Evaluating the older adult experience of a web-based, tablet-delivered heart failure self-care program using gerontechnology principles

doi:10.1016/j.gerinurse.2017.04.001

Geriatric Nursing

Volume 38, Issue 6, November–December 2017, Pages 537-541

https://doi.org/10.1016/j.gerinurse.2017.04.001 Get rights and content

Abstract

The goals of gerontechnology are to develop technology that facilitates goal attainment and improves satisfaction with life for older adults. Few mHealth technology systems have been evaluated using these criteria. The purpose of this paper was to present the qualitative analysis of participant post-intervention interviews from the tablet-delivered Penn State Heart Assistant intervention. Semi-structured interviews (n = 12) were conducted after the completion of a 30 day study protocol. Interviews were transcribed verbatim by a professional transcriptionist, then analyzed using an iterative process of coding, categorization, and thematic development using DeDoose software and a gerontechnology interpretive lens. Two themes with six subthemes arose: Benefits – information sharing with others, usability and learnability, use of help resources; Suggestions – continuing use after the study, technical problems, participant suggested improvements. Interviews suggested improved goal attainment and satisfaction with life for the older adults with use of the tablet.

Introduction

Geriatric nurses are increasingly confronted with both patient use of mHealth technology such as web portals and hand held devices as well as patient feedback on difficulties experienced with this technology. While the National Health and Aging Trends Study found that 40% of Medicare beneficiaries used e-mail or text messaging and almost 43% used the internet, many patients experience difficulties related to ease of use or familiarity with certain types of technology.¹ Gerontechnology brings together two separate fields of study – demography and technology – with the stated goal of developing technology that facilitates goal attainment and improves life satisfaction for older adults.² Using gerontechnology principles to develop new mHealth technology should result in fewer difficulties for older adults using new technology.

Over 5 million people in the United States have heart failure (HF), the majority of which are older adults.³ Advances in mechanical circulatory support devices and treatment regimens continue to increase the likelihood that individuals who are hospitalized with HF will recover sufficiently to be discharged home.⁴ However, more than 25% of these individuals will be re-hospitalized within 30 days⁵ and 50% will be readmitted within the first six months after discharge.4, 6 Many of these unplanned readmissions are related to failures in self-care regimens at home.6, 7 mHealth technology offers new approaches to improve individuals' self-care through self-tracking and increasing patient empowerment in cost effective ways.⁸ Our team is engaged in developing technology to improve self-care which hopefully will allow older adults with HF to be safely managed in the community.

Current HF technology studies have identified significant problems with effectiveness and broad implementation9, 10 suggesting the need for older adults to participate with technology designers earlier in the testing phase. However, to date, there has been relatively little report of participant feedback, on the technology itself, early in HF mHealth technology trials. When interviews have been conducted, participants have been asked about satisfaction with the technology or care delivery,11, 12 rather than being more broadly assessed to provide meaningful and specific feedback early in the development phase on their experience of the technology as currently designed and what changes they would like to see in the technology before future use. The purpose of this paper was to fill this gap by presenting the qualitative analysis of participant post-intervention interviews with older adults from the tablet-delivered Penn State Heart Assistant (PSHA) mHealth intervention using a gerontechnology interpretive lens. A gerontechnology interpretive lens involves the examination of the text for statements related to goal attainment or life satisfaction.

Section snippets

Design

A proof of concept trial involving the PSHA was conducted with 12 older adults to assess participants' experience and response to the technology, as well as elicit suggestions for improvement. The quantitative data is reported elsewhere.¹³ All participants were interviewed at the end of a 30 day trial with the PSHA.

Participants

Participants were recruited from a large, academic medical center in the mid-Atlantic region of the United States after Institutional Review Board approval of the protocol. Inclusion

Results

The average participant was a 65 year old married, college educated male (Table 1). Six of the nine participants who provided information about their technical ability stated that they were familiar with the tablet or technically literate.

