The incidence of diabetes, a common chronic disease among older adults, is increasing annually. The lack of blood glucose regulation can result in severe diabetes-related complications and substantial healthcare costs, making self-care programs specific to this population especially important. Combined with reduced numbers of healthcare professionals, the integration of healthcare and information technology and the older adults' adoption of telehealth services have become increasingly important. This study used a qualitative method to interview 18 older study participants who used a telehealth service. Subject perceptions and suggestions regarding using such a service for diabetes management were investigated. Content analysis was used to examine the interview data and determine the older patients' acceptance and perceived benefits of telehealthservice. Four main themes emerged: (1) initial trial encouragement from the doctors, nurses, and financial incentives; (2) enhanced self-management capability through continuous device use for better outcomes; (3) ambivalent feelings regarding dependence on others for problem solving; and (4) consideration for continual technology use for an uncertain future. These results serve as a reference for promoting, assessing, and verifying telehealth models for older patients with diabetes.
The medical expenses of patients with diabetes are at least 2.3 times those of patients without diabetes.1 Loss of labor and healthcare costs for hospitalization and postdischarge care can pose severe financial burdens to patients with diabetes.1,2 In the US, 25% of older adults (≥65 years old) experience diabetes, which makes it a chronic disease in this age group.3 The global population of patients aged 65 years and older with diabetes is expected to increase from 6.3 million in 2005 to 26.7 million in 2050,4 making the need for assistance with diabetes self-care management a crucial topic.
Because patients with diabetes need more self-care management at home and with the advancement of technology development, the use of telehealth may be a cost-effective alternative for health promotion. Patient-centered methods are designed to teach patients with diabetes to conduct self-care involve multiple tasks: blood glucose monitoring, prescription compliance, correct diet, and exercise.5,6 Compliance with self-care protocols will allow for a decrease in mortality and reduction in diabetes-induced complications.5,7 Because of worldwide population aging, health professional workforce is also exhibiting an aging trend. Telehealth service integrates healthcare with informatics and involves the transfer and exchange of health information through electronic devices. A home telehealth service also involves the remote delivery of health-related services via information and communication technologies (ICT) between a patient and a healthcare professional. This acts to eliminate the geographic constraints that may prevent patients with diabetes from receiving customized care.8 In recent years, telehealth has received the attention of health professionals and is proposed to facilitate the self-care management of patients with diabetes.9,10 Despite older adults' increasing acceptance of ICT such as cell phones, computers, and Internet, telehealth remains to be implemented to its full potential. The use of home telehealth for this age group is affected by multiple environmental factors including equipment, family support, patient intellect, and/or motor deterioration. The practice of telehealth often involves new ways for patients and healthcare providers to interact and communicate to achieve better outcomes than with traditional face-to-face healthcare. Previous studies have revealed that older persons will indeed use technologies if they feel the system will provide relevant benefits and if access to it is suitably adapted.11,12 However, other researchers reported older adults demonstrate low acceptance of innovative technology associated with blood pressure and blood glucose telehealth services because of insufficient equipment and user training.13
Technology acceptance remains a psychologically and emotionally charged variable when working with older patients. The technology acceptance model (TAM) theory as proposed by Davis et al14 has served as the basis for subsequent theories including TAM2, which states that the success of a system establishment is related to users' perceived usefulness and perceived ease of use.14,15 Venkatesh and Davis15 asserted in TAM2 that perceived usefulness is an essential variable predicting the behavioral intention of new technology use. As such, factors related to this variable are categorized in terms of social influence and cognitive instrumental processes. Social influence refers to how an individual in a social network is influenced by the behavior of others to confirm the behavior pattern that he/she should or should not adapt. Social influence involves the study patients' perception of a subjective norm, voluntariness, experience, and image. In the use of telehealth by patients with diabetes, subjective norm refers to how a user perceives his/her significant other's expectation of technology use. Voluntariness is the intentional behavior of using telehealth. Experience pertains to the users' encounter with telehealth. Image pertains to how using telehealth facilitates improving a user's self-image. Cognitive instrumental processes include the expected benefits from technology acceptance that is highly correlated with perceived usefulness. Cognitive instrumental processes pertain to job relevance, output quality, result demonstrability, and perceived ease of use. Job relevance is the assistance provided through telehealth in the control of blood glucose. Output quality refers to the outcome of blood glucose control. Result demonstrability pertains to the capability of demonstrating device use and self-care behavior. Perceived ease of use is the degree to which using telehealth is free from effort.
