The Effect of Tele-nursing Education on Medication Adherence and Health Literacy in COPD patients

Abstract

Background and aim

Chronic obstructive pulmonary disease (COPD) is one of the most common chronic conditions that requires effective management through medication adherence and improved health literacy. Tele-nursing, as a modern educational method, can play a significant role in enhancing these outcomes. This study aimed to investigate The Effect of Tele-nursing Education on Medication Adherence and Health Literacy in COPD patients.

Methods

In this quasi-experimental study with a pre-test–post-test design, 70 patients with COPD who referred to teaching hospitals in Zahedan in 2024 were selected through convenience sampling and randomly assigned by coin toss into intervention and control groups (35 patients each). The intervention group used a researcher-developed mobile application called "Hamdam-e-Salamat" for one month. This app included educational videos, medication reminders, and the ability to record vital signs. Data collection tools included the Morisky Medication Adherence Questionnaire and the TOFHLA Health Literacy Questionnaire, which were completed by both groups before and one month after the intervention. Data were analyzed using SPSS version 27 with Chi-square, paired t-test, and independent t-test.

Results

The majority of patients were male. The mean age in the intervention group was 68.82 ± 6.88, and in the control group, 69.97 ± 4.23. The mean score of medication adherence before the intervention was 3.91 ± 1.63 in the intervention group and 3.74 ± 1.22 in the control group. After the intervention, this score changed to 1.11 ± 0.86 in the intervention group and 3.68 ± 1.25 in the control group. Tele-nursing education led to a 2-point reduction in medication nonadherence score in the intervention group, which was statistically significant compared to the control group (p < 0.001). Additionally, the mean health literacy score in the intervention group increased from 49.25 ± 4.97 before the intervention to 56.02 ± 4.94 after the intervention, which was statistically significant (p < 0.001), while this change in the control group was not significant (p = 0.37).

Conclusion

Tele-nursing education can be an effective method for improving medication adherence and enhancing health literacy in patients with COPD. It is recommended that this educational approach be incorporated into care programs for patients with chronic illnesses.

Background

Chronic Obstructive Pulmonary Disease (COPD) is one of the most common chronic respiratory diseases worldwide, characterized by progressive and irreversible airway obstruction and chronic inflammation. Its main symptoms include dyspnea, chronic cough, and sputum production [1]. According to the World Health Organization, more than 213 million people globally were affected by COPD in 2021 [2]. In Iran, based on the Global Burden of Disease (GBD) project, the age-standardized prevalence of COPD has been reported at approximately 5,155 per 100,000 population [3]. COPD is one of the leading causes of mortality worldwide and is expected to become the third leading cause of death globally by 2030 [4].

Due to its chronic and complex nature, successful management of COPD cannot be achieved solely through medication prescription; it also requires the patient’s active and informed participation in the care process. In this context, health literacy plays a crucial role. Health literacy refers to an individual’s ability to obtain, understand, and apply health information, and it directly influences self-care behaviors, including medication adherence [5, 6]. Several studies have shown that patients with COPD and low health literacy often struggle with the correct use of inhaled medications and tend to have lower adherence to treatment regimens [5, 7]. Additionally, cognitive decline—such as reduced mental processing speed—which is common among these patients, further exacerbates difficulties in regular medication use, particularly when combined with limited health literacy [5].

Moreover, high comorbidity rates among COPD patients must be considered. More than three-quarters of individuals with COPD suffer from at least four other chronic conditions, which complicates their medication regimens and increases the risk of medication errors [8, 9]. As a result, treatment adherence in these patients is often poor; studies report non-adherence rates to inhaled medications ranging from 30% to 68% [10–13].

The World Health Organization defines treatment adherence as “the extent to which a person’s behavior corresponds with agreed recommendations from a healthcare provider” [14, 15]. In chronic diseases such as COPD, poor medication adherence leads to serious consequences, including exacerbation of symptoms, increased hospitalizations, reduced quality of life, and greater financial burden on healthcare systems [16]. Studies show that half of patients with chronic diseases, including COPD, do not adhere to prescribed treatments, which doubles the risk of hospitalization [17–19]. Despite the efforts of patients and healthcare providers, factors such as long treatment duration, treatment fatigue, hopelessness regarding recovery, and medication side effects often lead to non-adherence [20].

