valve replacement.⁵ TAVI has become an established treatment, supported by the ongoing development of a clinical pathway that includes early hospital discharge.⁶ This evolution places increased responsibility on patients to actively manage their own health.

Successful treatment requires that patients and their families learn about the disease and treatment, including limitations, risks, benefits and expectations associated with the procedure. This necessity applies to TAVI, just as it does to many other invasive procedures.^{7 8} The need for knowledge is also rooted in the expectation that patients will prepare for their hospital admission while still at home, including visiting the dentist, maintaining good health, adhering to medication regimes and planning for postdischarge arrangements (eg, transport home from the hospital and necessary follow-up care after the treatment).⁷ Being well-informed and prepared prior to treatment aligns with person-centred healthcare.⁹ To achieve this, easily accessible and understandable information provided by the healthcare services is vital for older adults to take an active role in their healthcare.9,11

Preoperative information has been shown to reduce complications, increase patients’ satisfaction and alleviate anxiety in relation to elective procedures.¹² However, information has no value unless it can be received and processed. Unfortunately, several factors, such as cognitive impairment, hearing loss, visual impairment and disability, can impede this.⁹ Many older adults have difficulties in understanding and recalling information conveyed during clinical consultations.¹³ This is closely related to patients’ health literacy.

The principles of health literacy

Health literacy is defined as the patients’ knowledge, confidence and comfort to access, understand, appraise, remember and use information about health and healthcare.^{14 15} Health literacy goes beyond functional health literacy, meaning the basic-level skills that are sufficient for individuals to obtain relevant information (eg, reading and writing). More advanced literacy skills enable individuals to extract health information and derive meaning from different forms of communication, as well as engage in interactions with others to understand the information available and make decisions (ie, interactive health literacy).¹⁶ This principle of health literacy is crucial, as we know that health knowledge and resources are often shared through the experiences of families and peers.¹⁵

Moreover, healthcare providers must work to create environments that support patients’ health literacy, through verbal, written, digital and other communication channels and resources, by actively taking the health literacy principles into account when developing health information.

This involves developing evidence-based written materials and graphics that are accessible, understandable and actionable for all individuals. It also includes engaging experts and stakeholders in the process, as well as developing digital resources. The content should be tested with a diverse group of potential users and continuously adapted based on feedback and emerging evidence.

Although approaches to increase health literacy are important in connection with elective hospitalisation, evidence indicates that older adults’ preferences regarding sources of information are inconsistent.¹¹ Additionally, healthcare providers and the healthcare system need to develop assets that recognise and accommodate patients’ health literacy strengths and preferences to optimise equitable access.¹⁵ The aim of this study was to explore how older adults undergoing elective hospitalisation for TAVI experienced the information received from the hospital and their preferences for modes of information delivery.

Methods

Study design and setting

For this in-depth exploration of older adults’ personal experiences and preferences, we used a qualitative study with individual semistructured interviews. To report the findings, the Consolidated Criteria for Reporting Qualitative Research (COREQ) was used.¹⁷ This study included patients from one TAVI centre at a public university hospital in Norway, which performs approximately 150 TAVI procedures annually.

Development of information materials for this study

The development of information materials on TAVI was informed by the principles of health literacy.^{15 16 18} A multidisciplinary team (consisting of a cardiologist, cardiac nurses, a graphic designer and communication advisors) developed quality-assured and evidence-based information on the course of treatment for TAVI at the hospital.

The information was made suitable for traditional brochures, the hospital website and the patient portal. The multidisciplinary team used novel technological approaches to include animated films and soundtracks—this was due to the potential benefits these different delivery modes could have for individuals with limited reading skills or impaired hearing or vision. Concurrently, the multidisciplinary team also employed a more traditional mode of information delivery by providing printed materials. These materials were anticipated to be especially valuable in helping individuals remember and use information received verbally from healthcare providers.¹⁹ Furthermore, the nurses strived to help individuals access the digital information by guiding them during telephone consultations prior to elective hospitalisation for TAVI.

Participants

Both clinical and anatomical contraindications (eg, anatomical features, estimated life expectancy less than 1 year and low likelihood of improved quality of life due to comorbidities)⁵ should be identified before a patient is approved for TAVI, which means that the study population was already a preselected group with relatively preserved cognitive status. All older adults accepted for elective TAVI at the hospital between October 2023 and March 2024 were eligible to participate in the study. Patients received study information by postal mail along with the TAVI patient information brochure and hospital appointment notice. In addition, a nurse personally informed potential participants about the study during a prehospitalisation telephone consultation. Inclusion and exclusion criteria are described in table 1.

