A survey of older Hong Kong people's perceptions of telecommunication technologies and telecare devices

Abstract

We investigated how older Hong Kong people perceive the application of telecommunication technologies in products that could enhance their safety at home. The telecare devices in the present study were: (1) the Personal Emergency Link Service (PELS), a 24-hour personal emergency link service; (2) a home-based non-intrusive motion monitoring system; and (3) a wearable vital signs monitoring system. Data were collected from a convenience sample of 368 elderly persons aged 65 years or above from 15 District Elderly Community Centres in Hong Kong, through a structured questionnaire administered during face-to-face interviews by trained interviewers. All three telecare devices were generally perceived as useful by the elderly participants: the PELS by 96% of them, the home-based non-intrusive monitoring system by 91% and the wearable vital signs monitoring system by 84%. However, although many respondents were positive about the function and usefulness of these devices, they stated that they would not personally use them. Technological innovations need to be perceived by the elderly as relevant to their everyday lives.

Introduction

Hong Kong has a rapidly ageing society. By 2033, more than a quarter of the population will be at least 65 years old.¹ There has been increasing concern about the safety of older people who are physically or cognitively at risk of harm. Telecommunications technologies can help in providing timely and preventive interventions. Such technologies range from the answering machine and personal response systems to dial-up services through the Internet. Remote care can be provided to elderly and vulnerable persons through the use of electronic sensors connected to an alarm system. Such assistive technology allows users to maintain independent living in their own homes. It can also help provide care for those living at home but without family or carer support.²

We have investigated how older Hong Kong people perceive the application of telecommunication technologies in products that could enhance their safety at home. The objectives of the present study were:

To examine elderly people's general knowledge and use of telecommunication technologies such as the mobile phone, personal computer or automated telephone answering systems;

To explore elderly people's perception of the usefulness of three telecare devices and their readiness to use the devices if available commercially.

The three telecare devices were the personal emergency link service (PELS), a home-based motion monitoring system (Motion Monitoring Device) and a wearable vital signs monitoring system (Vital Signs Monitoring Device).

PELS

The PELS is provided by a non-profit making charitable organization that provides 24-hour support service to elderly people in Hong Kong. Anyone can sign up for PELS and a doctor's prescription is not required. PELS subscribers pay HK$100 per month (∼US$13) for the machine rental and service.³ The PELS user is connected through a communication system to a 24-hour emergency call centre. By pressing the button on the main unit or a portable remote trigger, the client can speak to an operator. The operator can then identify the needs of the caller and provide the necessary support services, such as contacting the client's family or the ambulance service. The PELS is available in all geographical districts in Hong Kong. The only requisite is a residential telephone line.³

Motion Monitoring Device

The Motion Monitoring Device was a system of multiple wireless motion sensors located at different strategic points in the user's home to identify any abnormal activity patterns. The interval before the system would set off an alarm was set according to the user's regular activity pattern, which was individually assessed. When an abnormal activity pattern was identified, the system would send off an alert to the monitoring centre and/or a family member.

Vital Signs Monitoring Device

The Vital Signs Monitoring Device observed a person's heart rate, body temperature and body motion. The motion sensor would trigger an alarm if the user suddenly shifted position from perpendicular to horizontal, for example, when they fell from standing to a lying position. The device was a tiny loop made of malleable material which hung over the back of the user's ear.

Methods

A survey was conducted between March and May 2007. A structured questionnaire was used, comprising 15 closed questions. The questionnaire asked about: (a) the respondents' current knowledge and acceptance of technologies such as the answering machine, the mobile phone and the personal computer; (b) their perception of the usefulness of the three telecare devices and their readiness to adopt them; and (c) their social and demographic data. Pictures of the device prototypes were shown and their purposes were explained to the respondents before they were asked whether they thought the device would be useful – either for themselves or when they had to look after an elderly family member. The study was approved by the appropriate ethics committee.

All District Elderly Community Centres (DECC) in Hong Kong were invited to participate in the survey. The interviewers visited the centres that expressed an interest in participating, and explained the study purposes and procedures to potential respondents.

Eleven of the 15 DECCs agreed to participate in the study. A total of 368 elderly people were contacted, of whom 35 (10%) refused to be interviewed. Our response rate was similar to those of other local studies.⁴ The only inclusion criterion was DECC members aged 65 years or above. Convenience sampling was adopted and the team approached everyone referred to us by the DECC. The final sample consisted of 333 respondents. Eighty-eight per cent of them participated in centre-based activities and the rest were in-home service users. All relevant proportions (prevalence rates) about telecommunication utilization in this sample are more or less 30%. Suppose that the level of precision we required of a 95% confidence interval is no wider than 10%, the minimum sample size is 323.⁵ Our sample size was therefore appropiate.