Charness et al13 consider that older people's adoption of telehealth needs to be treated not only as technology acceptance but also with a usability view of technology adoption. Some older adults do not readily accept new technology and may be affected by deterioration of cognitive and memory functions as well as physical impairment.13 Some studies have indicated that various factors affect technology use by older adults.16,17 Chen and Chan16 confirmed that self-efficacy, anxiety, and facilitating conditions were statistically significant factors. Tseng et al17 argued that performance expectation, endeavor expectation, and social influence were also essential predictive factors. The ability to learn, efficiency, memorability, user experience, and satisfaction are five determinants of technology usability that can serve as a guide in the formative evaluation of older adult technology acceptance.13The experience of older adults (>65 years) with diabetes using telehealth merits further investigation by health professionals.
This study adopted a qualitative research design, in which one-on-one semi-structured interviews with older patients with diabetes were conducted. Purposive sampling was used to recruit, and interviews were conducted between October 2012 and July 2013.
Study Setting and Participants
The participants were recruited from a regional hospital in Taiwan, and all presented with HbA1c higher than 8.0%. Of the 18 participants, 12 were women, and the average age was 77.6 years (range, 65-91 years), with half between 75 and 84 years old. Two-thirds of the participants had an educational level of primary school (up to the sixth grade), and 12 of the participants had been using the telehealth program for less than 3 months. Fifteen of the interviewees relied on their families to operate the device for them. The participants in the telehealth program and case managers adapted telecommunication technology to aid self-care management of diabetes. The service content of the program included patient physiological tests, individual prescription review, health education (diet and exercise), and disease referral. Telehealth equipment was installed at the patients' homes. The designated telehealth physiological monitor weighed approximately 1 kg (2.2 lbs) with General Packet Radio Service, which means the device could be used wirelessly. After participants had measured their blood glucose, the digit number was displayed on the screen, and an indicator located at the upper-right side of the monitor would flash. The data were uploaded to the hospital telehealth information platform, and the monitor device would automatically shut down after the data were stored and transmitted. A typical telehealth blood glucose measurement involves six steps: (1) needle preparation, (2) disinfection, (3) needle administration, (4) blood sample collection, (5) data reading, and (6) data transmission.
Each interview session lasted 20 to 60 minutes, and the interview location was determined by the patients. Based on the study concepts derived from the TAM2 such as subject norm, device usefulness, device ease of use, output quality, usage intention, and usage behavior from the TAM2 framework (Figure 1), the following questions were used to guide the interview based on TAM2: (1) How does using telehealth help you? (2) What difficulties did you experience when using telehealth equipment? (3) What are your suggestions based on your experience of using telehealth? (4) What were your expectations regarding telehealth equipment and service?
The study received approval from the institutional review boards of the study hospital. Interviews were recorded with participant approval. Anonymity of participants and the organization were guaranteed throughout the research process. Right of withdrawal from the study at any time during the interview was made known.
Since the purpose of qualitative study is to explore the subject's unique lived experiences, words, phrases, and sentences are used to present the study findings. We did not count the number of words since word frequency may not adequately describe subjects' particular perceptions toward a phenomenon of interest.18 Therefore, we conducted the data analysis as follows: recorded interviews were transcribed verbatim and analyzed as proposed by Miles and Huberman.19 The qualitative data analysis was run by use of the Atlas ti Software (Atlas. ti Scientific Development Software GmbH, Berlin, Germany).20 The analysis began by organizing the data using open coding, and then data reduction was commenced via comparison and contrast with other data. Identified concepts or themes were arranged using tables or diagrams, indicating patterns or relationships among the themes. Major concepts were isolated, and themes were categorized to finalize drawing conclusions about the participants' descriptions. During this data coding process, concepts of TAM2 such as ease of use, usefulness, social influence, or cognitive instrumental process were applied for comparison and contrast purposes.