Table 1. Inclusion and exclusion criteria.

Inclusion criteria	Exclusion criteria
Patients undergoing elective TAVI. Being 65 years or older. Being able to read and understand Norwegian. Living at home at the time of inclusion.	Institutionalised. Undergoing TAVI in an acute setting. Diagnosed with a dementia disease.

TAVI, transcatheter aortic valve implantation.

Patients were recruited until the data collected captured information power, including the diversity, depth and nuances of the older adults’ experiences and preferences regarding modes of information delivery prior to TAVI. In line with Malterud, the aim was not to gain a complete description of all aspects of patients experiences, but to offer new insights that can contribute substantially to or challenge current understandings.²⁰ A total of 72 patients were screened, and 61 met the eligibility criteria. Of those, 19 patients (31%) provided consent to participate in this study.

Data collection

Data were collected through individual semistructured interviews conducted prior to hospital discharge. A semistructured interview guide developed specifically for this study was based on the information material developed in the project and the health literacy concept (table 2). Two of the female authors (GB and BL) conducted the interviews in the patient rooms at the hospital approximately 2 days after the TAVI. The interviewers did not know the patients before the interviews. Each interview lasted between 20 and 60 min, and all interviews were audio recorded and transcribed verbatim.

Table 2. Interview guide.

Questions
1	How would you describe the information you received before your TAVI?
2	How important do you feel it is to receive such information before undergoing the TAVI procedure?
3	How did you experience the information in the brochure you received before the TAVI procedure?
4	How did you experience the information available on the hospital webpage you received access to before the TAVI procedure?
5	Can you describe your experience with the oral information provided by healthcare providers before the TAVI procedure, including the telephone consultation with the Heart team nurse?
6	How did you feel about receiving information about the TAVI procedure in different delivery modes, such as oral, telephone, face-to-face, written and digital?

TAVI, transcatheter aortic valve implantation.

Data analyses

The data were analysed using the six phases of reflexive thematic analysis as described by Braun and Clarke.²¹ In the first phase, the authors familiarised themselves with the data by reading the transcripts several times. Preliminary codes that captured initial ideas were continuously noted. In the second phase, four interviews were coded and discussed by three of the authors (GB, THN and MHL), and the other interviews were then coded by the first author (GB). These codes were sorted into additional overarching codes that captured important elements of the study. In the third phase, codes were collated into clusters and potential themes, gathering all data relevant to each potential theme. Five potential themes were named by the first author (GB). In the fourth phase, two authors (THN and MHL) reviewed the themes. The themes were again discussed, and all the authors (GB, TF, CHR, BL, MHL and THN) agreed to move some extracted data to different themes. In the fifth phase, the authors met and discussed to ensure that the unique content of each theme was captured. The four final themes were defined and named. Finally, in the sixth phase, illustrative quotes underpinning the main findings related to the study aim were chosen. The quotations are reported using gender and age as identifiers.

NVivo qualitative data analysis software (V.14) was used for data management in the analysis.²²

Patient and public involvement

One experienced patient representative provided input on the development of the information.

Results

18 participants participated in the study. Their median age was 82 years (ranging from 67 to 91 years). More than two thirds of the participants were males, and more than half of them lived alone (table 3).

Table 3. Demographic and clinical characteristics of the participants (N=18).

Age (year) (median, range)	82 (range 67–91)
Gender
Female	5
Male	13
Living alone	11
Education level
Vocational school	9
High school	3
College/university	6
Born in Norway	16
BMI (median, range)	26 (range 22–36)
Medical history
Atrial fibrillation	9
Chronic renal disease	7
Coronary artery disease	9
Diabetes	2
Hypertension	11
Pacemaker/ICD	2
Heart failure	6
Stroke	4
Impaired mobility (severity: moderate to severe)	6
Impaired vision (severity: moderate)	6
Hearing loss (severity: moderate to severe)	9
Impaired function due to somatic illness (severity: moderate to severe)	5
Home-based service	2
Days in hospital (median, range)	4 (range 3–29)
Digital activities
Access to internet at home	16
Need support to handle digital tasks	8

BMI, body mass index; ICD, implantable cardioverter-defibrillator.

The data were categorised into four main themes: ‘The paper brochure is worth its weight in gold’, ‘Combination of different modes of information delivery increased understanding and recall’, ‘Trust reduced the need to access and understand information’ and ‘Family played a crucial role in accessing and interpreting health information’ (figure 1).