Individual face-to-face interviews were conducted at the DECCs. A few respondents who were more frail were interviewed at home. Each interview lasted about 20 min.

A standard package (SPSS version 16) was used for statistical analysis. Logistic regression was used for testing the predictor variables for adoption of telecare services.

Results

Characteristics of respondents

The majority of the respondents were female (73%), aged 75 years or above (66%), and had received only primary level education or below (80%). About two-thirds (64%) of respondents reported that their monthly disposable income was less than HK$2000 (HK$1 = US$0.13). About half of them (49%) lived in rental housing. Regarding their living arrangements, about two-thirds (34%) lived with their spouse and/or adult children's family, while 36% lived alone. With regard to health condition, most respondents (79%) reported that they suffered from chronic disease. Eighteen percent of the respondents reported having three or more types of chronic illness. Hypertension was the chronic disease most commonly reported (63%). One-fifth of respondents reported having diabetes and/or heart disease (see Table 1).

Table 1

Socio-economic characteristics of respondents (%)

		% (n = 333)
Age:	65–74 years	35
	≥75 years	66
Sex:	Male	27
	Female	73
Education:	Without formal education	44
	Primary level	37
	Secondary or above	20
Monthly disposable income:	≤ HK$2000	64
	>HK$2000	36
Housing ownership:	Rental housing	48
	Owned housing	47
	Others (e.g. hostel)	5
Living arrangement:	With spouse only	30
	With family member(s)	34
	Alone	36
Number of chronic disease:	0	22
	1–2	61
	3 or more	18
Major types of chronic diseases:	Hypertension	63
	Diabetes	20
	Heart diseases	19
	Arthritis and other orthopaedic problems	16
	Eye diseases	11
	Respiratory diseases	10
	Gout	7
	Gastrointestinal diseases	6
	High blood cholesterol	5

Current knowledge and use of telecommunication technologies

About half of the respondents (51%) had heard of automated answering systems (AAS) (Table 2). Of the 155 respondents who had heard of AAS, 46% said they had used such a system (Table 2). The two most common reasons for doing so were providing (62%) or gathering information (56%), followed by making medical appointments (52%). A few respondents (11%) used AAS for bill payments.

Table 2

Proportion of respondents having heard of and having experience in using AAS, PC and mobile phone (%)

Device	Have heard of (n = 333)		Have experience in^†
Device	Yes	No	Yes	No
AAS^#	51	49	46 (n = 71)	54 (n = 84)
PC*	70	30	24 (n = 57)	76 (n = 177)
Mobile phone	–	–	57 (n = 187)	43 (n = 142)

^#Subjects who did not have a home telephone allowing the auto-answering system (AAS) to function were not asked this question (n = 30)

*There were 3 missing data for the question of whether the subjects had heard of the PC

^†Only subjects who had heard of the device were asked about their experience of using it, so there was a different number in each subgroup

The use of AAS was significantly associated with age (χ² = 3.3, P = 0.03) and education level (χ² = 23.6, P < 0.001) (Table 3). AAS use was higher among those with secondary level or above (68%) than those with primary level education (41%) and those without any formal education (31%). As many as 70% of the respondents had heard of the personal computer (PC). However, only about a quarter of these respondents had used one (Table 2). Among PC users, the majority used them for recreational purposes (72%) or as a typewriter (65%). Some of them used a PC for surfing the Internet (39%) and communication (30%). About half of the PC users were able to gain access to a PC at home, while others accessed a PC at community centres. PC use was found to be significantly associated with gender (χ² = 11.4, P = 0.001), education (χ² = 34.2, P < 0.001), monthly disposable income (χ² = 6.8, P = 0.013) and living arrangement (χ² = 7.1, P = 0.028). Most PC users were men and had a higher education level. In addition, more PC users had a monthly disposable income of more than HK$2000, and lived with their spouse (Table 3).