To ensure trustworthiness of the qualitative data, credibility, dependability, confirmability, and transferability were established.21 Credibility is based on the researcher's ability to accurately capture the interviewee's usage experience during the data collection process by using the interview guidelines and asking the interviewee to give examples of their descriptions. Dependability was confirmed at separate times because two investigators recorded and reviewed the reflective thoughts of the participants during the interview process. Accuracy of communicated intent during interviews was confirmed by two-way communications between the interviewer and the interviewee. Then the recorded tapes were transcribed word by word and were rechecked by the interviewer by simultaneously reading the transcripts and listening to the tape recording. Numerous quotes from participants' verbal descriptions regarding the telehealth program enhanced transferability. These data were used by the principal investigator and the secondary researcher to examine the appropriateness of emergent themes and the logic supporting them. To ensure the objectivity of data analysis and to warrant conformability, data labels were continuously discussed with a nursing professor. All the researchers are doctoral prepared and have experience in conducting qualitative studies such as nurse users' experiences in telehealth programs.9,22
In the TAM2, subjective norm refers to how a user perceives his/her significant other's expectation of technology use. Output quality is one of the cognitive instrumental processes and pertains to the quality of outcomes achieved through technology use. Perceived ease of use is the degree to which new technology is considered free of effort. Job relevance is the assistance provided through telehealth in controlling blood glucose. Based on derived concepts of TAM2 (Figure 1), data analysis revealed the following four main themes: (1) initial trial encouragement from the doctors, nurses, and financial incentives; (2) enhanced self-management ability through continuous monitoring for better outcomes; (3) ambivalent feelings of depending on others for problem solving; and (4) consideration for continual technology use for an uncertain future.
Initial Trial Encouragement From the Doctors, Nurses, and Financial Incentives
The participants stated that because their blood glucose levels (BGLs) were unstable their attending healthcare professionals suggested the use of telehealth. Without reluctance, they accepted the suggestion because they trusted their physicians and nurse case managers.
I use this machine because my attending physician introduced it to me. Later, my case manager also encouraged me to participate (in the telehealth program) and taught me how to use the machine. As it was introduced by health professionals, I accepted the plan without reluctance! I wanted to see if this machine could really help control my blood glucose.
One study participant stated that diabetes self-management is a daily and constant process. As such, it can elicit indolence over time, which prevents them from completing the required disease management tasks. Telehealthenables nurses to serve as a supervisor and encourages patients' self-management behaviors, which increases their motivation in conducting self-management tasks.
Previously, I bought a blood glucose meter to monitor my condition at home. However, doing it every day—I eventually stopped doing so. To be honest, everyone can be lazy sometimes and feel that this is nothing important…. Using this machine (telehealth) is similar to having a nurse who constantly monitors me. If I know that a nurse is watching, I feel that I should pay attention to my blood glucose level. I become more aware.
A participant asserted that diabetes requires long-term monitoring. Therefore, the related monitoring equipment, self-test devices and logging of glucose levels, was both time and financially costly. The telehealthprogram provided equipment and tests devices free of charge, thereby relieving the economic pressure.
However, blood glucose test strips are actually the most costly expense. Before joining the program, I had to spend about $33 each month for the strips, disinfectant wipes, and needles. This is a chronic disease. Joining the program allows me to save so much money.
While participants were reluctant to engage in the initial telehealth trial, encouragement from the professional healthcare provider and financial reasons were identified as the major incentives to join the trial.