Figure 1. Visual presentation of the four themes.

‘The paper brochure is worth its weight in gold’

All patients reported that the paper brochure they received by postal mail was valuable in their preparation prior to hospitalisation and the TAVI procedure. They highlighted the importance of simple language and a logical order. Some participants compared the language delivered both orally and written and said that, while they struggled to understand everything the doctor communicated orally, they had no such issues when reading the paper brochure.

Several noted that it was often challenging to remember oral information, making the brochure invaluable for review when questions arose. Additionally, several participants said that they also used the brochure to write notes and mark information they found especially important. For instance, they created a packing list prior to hospital admission based on the information in the brochure. Many participants emphasised the importance of having easy and immediate access to the information, both for repetition to increase their understanding and to ensure that they remembered the details accurately. Many also brought the brochure to the hospital and read it repeatedly throughout the hospital stay.

I looked it up after I got here (to the hospital) just to get a recap of what was written about the phase before the operation and the day of the operation. Now I have to review the information about the period following the operation. There are no surprises. I really appreciate that you have made this brochure. (Female, 80 years old)

Most of the participants reported that it was easier to read the information on paper than on digital devices. They emphasised the readability of the brochure related to the size of the font and its layout. This, in particular, made the brochure useful for those with impaired vision, which often accompanies older age. In comparison, they had to keep zooming in on the text to be able to read the digital information properly; most of the participants said that they ended up printing the digital information to be able to read it accurately.

It works fine for me, who has a printer and can print and take the time to read it afterwards. However, many old people do not have a printer at home. Therefore, the brochure is worth its weight in gold. (Female, 80 years old)

The combination of different modes of information delivery increased understanding and recall

The participants highly valued the combination of different modes of information delivery. They expressed appreciation for the diverse methods used, including the brochure, with both text and pictures, which was sent by postal mail; the animated film on the website; and the telephone consultation. They felt that these different modes of delivering information complemented each other.

However, only a few of the participants talked about the value of digital information on the hospital webpage, which included the newly developed animated film. Those who had seen the animated film said that, alongside reading the brochure, the animated pictures gave them a better understanding of what they needed to know prior to undergoing TAVI. Furthermore, the subtitling of the animated film was good for those with hearing impairment, and the animated film was experienced as very realistic. It was also expressed that the animated images did not evoke unpleasant feelings in the way that pictures or films with real people would. However, some found the picture of the implementation valve in the brochure misleading and scary.

When I read it, the information does not stick very well, at least for me, who is so old. Therefore, I had to read it several times, not to understand the content, but to ‘take it in’. However, the animated film went right into my memory. (Female, 87 years old)

The opportunity to obtain information in person prior to undergoing TAVI was valued because it gave them the chance to ask questions that were important to their individual situation and health literacy. Getting additional oral information was said to be essential because the information in the brochure, the animated film, the webpage and the patient portal all contained standardised information—that is, not tailored to their individual needs.

While many of the participants found this standardised information to be sufficient, others said that they needed more detailed and more personalised information, such as how the new valve would be securely placed into the existing valve or how the procedure could be done using only local anaesthesia. Notably, all emphasised that information about severe risk factors, such as the risk of stroke and arrhythmia, should be delivered verbally by the hospital doctor.

I talked to him (the doctor) before the TAVI and asked some questions about different things and he drew (pictures) and explained in a very good way. It was very good to get information from someone with top expertise and someone you have trust in. (Male, 83 years old)

Trust reduced the need to access and understand information

The participants generally expressed a high level of trust in the public healthcare service. Getting oral information from healthcare providers, especially doctors, was said to create a feeling of being looked after. The participants emphasised that, due to their trust in the healthcare provider’s competence, they were not too stressed or anxious prior to the TAVI. Moreover, they said that their individual preferences concerning personal decisions and participation in shared decision making were less important to them than the clinicians’ advice and recommendations. Several of them underscored this by saying that they did not need extensive information because they trusted the doctors’ expertise.

Honestly, I have not thought anything about it (the TAVI procedure). I did not ask how it was going to happen because I trusted that the doctors would sort it out. (Male, 67 years old)

Several of the patients said that participating in decisions about treatment choices was irrelevant to them because they trusted the decisions made by the clinicians. This included decisions on the choice between open heart valve surgery, TAVI or conservative treatment with medication only.