Analysis of the narratives resulted in two themes arising: theme 1: Benefits from current use which included the sub-themes – information sharing with others, usability and learnability, use of help resources; and theme 2: Suggestions for future use included

Acknowledgements

The team acknowledges the instrument help provided by Eric Balaban, BS, John Chan, BS, Penn State medical students, as research assistants and interventionists on this project.

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This review aimed to evaluate the effect of mobile health applications (apps) use on medication adherence in heart failure (HF) patients, and to verify their quality of use.
We searched MEDLINE, Embase, Web of Science, Scopus, CINAHL, LILACS, Cochrane, Clinical Trial Registries, Google Scholar, ProQuest, Open Access Theses and dissertations (OATD), Annual Symposium Proceedings of the American Medical Informatics Association (AMIA).
Of the 836 records identified, eight studies (five randomized clinical trials (RCTs) and three observational studies) were included, totaling 484 participants, with a mean age ranging from 51.1 to 72 years and 65% were male. The apps improved medication adherence when compared with their comparators in only two RCTs (n = 111, Cohen d = 3.23, 95% confidence interval (CI) 2.66; 3.80 and n = 80, d = 1.20, 95% CI 0.71; 1.66), and two observational studies, one of them with large effect size (n = 142, Cohen d = 1.51, 95% CI 1.12; 1.90). Apps proved to be more effective interventions than their comparators allowed continuous monitoring of patients. All included studies used self-report measures to assess medication adherence behaviors and their results should be interpreted with caution, as such tools may cause social desirability bias or recall bias.
The included studies indicate a possible outcome in favor of the use of apps to improve medication adherence in HF patients, but with very low quality level of evidence. Further studies are needed to investigate the effects of the use of apps, optimal frequency and duration of its use in HF patients.
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Major topics were extracted from the transcribed interviews through coding, and weighting was applied by considering the intensity of responses during the interview and the repetition of answers. Interview transcripts were conducted in five steps: 1) initial reading of text data; 2) identify specific text segments related to the goal; 3) create categories by labeling text segments; 4) reduce duplication and duplication between categories; 5) create a table containing the important categories (Buck et al., 2017). Even though the codes are analyzed qualitatively, each research subject's value is further tracked and well understood when codes are weighted by their number (Leonard, Fitzgerald, & Bacon, 2016).
This study was conducted to investigate the factors that attract rural elderly retirees to experience nature. This was accomplished by questioning the common thought that the closeness between the elderly and nature is always positive, that the increase in age is typically proportional to the preference to experience nature, and that aging leads people to return to nature. Qualitative in-depth research was conducted among nine rural elderly retirees living in northern West Virginia, USA. Multiple sessions of long and intensive interviews were conducted with each respondent, where the participants’ recognitions of nature experience were examined over life cycles based on grounded theory and analyzed by mixed method analysis. The study results showed that nature experience in childhood affects leisure activities during adult years and perception of returning to nature by the elderly. In particular, extensively experiencing nature in childhood and outdoor activities with parents were important influential factors for preferring a natural landscape and seeking outdoor activities in elderly years. In conclusion, preferring a natural environment in elderly years was found to be related to nature experience during childhood, especially where the effects of outdoor activities enjoyed with parents were transmitted intergenerationally.
The effectiveness of a nurse-led home-based heart failure self-management programme (the HOM-HEMP) for patients with chronic heart failure: A three-arm stratified randomized controlled trial
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Following the rapid growth and ubiquitous use of mobile technology and the increasing coverage of 4G networks, new ways for healthcare providers to provide personalized support have been established. Mobile health (mHealth) is increasingly being used in chronic disease management (Buck et al., 2017). In HF disease management, mHealth can improve patient self-care by providing continuous reminders and feedback on key aspects of self-management and symptom tracking (Buck et al., 2017).
Although important, heart failure self-care remains a challenge for many patients. This study aimed to evaluate the effect of a nurse-led, home-based self-management psychosocial education intervention (HOM-HEMP). The primary outcome was patient's HF self-care in terms of maintenance, management and confidence. The secondary outcomes were cardiac self-efficacy, psychological wellbeing in terms of perceived social support, health related quality of life and levels of anxiety and depression. The clinical outcomes included New York Heart Association (NYHA) functional class and numbers of unplanned health service visits due to cardiac-related reasons.
A three-arm stratified randomized controlled trial was conducted (Clinical trial registration number: NCT03108235).
A total of 213 participants admitted for heart failure were recruited from the inpatient wards of a tertiary public hospital in Singapore. They were randomly allocated to the control group, the experimental group A or the experimental group B. All participants received the usual care provided by the hospital. Participants in experimental groups A and B received the HOM-HEMP intervention, and those in experimental group B received an additional supplemental smartphone application. Data were collected at baseline, 6 weeks, 3 months and 6 months from baseline.
Compared to the control groups, participants in either of the experimental group had significantly higher levels of heart failure self-care maintenance (F = 4.222, p = 0.001), self-care confidence (F = 5.796, p < 0.001) and self-care management (p < 0.05) at 6-week, 3-month and 6-month follow-ups. In addition, both experimental groups had significantly higher levels of cardiac self-efficacy, better health related quality of life and lower depression levels than the control group after the study intervention. A higher proportion of participants in both experimental groups had a better New York Heart Association functional class at 6-week and 3-month follow-ups. Participants in the experimental group B also had significantly fewer cardiac-related unplanned hospital admissions and emergency room visits than the control group at 6-month follow-up. Results on perceived social support were not significant. The study outcomes in experimental group A and B were not significantly different at any of the post intervention follow-up.
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Technology can be used to allow more equitable access to care (Hamilton et al., 2018). Technology-based interventions have been shown to produce good outcomes with lower rehospitalization and mortality rates (Aronow and Shamliyan, 2018), high satisfaction (Buck et al., 2017), and cost savings (Boyne et al., 2013). A growing proportion of the population at all ages uses technology so presumably technology will be used with increasing frequency in the future.
Self-care is a fundamental element of treatment for patients with a chronic condition and a major focus of many interventions. A large body of research exists describing different types of self-care interventions, but these studies have never been compared across conditions. Examination of heterogeneous interventions could provide insights into effective approaches that should be used in diverse patient populations.
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Scoping review
Four electronic databases – PubMed, EMBASE, PsychINFO and CINAHL – were searched from January 2008 through January 2019.
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: Conflict of Interest: none.