Table 3

Distribution of AAS, PC and mobile phone users by demographic variables (%)

		AAS			PC			Mobile phone
		Users	Non-user		Users	Non-user		Users	Non-user
		(n = 71)	(n = 84)	P value	(n = 57)	(n = 177)	P value	(n = 187)	(n = 142)	P value
Age, years	65–74	32**	68	0.030	29	71	0.210	66*	34	0.014
Age, years	≥75	16	84		22	78		52	48
Gender	Male	25	75	0.208	41**	59	0.001	66	35	0.060
Gender	Female	20	80		19	81		54	46
Education	No formal education	31**	69		8**	92		50*	50
	Primary level	41	59	<0.001	28	73	<0.001	57	43	0.011
	Secondary or above	70	31		50	50		72	28
Monthly disposable income, HK$	≦ 2000	20	80	>0.999	18**	82	0.013	53	47	0.090
Monthly disposable income, HK$	> 2000	26	74		34	66		63	37
Housing ownership	Rental housing	49	51	>0.999	29	71	0.362	59	41	0.316
	Own housing	46	54		22	78		54	47
	Missing	9			14			22
Living arrangement	Only with spouse	55	45	0.097	33*	67	0.028	61	39	0.331
	With family member(s)	46	54		14	86		48	52
	Alone	36	64		29	71		61	39

*P < 0.05 association between demographic variables and user/non-user

**P < 0.01 association between demographic variables and user/non-user

More than half of the respondents (57%) were mobile phone users. Similar to the users of AAS and PC, the mobile phone users were generally younger and had a higher level of education (Table 3). Demographic variables that showed significant differences between the user and non-user groups included age (χ² = 26.9, P = 0.014), gender (χ² = 3.6, P = 0.060) and education (χ² = 9.1, P = 0.011).

Perceived usefulness of telecare devices

PELS has been available in Hong Kong since 1996, and most (93%) respondents reported that they had heard of it, and among them 96% knew about the functions of the PELS. In contrast, the two more recently developed telecare devices were new to many respondents. More than 90% thought that the Motion Monitoring device and 84% the Vital Signs Monitoring Device would be useful (Table 4).

Table 4

Reasons given by respondents who would and would not consider using telecare devices (%)

	Usefulness/ Reasons	Home-based non-intrusive Motion Monitoring System (%)	Wearable Vital Signs Monitoring System (%)
Perceived usefulness	Useful	91	84
	Not useful	9	16
	Total (n)	100 (331)	100 (333)
Unwilling to try	Good health	39	43
	Have family support	21	7
	Financial constraints	16	13
	Have alternative means (e.g. services, devices)	12	17
	Not user-friendly (inconvenient/too complicated)	11	20
	Total (n)	100 (196)	100 (181)
Willing to try	Real-time monitoring function	40	50
	For health and safety reasons	22	22
	Financial concerns	19	16
	Effectiveness concerns	17	13
	Others	2	0
	Total (n)	100 (103)	100 (96)

Readiness to use telecare devices

One-third (32%) of respondents were PELS users; 32% and 29% of the respondents said they would try the Motion Monitoring Device and Vital Signs Monitoring Device if they were available. For those who chose not to use PELS, open questions were used to investigate the reasoning. Subsequently the answers were grouped into five main categories. Thirty-seven percent said they were in good health, another 37% said they had family support, and the remainder said the device was not user-friendly (10%) or that they faced financial constraints (4%) (Table 5).

Table 5

Respondents' reasons for not using PELS (n = 198*)

	%	Frequency
Had family support	37	74
Good health	37	73
Financial constraints	12	23
Not user-friendly (inconvenient or too complicated)	10	20
Other	4	8
Total	100	198

*Only subjects who had heard of the device were asked about their experience of using it

The sociodemographic variables and the variables describing experience of using AAS and experience of using PCs were entered into the regression model to determine what factors would predict willingness to use telecare devices. Regression analysis indicated that the type of service users, those aged 75 years or over, with secondary education or above, living alone, and owning their own home (with those in rental housing more likely to subscribe to PELS, χ² = 34.4, P < 0.001) were factors associated with the use of PELS. Respondents who lived alone and who were DECC in-home service users were nine times more likely to use PELS. Those who had secondary education or above were almost three times more likely to use PELS. Those aged 75 years and above were two and a half times more likely to use PELS than those aged between 65 and 74 years (Table 6). When examining the predictor variables that accounted for the likelihood of using the Motion Monitoring Device, only secondary education or above (odds ratio [OR]: 0.40, 95% confidence interval [CI]: 0.17 to 0.95) and gender (OR: 0.46, 95% CI: 0.21 to 0.99) were significant. However, this model explained only 13% of the variance.

