title: Views of People With High and Low Levels of Health Literacy About a Digital Intervention to Promote Physical Activity for Diabetes: A Qualitative Study in Five Countries.
abstract: BACKGROUND
  Low health literacy is associated with poor health-related knowledge, illness self-management, health service use, health, and survival, and thus addressing issues related to low health literacy has been highlighted as a pressing international priority.
  
  
  OBJECTIVE
  To explore views of a digital health promotion intervention designed to be accessible to people with lower levels of health literacy, in particular examining reactions to the interactive and audiovisual elements of the intervention.
  
  
  METHODS
  Qualitative think-aloud interviews were carried out with 65 adults with type 2 diabetes in the UK, Ireland, USA, Germany, and Austria, with purposive sampling to ensure representation of people with lower levels of health literacy. Inductive thematic analysis was used to identify common themes. We then systematically compared views in subgroups based on country, health literacy level, age, gender, and time since diagnosis.
  
  
  RESULTS
  Most participants from the chosen countries expressed positive views of most elements and features of the intervention. Some interactive and audiovisual elements required modification to increase their usability and perceived credibility and relevance. There were some differences in views based on age and gender, but very few differences relating to health literacy level or time since diagnosis.
  
  
  CONCLUSIONS
  In general, participants found the intervention content and format accessible, appropriate, engaging, and motivating. Digital interventions can and should be designed to be accessible and engaging for people with a wide range of health literacy levels.
authors.affiliation: Department of Psychology, Faculty of Social and Human Sciences, University of Southampton, Southampton, United Kingdom.
authors.forename: Alison
authors.identifier: http://orcid.org/0000-0003-2962-029X
authors.initials: A
authors.lastname: Rowsell
authors.forename: Ingrid
authors.identifier: http://orcid.org/0000-0001-9341-6133
authors.initials: I
authors.lastname: Muller
authors.forename: Elizabeth
authors.identifier: http://orcid.org/0000-0002-8932-3695
authors.initials: E
authors.lastname: Murray
authors.forename: Paul
authors.identifier: http://orcid.org/0000-0003-3664-1873
authors.initials: P
authors.lastname: Little
authors.forename: Christopher D
authors.identifier: http://orcid.org/0000-0001-6322-7753
authors.initials: CD
authors.lastname: Byrne
authors.forename: Kristin
authors.identifier: http://orcid.org/0000-0001-7322-6754
authors.initials: K
authors.lastname: Ganahl
authors.forename: Gabriele
authors.identifier: http://orcid.org/0000-0002-1591-0539
authors.initials: G
authors.lastname: Müller
authors.forename: Sarah
authors.identifier: http://orcid.org/0000-0001-6298-8921
authors.initials: S
authors.lastname: Gibney
authors.forename: Courtney R
authors.identifier: http://orcid.org/0000-0002-1111-8595
authors.initials: CR
authors.lastname: Lyles
authors.forename: Antonia
authors.identifier: http://orcid.org/0000-0002-8871-5726
authors.initials: A
authors.lastname: Lucas
authors.forename: Don
authors.identifier: http://orcid.org/0000-0001-6497-2827
authors.initials: D
authors.lastname: Nutbeam
authors.forename: Lucy
authors.identifier: http://orcid.org/0000-0002-3853-883X
authors.initials: L
authors.lastname: Yardley
mesh_terms: D000328:Adult; D000368:Aged; D003924:Diabetes Mellitus, Type 2; D018479:Early Intervention, Educational; D005260:Female; D057220:Health Literacy / Q000592:standards*; D006293:Health Promotion; D006801:Humans; D008297:Male; D008875:Middle Aged; D009043:Motor Activity; D036301:Qualitative Research
keywords: health literacy, digital intervention, diabetes, qualitative, physical activity