: Funding: Department of Public Health Sciences and Department of Medicine, Penn State College of Medicine, Hershey, PA.

¹: Present address: Healthwise, 2601 N. Bogus Basin Rd., Boise, ID 83702, USA.

View full text

Feature ArticleEvaluating the older adult experience of a web-based, tablet-delivered heart failure self-care program using gerontechnology principles

Abstract

Introduction

Section snippets

Design

Participants

Results

Acknowledgements

Patterns of technology use among older adults with and without disabilities

Gerontologist

Gerontechnology in perspective

Gerontechnology

2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines

Circulation

Rehospitalization for heart failure predict or prevent?

Circulation

Transitional care interventions to prevent readmissions for persons with heart failure: a systematic review and meta-analysis

Ann Intern Med

Patient-identified factors related to heart failure readmissions

Circ Cardiovasc Qual Outcomes

Comparison of self-care behaviors of heart failure patients in 15 countries worldwide

Patient Educ Counseling

Connected health: a review of technologies and strategies to improve patient care with telemedicine and telehealth

Health Aff

Telemonitoring in patients with heart failure

N Engl J Med

Effectiveness of remote patient monitoring after discharge of hospitalized patients with heart failure: the Better Effectiveness After Transition-Heart Failure (BEAT-HF) randomized clinical trial

JAMA Intern Med

Feature Article
Evaluating the older adult experience of a web-based, tablet-delivered heart failure self-care program using gerontechnology principles