Yes, it was mentioned that the decision was up to me. However, it was not a question for me because when a whole army of doctors and nurses recommended that I get a new valve, I had to say yes. There was nothing else to do. If I had said no, there would have been protests from the family at home. (Female, 84 years old)

Family played a crucial role in accessing and interpreting health information

Participants expressed that they did not have to navigate health information alone because family members helped them to find and access it. They said that they shared the information they had received from the hospital and involved their family in the planning prior to hospitalisation. Notably, several participants reported great benefits from having a healthcare provider in their family with whom they could ask questions and discuss information and treatment decisions. They highlighted the importance of involving family members, not only for receiving social support but also to reassure family members about the safety of the procedure.

They (the family) also want to get information because they are more anxious than I am. I do not worry too much, you know. But I know them well and can feel that they are more worried. (Male, 83 years old)

However, some participants said that they lacked the necessary digital competence to access online health information provided by the hospital. In these instances, family members played a crucial role in facilitating digital access: for instance, by helping them to search for health information (eg, by Googling), downloading and printing information from the patient portal and locating and playing the animated film on the hospital’s web page.

We are old people, you know. We don’t have … well, my wife and daughter have a tablet. But if they are not here, then I will have a problem (with digital tasks). (Male, 85 years old)

Additionally, some said that they had searched for supplementary information on the internet prior to undergoing TAVI. However, several participants also voiced scepticism about the reliability of the information available on the internet. Despite this, most of them used the internet to read newspapers and access social media, especially Facebook. Notably, they expressed varying levels of interest in using digital solutions to access information. Although some individuals felt overwhelmed by digital tasks, others demonstrated proactive efforts to manage these independently. Some also said that they had approached the local library for help.

I have learned that (to access the patient portal) now. Otherwise, I have two daughters to help me. They help us both, my husband and me. He is not good with digital tasks, either. He is the same age as me. (Female, 84 years old)

Discussion

To our knowledge, this is the first study to explore how older adults undergoing elective hospitalisation for TAVI experience information and their preferences for modes of information delivery prior to the procedure. The participants highly valued the paper brochure, in part because of the visual imagery that complemented the text. They emphasised how this facilitated reading comprehension and recall, either alone or in combination with digital animated information. The participants also appreciated the oral information and support received from the healthcare providers, whom they trusted to decide the best treatment for them. Furthermore, the participants greatly benefited from their family’s assistance in accessing and understanding information, especially when the information was provided digitally, which necessitates more advanced interactive health literacy.

Comparison to other literature and the wider context

This study’s findings are in line with a recent study on patients with cancer that highlights the continued importance of traditional written formats and the opportunity to ask questions in patient education.²³ Moreover, adding pictures to written and spoken information has been found to increase reading comprehension and recall, as well as attention.²⁴ Notably, the fact that few participants said that they had the opportunity to print the digital information suggests that printed information should be made available to ensure that patients are sufficiently informed prior to elective hospitalisation. Nevertheless, there is a need for studies comparing reading comprehension and recall between paper-based and digital information among older adults, with and without chronic diseases.

The digitalisation of information has provided more opportunities for information delivery.²⁵ The study participants who took advantage of the different modes of information delivery said that the modes complemented each other and thereby increased their understanding of the procedure. Nevertheless, having various possibilities for information delivery requires that healthcare providers are vigilant and consider the patients’ needs when offering information to patients.^{19 25} It is also important to acknowledge that even patients with adequate literacy can struggle with information recall, suggesting that this is a challenging task for all patients.¹³ It could therefore have been useful to implement communication methods such as teach-back, where the healthcare providers encourage patients in a supportive and non-shaming way (ie, asking patients to repeat information, not to test the patient but to ensure that the providers have explained things sufficiently). This approach has been shown to improve knowledge, self-care and recall of follow-up instructions in patients with chronic diseases.^{26 27}

Most of the existing studies have focused on the discharge process, rather than preparations for elective hospitalisation. Therefore, further research is required to investigate the effectiveness and experiences of information delivery techniques (like the teach-back method) across different healthcare settings and stages of patient care.²⁷ However, its application in preparing for elective hospitalisation, such as for TAVI procedures, needs further exploration to determine its full potential and effectiveness.