Given these challenges, there is a clear need for effective strategies to improve both health literacy and medication adherence [21]. One innovative approach that is particularly suitable for patients with physical limitations—such as those with COPD—is telenursing education. This method utilizes information technology to provide flexible, cost-effective, location-independent education, follow-up, reminders, and support for patients [22–24]. Some studies have demonstrated the positive impact of this approach on medication adherence [25, 26], but there is still insufficient evidence regarding its simultaneous effect on both health literacy and medication adherence.Therefore, the present study was conducted to examine the impact of telenursing education on medication adherence and health literacy in patients with COPD, aiming to address existing gaps in both research and clinical practice.

Methods

Population, inclusion, exclusion criteria and sample size

This study was a quasi-experimental design with two groups and a pre-test–post-test structure. The study population included all patients with COPD who referred to teaching hospitals in Zahedan in 2024. The sample size was estimated based on the mean and standard deviation of the study by Sokhek et al. (2014) with a confidence interval of 95% and based on the formula of 27 people in each group [27]. In order to increase the assurance of the adequacy of the sample size and possible sample attrition, 35 people were taken in each group and a total of 70 people were taken.

Inclusion criteria were: age over 60 years, access to a mobile phone at home, ability to read and write, and capability to use a mobile phone and the internet. Exclusion criteria included: patient death, critical illness, or loss of contact for more than one week. The reason for selecting patients over 60 years of age in this study was multidimensional and based on the clinical and epidemiological characteristics of this age group. More details about the justification of this criterion are provided in the discussion section of the article. In this study, for ethical and practical reasons, a two-group quasi-experimental design was used in the randomization of patients with chronic obstructive pulmonary disease. This design provides an effective comparison of the telenursing educational intervention in real-world conditions, while with interventional controls via pretest, the groups are assured of achieving the desired outcomes. This method also saved time and money and provided greater flexibility in implementing educational interventions.

Measurement instruments

The data collection tool in this study consisted of three parts, all completed through face-to-face interviews with the patients. The first part was a demographic information form including gender, educational level, ethnicity, marital status, employment status, and place of residence. The second part was the Morisky Medication Adherence Scale (MMAS), which measures medication adherence using a Likert-type format. This questionnaire includes items such as “During the past two weeks, has there been a day when you did not take your medications for any reason other than forgetting?” It contains seven dichotomous (yes/no) items and one item scored on a five-point Likert scale ranging from “never” (1 point) to “always” (0 points). The total score ranges from 0 to 8, where lower scores indicate higher adherence. Content, face, and criterion validity of the scale have been evaluated as appropriate in the study by Sarmad et al. [28]. Furthermore, the internal consistency (Cronbach’s alpha) reported by Dianati et al. was 0.72 [29]. The MMAS-8 is availble for use explicit licensing, based on https://ekeshoo.ir/morisky-medication-adherence-mmas-8. The questionnaire used in this study is an adapted version of instrument published in in the study by Bahoor et al.

The third part of the tool was the Test of Functional Health Literacy in Adults (TOFHLA), which has been validated in Iran by Dr. Beni Hashemi Tehrani and colleagues. The reliability coefficients were reported as 0.79 for the numeracy section and 0.88 for the reading comprehension section [30]. This questionnaire includes two parts: numeracy and reading comprehension. The reading comprehension section evaluates patients’ ability to understand actual health-related texts and includes 50 items. The numeracy section involves a series of explanations related to prescribed medications, medical appointments, steps to receive financial support, and interpretation of medical test results. After receiving this information in the form of cards, participants answered 17 related questions. The health literacy score ranges from 0 to 100 and is classified into three levels based on cut-off points of 59 and 74: inadequate, marginal, and adequate. The reliability of the questionnaire was 0.79 for the calculation section and 0.88 for the reading section [31].