Table 6

Predictor variables of subscription to telecommunication device

	Predictor variable	B	OR (95% CI)	P value	R²
Subscription to PELS	Type of service user	2.209	9.1 (2.6 to 31.4)	<0.001	0.45
	Aged 75 years or above	0.926	2.5 (1.1 to 5.8)	0.030
	Secondary education or above	1.038	2.8 (1.2 to 6.9)	0.023
	Housing ownership	−1.441	0.24 (0.10 to 0.55)	0.001
	Living alone	−2.435	9.1 (4.1 to 20.2)	<0.001
Will try motion sensing device	Type of service user	0.916	2.5 (0.9 to 6.9)	0.077	0.13
	Aged 75 years or above	−0.592	0.55 (0.29 to 1.1)	0.079
	Secondary education or above	−0.911	0.40 (0.17 to 0.95)	0.038
	Three or more chronic illnesses	0.703	2.0 (0.9 to 4.6)	0.095
	Use of automated answering systems	0.710	2.0 (1.0 to 4.3)	0.059
	Gender	−0.785	0.46 (0.21 to 0.99)	0.048
Will try Vital Signs Monitoring Device	Age 75 years or above	−1.284	0.28 (0.14 to 0.54)	<0.001	0.22
	Gender	0.633	1.9 (0.9 to 3.9)	0.092
	Three or more chronic illnesses	1.718	5.6 (2.3 to 13.3)	<0.001

In the model that tested the predictors of the use of the Vital Signs Monitoring Device, those with three or more chronic illnesses were almost six times more likely to try to use the device if available. Gender (OR: 1.88, 95% CI: 0.90 to 3.94) and age 75 years or above (OR: 0.23, 95% CI: 0.90 to 3.95) were the other significant predictor variables. This model explained only 22% of the variance. The model that predicted the use of PELS was the one that had the highest degree of explanatory power (R² = 0.45).

Reasons for willingness/unwillingness to use telecare devices

About one-third of respondents said they would consider using the two telecare devices developed by our project team, and provided reasons. A simple keyword analysis was performed and the responses were grouped into five main categories (Table 4).

Most of those who said ‘yes’ to trying out the two telecare devices were attracted to the real-time monitoring function. About one-fifth mentioned health and safety reasons. The remaining respondents, although willing to try new products, raised concerns about using telecare, such as the financial implications and effectiveness.

About two-thirds of the respondents indicated that they would not try the two telecare products. Apart from financial considerations and the availability of family support and other alternatives, many respondents (39% and 43% for the Motion Monitoring and Vital Signs Monitoring Devices, respectively) said they were in good health and did not require these devices. Also, one-fifth of the respondents said they would not try out the Motion Monitoring Device because of the availability of family support (21%). For the Vital Signs Monitoring Device, complicated operational procedure discouraged one-fifth of respondents (20%).

Discussion

Sample characteristics

The majority of respondents were female, older, of limited education and not affluent. Hong Kong has 7 million people. Those aged 65 years or above constitute 13% of the total population.⁶ Sixty percent of the older population is aged 65–74 years, and 40% are aged 75 or above.⁷ Our sample had a higher percentage over 75 years. Hong Kong elderly are 52% female.⁸ We had a much higher proportion of females. One reason could be a higher tendency for females to join a DECC.⁹ Forty-four percent of our sample had no formal education, compared to 36% in the general older population.⁸ Nineteen percent (167,000) of the elderly population in Hong Kong receive Comprehensive Social Security Allowance (CSSA, ranging from HK$2590 to $4420 per month), and 54% (475,000) receive Old Age Allowance (OAA, HK$1000 per month). The OAA is an universal cash subsidy available to everyone over 70 in Hong Kong.¹⁰ In 2006, the median monthly income of older persons from their main employment (if employed) was HK$6500.⁸ Our sample did not appear to be a very well-off group.

Forty-one percent of the elderly in Hong Kong live in private housing and another 41% in public rental housing,⁸ which was similar to our sample. Twenty-one percent of Hong Kong elderly live with a spouse only, 53% with family members and 12% alone.⁸ Our sample had a much higher proportion of elders living alone.

Half of the Hong Kong elderly (49%) had one or two kinds of chronic disease, while 22% had three or more.⁷ The percentage with one or two was 11% higher in our sample, whereas 5% fewer had three or more chronic diseases. The health status of our sample was therefore slightly poorer than average.