Enhanced Self-Management Capability Through Continuous Monitoring for Better Outcomes
After participating in the telehealth program, the participants conformed to the guidance of the case managers and altered their behaviors. Previously, the fasting plasma glucose (FPG) level was only measured in the morning. The participants then realized that the postprandial glucose excursion is also an essential indicator of disease management. It enables determining which meal is inappropriate for managing diabetes. This allows the participants and health professionals to more readily control diet content and disease conditions.
I always thought that it was weird; my FPG level was normal, but my HbA1c value measured was undesirable. The nurse asked me to measure my blood glucose levels before and after each meal. Then I realized that my blood glucose level 2 hours after lunch exceeded 140 (mg/dl). The nurse noticed the abnormality and phoned me immediately to ask what I have been eating. After discussion, I realized that the lunch was too heavy for my body. Since then, I have paid attention to my lunch content.
The study participants noted that after joining the telehealth program, they realized inappropriate diet is a main factor influencing BGLs. By participating in the program, they were given an opportunity for more insightful understanding, allowing them to reevaluate their meals and select more healthy food options. They also asserted that appropriate diet control facilitated regulating blood glucose, despite impaired physical functioning that prevented some from regular exercise.
After that (joining the telehealth program), I obediently monitored my blood glucose on time. I found out that I ate too much meat, so my blood glucose increased. High blood glucose is not always due to eating sweet foods. Now, I eat more vegetable and less meat. I understand I am old and have bad joints. I cannot move around easily, so I rarely exercise. However, proper diet control and the blood glucose meter allow me to manage my disease.
The participants asserted that through regular monitoring of BGLs they were able to evaluate the relationship between their BGLs and sense of hunger. They also realized that not overeating is essential to blood glucose control.
After having monitored my blood glucose, I could tell that a sense of hunger indicates the blood glucose level is low. When feeling very full, my blood glucose level must be high. Therefore, both the type and amount of food intake are important. I understand why the case manager advised me to eat until I feel 80% full. To me, eating no more than 80% full is important to control my blood glucose.
Telehealth enhances participants' self-efficacy on disease control, proper diet/eating habit, and symptom management to promote the blood glucose control.
Ambivalent Feelings of Depending on Others for Problem Solving
The participants noted that they would not voluntarily choose to learn to operate the telehealth equipment. If they had family members supporting them in monitoring their BGL, there was no motivation for them to become self-reliant. Some stated that they were concerned about destroying expensive equipment. They demonstrated no intention of learning how to use the technology.
My wife was a hospital volunteer. She knows how to measure blood glucose, so I let her measure mine. I never operate the equipment myself. It is fine as long as she knows how to do it. I cannot remember (how to use the equipment)—I don't want to break it. It (the equipment) is very expensive, I don’t have to learn! Too troublesome!
The participants noted that when a problem was encountered using the equipment they preferred that health educators examine the equipment on site. Even though case managers had informed patients that they were welcome to contact them via phone whenever experiencing a problem, the participants did not prioritize phone contact as a solution to the problem.
The nurse told me that I can phone them whenever I have problems with the equipment. I do not like contacting them through phone because I feel that I cannot speak or hear clearly when using a phone; currently, I don't phone them. Instead, I bring the equipment with me during my next checkup. This allows the nurse to demonstrate the equipment to me in person; this way is more informative.”
However, when experiencing a problem concerning equipment use, some participants not only disliked contacting nurses via phone but also preferred to use trial and error to attempt solving the problem.
The equipment rarely has problems. However, once, I put a test strip into the equipment, but it was not working. I kept trying, and it turned out that after a test strip is put into the equipment, it becomes unusable (one cannot insert the test strip into the equipment again) despite not having been used (to collect blood sample). Therefore, I identified the problem without calling the nurse. I don't want to burden other people.
Most older patients with diabetes relied on family to check their blood glucose. If participants used telehealth by themselves and encountered problems, they would rather use trial and error or depend on case managers for problem solving in person rather than use the phone to call for help.
Consideration for Continual Technology Use for an Uncertain Future
The study participants asserted that the physician did not actively participate in the telehealth program as part of the diabetes healthcare team. They noted that the attending physicians should also be informed with the physiological test results.