Intervention

Initially, in both the intervention and control groups, the standard questionnaires on medication adherence and health literacy were completed through face-to-face interviews by the researcher. Then, for patients in the intervention group, the educational mobile application “Hamdam-e-Salamat” was installed on their smartphones, and instructions for its use were provided. This software was designed and implemented by Fanavaraneh Company in the Science and Technology Park of Zahedan University of Medical Sciences. The company has a proven track record in developing digital health solutions and has valid certifications in the field of medical software. The educational content of the software was compiled by researchers according to the latest GOLD (2023) clinical guidelines [32]. And this content was reviewed and approved by 3 faculty members of the Nursing Department of Zahedan University of Medical Sciences, 2 respiratory disease specialists, and 1 senior health education expert. After registering in the application, patients entered their personal information, medical history, and contact details. All information was securely encrypted and privacy was strictly maintained.

The application contained a series of short, high-quality videos with subtitles and simple language, covering topics such as disease symptoms, proper use of medications and their potential side effects, correct breathing techniques, respiratory exercises, and management of respiratory attacks. The educational content was developed through a review of relevant literature and validated by faculty members from the School of Nursing and Midwifery at Zabol University of Medical Sciences.

Additionally, the application enabled patients to record their medication times and dosages, with an intelligent reminder system sending alerts at scheduled times. The app also provided reminders for performing respiratory physiotherapy exercises or contacting physicians. Patients were able to log their vital signs (e.g., heart rate, oxygen saturation, respiratory rate), which were presented in graphical reports and shared with healthcare providers to facilitate timely interventions if needed.

To ensure daily use of the app, the researcher contacted the intervention group patients by phone twice weekly. Patients who did not use the application for more than five consecutive days were excluded from the study. During each call, the researcher asked about the number of educational videos viewed, assessed the patients’ comprehension of the content, and answered their questions or resolved any ambiguities.

Statistical analysis

Data were collected, coded, and analyzed using SPSS software version 26. First, sample characteristics including frequency, percentage, mean, and standard deviation were calculated and reported. The normality assumption of the data was examined using the Shapiro-Wilk test. To compare the means before and after the intervention in each group, the paired t-test was used if normality was met. Also, to compare the means between the intervention and control groups, the independent t-test was employed if normality and homogeneity of variances were established. The chi-square test was used to compare the frequency distribution of nominal/ordinal qualitative variables between the two groups. In cases where the assumptions of normality or other parametric test assumptions were not met, the equivalent non-parametric test was used (Wilcoxon test instead of paired t-test, Mann-Whitney test instead of independent t-test). The significance level in this study was considered less than 0.05.

Findings

A total of 70 participants were included in the study. At the beginning of the study, the two groups did not differ significantly in any demographic characteristics, including age, gender, education level, ethnicity, marital status, and employment status, indicating homogeneity between groups (p > 0.05). According to the study findings, the majority of participants had a high school diploma, and most patients were unemployed (Table 1).

Table 1.

Frequency distribution of demographic variables in patients with chronic obstructive pulmonary disease

Variables		Intervention group		Control group		P-value
Age		68/82 ± 6/88		69/97 ± 4/23		P = 0/40
Gender	male	30	85/7	31	88/5	P = 0/71
	female	5	14/2	4	11/4
Level of education	under diploma	12	34/2	10	28/5	P = 0/48
	diploma	18	51/4	12	34/2
	university	5	14/2	9	25/7
Ethnicity	Fars	16	45/7	21	60	P = 0/47
	Baloch	13	37/1	9	25/7
	other	6	17/1	5	14/2
Marital status	single	0	0	3	8/5	P = 0/48
	married	16	45/7	19	54/2
	deceased wife	15	42/8	12	34/2
	divorced	4	11/4	1	2/8
Employment status	employed	9	25/7	14	40	P = 0/30
	Unemployed	26	74/2	21	60
Place of residence	city	29	82/8	31	88/5	P = 0/73
	the village	6	17/1	4	11/4

The assumption of normal distribution for medication adherence and health literacy, as well as their domains, was confirmed (p > 0.05). A comparison of medication adherence and health literacy scores between the two groups before the intervention showed no statistically significant differences in the mean scores of medication adherence and health literacy and its domains, based on the results of the independent t-test, indicating the groups were homogeneous (p > 0.05). One month after the intervention, the comparison of medication adherence between the two groups revealed that the mean ± standard deviation score for medication adherence was 11.1 ± 0.86 in the intervention group and 3.68 ± 1.25 in the control group. The independent t-test indicated that this difference was statistically significant (p < 0.001). Similarly, the mean ± standard deviation of health literacy in the intervention group was 56.02 ± 4.94, while in the control group it was 50.82 ± 6.92, with a statistically significant difference (p < 0.001) (Table 2).