In summary, concerning age and gender distribution, living arrangements and chronic disease status, our respondents were slightly disadvantaged compared to the general Hong Kong elderly population. Samples reported in overseas studies on telecare also seem healthier and better educated. For example, among Czaja et al.'s respondents, only 15% had not completed high school.¹¹

Use and acceptance of information and communication technologies

Generally, Hong Kong society has embraced communication technologies. There were 11.8 million mobile phone service subscribers (a 169% penetration rate) and 1.99 million registered broadband service users in July 2009. Almost 80% of local households use a broadband service.¹² However, older age is sometimes associated with a lower use of technologies.^13,14 International and European studies reported a low percentage of older people actually owning computers, and they also had problems accessing computers.² A survey in Hong Kong found 59% of elderly people (n = 2379) expressing an interest in learning to use computers, but only 22% had experience using one.¹⁵ Another local survey in 2008 found that 31% of those aged 55 years or over knew how to use a computer, compared to only 7% of those aged 65 years and over.¹⁶

The computer literacy of older adults in Hong Kong is much lower than in other countries. For example, the prevalence of computer use of those aged 50 years or above was 37% in the UK and 58% in the Netherlands.¹⁶ In the US, Internet usage among 70- to 75-year-olds has increased from 26% in 2005 to 45% in 2008.¹⁷

Another local study surveyed the awareness and utilization of information technologies of those aged 50 years and above (n = 401); although more than half of respondents were aware of technologies such as MP3, PDA, and so on, their utilization of these technologies was low. More than half of them were positive about information technology as a way of living, although they were also concerned that they might not be able to adapt to a rapidly changing technological environment.¹⁸ Our results also showed lower acceptance of new technologies. The European project MOBILATE, a collaborative study (n = 3950) between 5 countries (Finland, Germany, Hungary, Italy and the Netherlands), also found that those aged 75 years and over used fewer technologies than those aged 55 to 74, with women using them less than men.¹⁴

Two key barriers reported in the local literature with regard to learning to use a computer were lack of knowledge (citing reasons like poor in English, difficult to comprehend) and financial constraints.¹⁵ Our respondents cited the same reasons. Also like our survey, respondents living alone were more inclined to learn about information technology.¹⁸ Beach et al. found that health status influenced people's acceptance of technology use to enhance their quality of life, with the disabled more willing to try.¹⁹ Our survey also revealed that the variable ‘three or more chronic illnesses’ was a predictor for use of the Vital Signs Monitoring Device, but not the Motion Monitoring Device.

Perceived usefulness of telecare devices and predictors of adoption

In Rahimpour et al.'s study examining factors affecting patients' perception of a Home Telecare Management System (HTMS), most participants thought the system useful and convenient.²⁰ However, there were concerns about cost, ease of use, clinical support, low self-efficacy, and anxiety regarding use of the HTMS. In our study, the majority also thought that the two newly-developed telecare devices would be useful, but few were willing to try them if available. Financial constraints and user-friendliness were also cited as concerns.

Levy et al. reported that those living alone might be more likely to accept telecare devices, but our survey results differed.²¹ The two most frequently cited reasons for not being a PELS subscriber or being unwilling to try our telecare devices were ‘good health’ and ‘family support’.

To promote telecare to elderly people, it is important to avoid labelling them as technophobic. In our survey, being aged 75 years or over was a significant variable predicting the adoption of PELS and telecare devices. However, we cannot assume that age is the most critical factor triggering resistance to advanced technologies. There is a theory suggesting that the diffusion of any innovation depends on the circumstances of its introduction, and the people's exposure to the innovation and perception of its usefulness.²² Lin and Yang found that the most critical factor affecting behavioural intentions towards their asthma care mobile service was user attitude, followed by perceived usefulness.²³ Appropriate training can modify older people's attitudes and behaviours.²⁴ Technological innovations must be perceived by the elderly as relevant to their everyday lives.

Study limitations

Some limitations in our study need to be noted. First of all, although the 15 DECCs involved in the survey covered all 11 Social Welfare District Offices of Hong Kong, there appears to have been a self-selection bias. In other words the willingness (or otherwise) of a centre-in-charge to facilitate members of DECC to take part in individual face-to-face interviews might have affected the quality of the data. Second, convenience rather than random sampling may limit the interpretation of the results of this study.

Conclusion

Telecare has an important role to play in promoting or re-establishing people's self-care ability. Two-thirds of our sample could not be described as ready to embrace technology in health care. To make better use of telecommunication technologies and telecare to help the elderly in their living environment, perceived ease of use, effectiveness and affordability are important factors to be considered. Technological innovations need to be perceived by the elderly as relevant to their everyday lives. A person-centred approach, putting emphasis on human aspects, seems to be the most appropriate way to examine the interactions between the elderly and technology.

Footnotes

Acknowledgments

The study was funded by the Hong Kong Jockey Club Charities Trust. We thank Professor Arthur Mak, Dr Carrie Lee, Mr Niki Wong, Mr Timothy Ma and Mr Rigo Tang for their contributions to the survey.

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