The physician asked me to apply for this program, but when I came to visit him, he was clueless regarding changes in my blood glucose level during this period. Although I reminded him to check my data from the computer, he still asked for case manager's printouts. I feel like using this machine did not help the physician further understand my disease condition, because the physician didn't even know whether I was using the machine!
One participant stated that the telehealth equipment was not suitable to be carried with them, because it does not display the remaining battery time.
The machine has a charging function but does not display its remaining battery power, and I don't know how much of the battery power is still available. Therefore, I decided not to bring it when I took a trip for a few days, because I would have to worry about charging the machine. It was not convenient. I could not monitor my blood glucose during the trip.
Participating in the telehealth program free of charge enabled the participants to experience how immediate feedback from nurses and health educators facilitated their disease self-management. The participants looked forward to continuing the program and were willing to partially pay for the program cost.
The case manager told me that this program is ending. It's very unfortunate. We could not understand the previous health education sessions, but through this machine and the care provided by the case manager, we understand how to adjust our diet and exercise habits; I hope that I can continue to use this service. Though we have limited budgets, but as long as it is not too expensive, maybe around $33 per month, most people may afford this expense.
The diabetes care team actively participates in the telehealth program. If the equipment fits their lifestyle and healthcare needs, older patients will have a greater incentive to use this technology, even though they may need to partially pay for the program cost.
As people grow older, they may experience heightened intellectual and motor deterioration. As a result, if the telehealth program is not well designed or there is a lack of family support in the trial use of new devices, such impairment may create extra difficulty in learning technology-related tasks and cause additional limitations to its use, making this age group less likely to accept new technologies.13,23 In the TAM2 theory, subjective norm is the social influence process associated with the significant other. Specifically, it pertains to how a user views his/her significant other's (or another group's) expectation of technology use.24 In the present study, in addition to family members providing an important influence as significant others, participants trusted their attending physicians and nurse case managers as professional advisors and readily accepted the telehealthtechnology. During the telehealth program, the patients felt that the case managers adequately served in the role of the significant other by supporting them in maintaining disease management behaviors. As a result, they were able to overcome their propensity to be lax in testing BGLs and, instead, continued to monitor results regularly. This indicates that the subjective norm is a primary factor facilitating the patient's acceptance of telehealth technology.
Older people easily perceive new technology as being expensive and complex.16 Most are retired, living on limited incomes; therefore, the monetary cost of technology is usually the main factor affecting their use of new technology.16 The telehealth service was provided to the patients free of charge in the present study, and expendable materials including disinfectant wipes and test strips were provided similarly. This facilitated the willingness of the patients to accept and experiment with the innovative telehealth technology.
Previous studies have asserted that the medical aim of health professionals in using telehealth is to assist and support patients' self-management capability according to the patients' BGL.25,26 In the present study, because of the immediate feedback capability of the telehealthcare support system, patients were easily motivated to adjust their diet because they recognized the influence of their food choices. Self-efficacy is the belief in one's capability to perform specific behaviors necessary to achieve his/her goal.27 In the case of diabetes self-management, self-efficacy is the patient's confidence in his/her ability to perform a variety of diabetes self-management behaviors. The telehealth program facilitated the reevaluation of their diets, enabling them to substitute healthy foods in place of inappropriate food choices while satisfying their subjective satiety needs. Through controlling diet and regulating blood glucose, the patients could prevent or delay the occurrence of complications. As a result, the participants had high self-efficacy in their ability to change and control their diabetes.27
From TAM2 theory, perceived ease of use is the degree to which using new technology is free of effort. In addition to physical deterioration, expense and complexity are also factors that are causing older adults to perceive new technology as being difficult to use.16 Consequently, older adults are usually slow to adopt innovative technology. Home telehealth technology specific to this age group is usually operated by other family members or friends.13 In the present study, participants did not voluntarily learn to use the equipment if their family members were capable of operating it for them. Blood glucose meters are also available with multiple features and intricate designs. Working with new technology, the older adults were concerned with making mistakes in the multistep procedures.16 Home telehealth may place an additional burden on the caregivers. Some older patients may be concerned about bothering their family members to operate the equipment.13,16 This makes it important that telehealthtechnology be designed with simplified procedures and easy-to-use operations to enhance the willingness of older adults to use the technology themselves.28