Table 2.

Comparison of the mean scores of medication adherence and health literacy and its dimensions before and after the intervention in patients with chronic obstructive pulmonary disease in the intervention and control groups

Variable		Intervention group Mean ± standard deviation	Control group Mean ± standard deviation	p-value
Adherence to drug treatment	Before intervention	3/91 ± 1/63	3/74 ± 1/22	P = 0/62
	After the intervention	1/11 ± 0/86	3/68 ± 1/25	P < 0/001
	The result of the paired t test	P < 0/001	P = 0/32
Health literacy	Before intervention	49/25 ± 4/97	50/57 ± 7/08	P = 0/37
	After the intervention	56/02 ± 4/94	50/82 ± 6/92	P < 0/001
	The result of the paired t test	P < 0/001	P = 0/06
Reading	Before intervention	28/45 ± 3/72	29/22 ± 4/53	P = 0/43
	After the intervention	31/60 ± 3/90	29/34 ± 4/62	P = 0/03
	The result of the paired t test	P < 0/001	P = 0/32
Calculations	Before intervention	20/80 ± 4/11	21/34 ± 6/55	P = 0/67
	After the intervention	24/42 ± 3/69	21/40 ± 6/55	P = 0/008
	The result of the paired t test	P < 0/001	P = 0/16

Telenursing-based education led to improved health literacy scores and decreased medication adherence scores in the intervention group compared to the control group. The difference in mean scores of health literacy and medication adherence before and one month after the intervention in the intervention group was statistically significant (p < 0.001), whereas no significant difference was observed in the control group during the same period (p > 0.05). Furthermore, at this stage, there were statistically significant differences between the two groups across all domains of health literacy, with patients who received the intervention achieving higher scores in the mentioned domains (Table 2).

Discussion

The findings of the present study demonstrated that telenursing education significantly improved both medication adherence and health literacy among patients with Chronic Obstructive Pulmonary Disease (COPD). These results align with numerous previous studies that have reported the effectiveness of remote interventions in managing chronic diseases. For instance, Seraj et al. (2022) showed that using WhatsApp as a platform for telenursing intervention among adolescents undergoing cardiac surgery led to improved treatment adherence [24]; a similar effect observed in this study, achieved through regular calls and proactive nurse engagement. The common feature between these studies lies in the continuous communication between the healthcare provider and the patient, timely responsiveness, and the resulting sense of support.

Similarly, the findings of Bikmoradi et al. (2016) on patients post-coronary artery bypass graft surgery confirm the critical role of continuous telephone follow-ups by nurses in enhancing treatment adherence [33]. In the present study, weekly structured phone calls and the ability to log health status via the application functioned similarly to those follow-ups, reinforcing patients’ sense of responsibility. Kamarani et al. (2015) also found that combining face-to-face education with telephone follow-ups was more effective than education alone [34]; this was optimized in the present study through a two-way, interactive system of education and follow-up delivered via both an application and telephone calls.

A scoping review by Wahyuni et al. (2023) further supports that telenursing—especially in chronic conditions such as diabetes—can enhance self-care and medication adherence through regular contact [35]. In this study, similarities in the chronic nature of the disease, the patient-centered design of the educational materials, and the use of accessible technology were key contributors to intervention success. Selima et al. (2023) also demonstrated that weekly phone calls and cultural and linguistic considerations improved treatment adherence among hemodialysis patients [36]. Our intervention similarly featured simplified educational content, understandable subtitled videos, and cultural sensitivity tailored for older patients to facilitate comprehension and access. Soliman et al. (2016) reported that a three-month telephone intervention significantly improved medication adherence among diabetic patients [37]. Shared features with the present study include continuity of communication, individualized feedback, and identification of treatment-related challenges. What distinguishes this intervention from previous studies is its localized software design, content based on the latest GOLD 2023 clinical guidelines, and a smart medication reminder and follow-up system that worked in full integration with human-led telephone support.