Study findings nevertheless underscore the important role that information delivery plays in creating an environment that builds trust in the healthcare service and providers. Failure to provide information in a reassuring way can lead to fear. In a preoperative context, this means that patients must be provided with both standardised and personalised information. The need for individualised information about anaesthetic and surgical techniques has also been reported in a systematic review reporting a decrease in anxiety symptoms as a benefit.¹² Our study indicates that a holistic approach to patient information is essential for fostering patients’ confidence and supporting their ability to self-manage the TAVI process. This may help to ensure that patients remain engaged with essential information prior to TAVI, especially due to fear. This aligns with the principles of health literacy, which emphasise that organisational health literacy plays a key role in empowering patients.²⁸

However, some participants found it irrelevant to make decisions regarding their treatment, primarily because they trusted the clinicians’ recommendations. This may stem from the participants perceiving their own knowledge and experiences as uncertain, which led to hesitancy in participating in the final treatment.²⁹ Additionally, the information materials developed in the study were designed to be provided to older adults at the time the decision for TAVI was made, potentially influencing the findings. Notably, this is not an unexplained phenomenon; research has shown that patients’ treatment preferences are often influenced by their perceptions of healthcare providers’ recommendations.³⁰ A possible solution is to implement decision aids in preoperative clinical practice to enhance patients’ knowledge and empowerment, as well as their treatment preferences and confidence. Importantly, this may pose challenges for older adults who lack the capacity to make treatment choices,³¹ which could necessitate the involvement of family members or significant others.³² However, there is a lack of high-quality decision aids tailored to various health literacy levels for patients with AS that support shared decision making.³² This highlights the need to develop more clinical trials on shared decision making that include older adults in cardiovascular care,⁹ to identify the best approaches to the informational aspects of care.

The importance of social support for health, discussed in our study, aligns with a previous systematic review demonstrating that families play a crucial role in fostering engagement and support for the self-management of chronic conditions.³³ This also corresponds with the WHO’s description of community health literacy, which emphasises that patients often obtain health information through interactions with others.¹⁵ This social support helps balance the challenges faced by patients with low health literacy, as they also possess strengths, complicating the notion of high versus low health literacy.³⁴ Thus, the current study underscores the significance of including family members in preparations for elective hospitalisation and raises awareness of their vital role in helping older adults access digital health information.

The engagement of family members to enhance access to and understanding of information was highly valued, as participants expressed having limited experience with digital health resources. They relied on their families to navigate and use contemporary and digital modes of information delivery. This underscores the importance of assessing patients’ levels of digital health readiness, including factors such as digital access, skills, motivation, learnability and health literacy³⁵ of the patients so that digital exclusion is avoided. The digitalisation of information offers numerous opportunities for enhanced information delivery.²⁵ This study indicates that healthcare organisations and providers must adapt to ensure that older adults can easily navigate, understand and use information and services through digital resources to manage their health effectively. Overall, the findings align with previous understandings of the healthcare system’s responsibility to create equitable access to information¹⁵ and highlight the need to consider patients’ abilities to benefit from innovations when implementing new methods of healthcare delivery.

Strengths and limitations

The research team possesses extensive experience in the field of TAVI with deep familiarity with both the clinical context and previous research on the areas. A rigorous systematic approach was conducted to ensure credibility, dependability, conformability and transferability. To reduce researcher bias, two female study nurses conducted the interviews. Some of the first interviews were also performed with both the interviewers present. All phases of the data analysis were performed in close collaboration with all coauthors, ensuring transparency and dependability by reducing the potential bias by the authors’ preunderstanding. Moreover, two experienced researchers on qualitative methods were involved in the study, which secured that the data analysis became internally consistent, ensuring that interpretations were grounded in the data rather than individual bias.

Our sample showed variation regarding various experiences of the information and preferences for different delivery modes. With that said, we cannot rule out that additional participants might have added further perspectives to the analysis.

Although the transferability may be somewhat limited, as the patients were from a single university hospital, the findings provide valuable insights into how to address the needs of older adults undergoing elective hospitalisation; they also highlight the importance of comprehensive communication strategies involving both patients and their families. It should also be noted that conducting interviews in a hospital setting may have been a limitation, particularly in terms of patient stress and comfort.

The COREQ checklist was used to ensure transparency in reporting.¹⁷

Conclusions

Study findings highlight the importance of offering different modes of delivery when providing information prior to hospitalisation for elective hospitalisation in older adults. Most of the participants found the traditional modes of delivery valuable, either independently or in combination with more contemporary modes of delivery, such as the animated films accessible on the hospital web page. Importantly, accessing digital information often required family support. Findings indicate that digital readiness among some older adults may lag behind digital developments. This points to a need for more research on interventions to improve digital health literacy and readiness among older adults.

Data availability statement

Data are available upon reasonable request.