In the present study, very few participants operated the equipment independently. In addition, most of them suffered from hearing and sight impairment. When they encountered a problem during equipment use, telephoning related personnel for help was not a feasible method because their hearing deficit obstructed smooth communication. Older adults might feel embarrassed when they fail to correctly operate technological products. When teaching patients to use home telehealth technology, nurses must be sensitive to the emotional and psychological status of the patient. The education process must be provided in a supportive environment that facilitates practical application. Health education should be taught patiently to older adults when cognitive and sensory functions are impaired. Through a positive and supportive learning atmosphere, older patients can experience recognition, approval, and respect in health education.16,29
Patients with diabetes in this study noted that the physicians did not further understand their disease conditions after they joined the telehealthprogram. Findings from the previous study9 supported that the involvement of attending physicians was an essential factor enhancing the effectiveness of telehealth. Rai et al30 examined consumers' personal acceptance of mobile services and determined that most people are willing to use telehealth services. Older healthcare consumers want to strengthen their patient-physician relationship; however, telehealth does not replace the conventional face-to-face medical inquiry method. Telehealth systems can be designed to transfer the blood glucose data of patients to their electronic medical records. This enables integrating the system into the clinical tasks of physicians, which can also increase the physicians' acceptance of the system and facilitate their patient-physician relationships. This approach enables enhancing older patients' willingness to use telehealth technology, achieving the goal of disease self-management.31
The main purpose of using telehealth for older adults is to develop their self-care disease management skills and maintain quality of life. Older patients have different usability concerns and barriers to technology use supporting healthcare than younger individuals.13 Similar to other assistive devices for older adults (ie, wheelchairs and commodes), telehealthtechnology should be designed to enhance perceived ease of use and contribute to usability.32 Accounting for this aspect will allow for greater technology integration and use in the daily life of older patients.13,32Telehealth equipment should be portable, rechargeable, and capable of displaying the remaining battery time. These functions are essential to older adult users. A previous study on long-term telehealth monitoring of diabetes patients reported that despite significant improvements in the patients' blood glucose control and self-care ability the patients were unwilling to continue using it when not provided to them free of charge.33Older adults primarily use technology because of their compromised health, despite being slow to adopt technology.34 Young et al25 asserted that patients' perceived satisfaction with telehealth increased over time. The participants in this study approved of using the telehealth service and were willing to pay approximately $30 for the service. Although this cost figure is significantly lower than the general expense of telehealth, $92 to $220,35the patients indicated a willingness to pay for telehealth despite their limited budgets.
Study Limitations and Suggestions
The purpose of this study was to explore the experiences of older adults with diabetes using telehealth. The researchers interviewed 18 participants. Twelve of them had been using the telehealth program for less than 3 months. This sample characteristic should be taken into consideration in the interpretation of results. Future studies could include older patients who had more than 3 months experience with telehealth, therefore allowing a more comprehensive analysis of changes in attitudes and behaviors toward self-care management.
The primary factors affecting participants' willingness to use telehealthtechnology included the perceived support by the healthcare team, perception of self-efficacy in disease management, and reduced healthcare cost. Telehealth enables participants with diabetes to independently manage their disease. However, most of them still relied on their family members to operate the equipment. The subjective norm and output quality of telehealth are primary factors contributing to participants' use of home telehealth. If physicians can actively engage in telehealth and if patient concerns regarding the battery life and charging of telehealth equipment can be resolved, participants' willingness to use such equipment will be enhanced even if they are required to bear part of the expense. Although supported by the TAM2 theory, social stigma of incompetence may be the patients' other concern in this technology adoption process. The future goal of telehealth application should involve the development of user-friendly products for older patients with diabetes to enable them to live with dignity in their later years.
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