Nevertheless, some studies report findings inconsistent with those of the present research. For example, Chen et al. (2025), despite using advanced digital technologies and artificial intelligence, did not observe significant improvements in medication adherence among COPD patients [38]. The likely reasons include lack of human interaction, technical complexity, and patients’ unfamiliarity with digital tools. In contrast, our intervention utilized a simplified, user-friendly application alongside complementary telephone calls to strengthen engagement. Likewise, a systematic review by Long et al. (2023) concluded that in older adults with COPD, telenursing—when accompanied by insufficient training or complex tools—is less effective than in-person education [39]. The present intervention was explicitly designed to overcome these limitations: participants were over 60 years old with low health literacy, the application interface was simple and intuitive, language was accessible, and regular human interaction was ensured.

Akbari-Rad et al. (2023) found that reminder text messages alone had no significant effect on health beliefs or medication adherence in diabetic patients [40], likely due to the absence of human interaction. In contrast, the present study implemented a multifaceted system—incorporating education, reminders, interaction, follow-up, and analysis of vital signs—which addressed these shortcomings effectively. Similarly, in the study by Muñoz-Villaverde et al. (2024), remote care for cancer patients improved health literacy but had no significant effect on medication adherence [41]. This discrepancy may stem from the specific psychological conditions and complexity of cancer treatment, which often demand in-person support. In our study, the target population consisted of relatively stable patients with a manageable chronic condition.

One of the most notable strengths of this study was the selection of older adults (aged 60 and above) as the target population. Given the progressive and cumulative nature of COPD and its increased prevalence and severity with age, older individuals are ideal candidates for educational interventions. These patients often face multiple challenges, including low health literacy and limited access to healthcare facilities, making remote education and telenursing particularly impactful. Additionally, restricting the sample to those over 60 helped control for confounding variables such as physical activity levels and employment status, contributing to a more homogeneous sample and enhancing both internal validity and generalizability.

Another noteworthy aspect was the absence of participant dropout during the intervention, which significantly strengthened the study’s credibility. This retention may be attributed to the thoughtful and engaging design of the intervention, appropriate scheduling of contacts, and the establishment of a continuous supportive relationship between nurse and patient. Timely responses to patient inquiries, fostering a sense of human connection, and tailoring content to individual needs were likely key factors in maintaining motivation and sustained participation—challenges commonly reported in previous remote care interventions.

Finally, this study has several limitations that should be considered. Conducting the research in a single city and relying on interviews may introduce bias and reduce the generalizability of the findings. The short duration of the study limited the possibility of long-term follow-up. Variations in participants’ literacy levels and the use of a mobile application posed challenges such as limited access to technology. Additionally, restricting the sample to patients over 60 years of age limited the applicability of the results to other age groups. The absence of direct observation of patients may also have influenced the effectiveness of the interventions.

Conclusion

The findings of this study indicate that telenursing education can effectively enhance medication adherence and health literacy among patients with COPD. Considering the growing burden of this disease, employing innovative care strategies such as telenursing offers a practical approach to improving self-care, reducing recurrent hospitalizations, and enhancing patients’ quality of life. It is recommended that such interventions be incorporated into community health programs through long-term planning, use of simple technologies, and alignment with the functional capacities of patients.

Abbreviations

COPD

Chronic Obstructive Pulmonary Disease

Author contributions

All authors have read and approved the manuscript. Study design: ZK-F, LMF; data collection and analysis: SF-K, HR; manuscript preparation: ZK-F and critical Review: SF-K.

Funding

This study was funded by the research project number 11394 at Zahedan University of Medical.

Sciences.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethical approval and consent to participate

All methods were carried out in accordance with relevant guidelines and regulations. The study protocol was approved by the Ethics Committee of Zahedan University of Medical Sciences (Approval code: IR.ZAUMS.REC.1403.259). Informed consent was obtained from all participants before they took part in the study. Research participants were informed of the confidentiality and voluntary nature of the information. All methods of participation in the study were conducted in accordance with relevant guidelines and regulations, consistent with the Declaration of Helsinki. Clinical Trial Number: Not applicable; this study does not require a clinical trial.

Consent for publication

Not applicable

Competing interests

The authors declare no competing interests.