Chinese adult segmentation according to health skills and analysis of their use for smart home: a cross-sectional national survey

Along with accelerated industrialization, urbanization, and population aging, China's disease spectrum continues to change. The death rate from chronic non-communicable diseases is in the proportion to 88% of all deaths. The resulting disease burden accounts for over 70% of the total disease burden. Chinese government developed a "Healthy China" strategy in 2017 to improve the health literacy of residents, prevent diseases, and improve the quality of life of residents [1]. The Internet of Things (IoT) has experienced rapid growth in the past decade, covering many fields, especially digital health.

Following the development trend of technology, the World Health Organization (WHO) has proposed a global digital health strategy for 2020–2025, advocating the promotion of digital health and the application of digital health to achieve the goal of universal health [2]. To help drive the development of health in China, the government is also using Internet technology. It has been continuously focusing on the innovative home sector since 2008, promulgating policy documents to support the development of smart homes [3]. The report "China Internet Development 2021" released by the Internet Society of China shows that China's Internet penetration rate has reached 70.4%, the internet of things market size reached 1.7 trillion yuan, the artificial intelligence market size rose to 303.1 billion yuan, and the market size of online medical and health services climbed to 196.1 billion yuan [4], which in general means that China has a good Internet foundation to carry out digital health.

Smart home means the growing variety of devices and appliances in a home environment that are connected to each other via the internet for automatic and remote control to enhance the home life experience [5]. Previous studies have shown that smart home play an important role in digital health and that the use of smart homes can improve human health outcomes. Smart home can relieve stress [6], alleviate loneliness [7], increase security [8], enhance ease of movement [9], improve quality of life [10], and improve blood pressure [11]. These benefits are particularly evident for special groups. Firstly, smart home can help people with disabilities who have communication difficulties to enhance their understanding of speech and improve their communication [12]. Secondly, remote support services can help enhance the sense of security provided by people with intellectual and related developmental disabilities [13]. In addition, smart home can improve personal safety and social communication issues for older people [14].

Health skills is defined as the ability to assess, identify, and target aspects of health in various settings in order to improve the overall wellbeing of an individual or organization [15]. Through a review of the literature, we identified five health skills that influence health management. Firstly, high social support is associated with better health-related quality of life [16]. Secondly, family functioning has also been shown to be strongly associated with health-related quality of life [17]. In addition, social media is an effective tool to promote COVID-19 prevention behaviors among the general public, to increase understanding of disease and health, and to better prevent disease. In addition, chronic diseases are important determinants of health-related quality of life [18]. Healthy habits and behaviors, such as a regular routine and exercise in leisure time, can improve health outcomes [19]. Finally, a survey showed that health literacy was a protective factor for depression during the COVID-19 pandemic [20]. Thus, five important aspects related to health skills can be identified as: social support, family health, media use, self-management, and health literacy. These aspects related to health skills can help people develop healthy behaviors [15].

In the context of the COVID-19 pandemic, the importance and convenience of digital health are becoming more and more prominent [26, 27], with telemedicine enabling people to have medical consultations at home and avoid infections, and many countries and regions are actively promoting the development of digital health [28, 29]. Identifying the utilization rate of different groups of people for smart home is important to promote the implementation of digital health strategies, and we conducted a cluster analysis of the population based on health skills, divided into three groups: the good health skills group, the middle health skills group, and the poor health skills group, and confirmed the differences in the utilization rate of different groups of people for smart homes through research and analysis.

The good health skills group has the best smart home use of all types of smart homes, both in terms of breadth utilization use and utilization rate. The good health skills group had higher health literacy and chronic disease self-behavior management had a stronger health mindset, were better able to self-manage their diseases [30, 31], and were more likely to use smart home for health management. In addition to this, the population of the good health skills group had the best media use among those, with greater information exposure, and more likely to learn about smart home-related information. In addition to these factors, sociodemographic characteristics also had an impact on smart home use in the three groups.

The age distribution of the good health skills group was younger than the other two groups, with younger people using smart home better than older people, and Alhuwail D's study also indicated that younger people used smart devices more than older people [32]. Our analysis suggests that age affects smart home use in four main ways. Firstly, consumer perceptions are different; while older people show positive attitudes during the experience of VR glasses, they do not have a strong desire to buy them, believing that smart homes are unnecessary in their lives, while younger people associate the experience more with the content being fun [33]. In addition, the China Quality of Life Development Report for the Elderly (2019) shows that about 29.6% of the elderly in China have not attended school, 41.5% have a primary school education, and 25.8% have middle and high school education. It can be seen that the literacy level of older people in China is relatively low [34], and the low level of education limits the use of smart products by older people. Finally, due to the deterioration of physical functions, the elderly has difficulty in understanding the operation of smart home and are worried about not being able to use them independently without help [35, 36].

The good health skills group has the highest proportion of high-income people, and income is one of the influencing factors for smart home use. Smart home products have higher technical requirements for research and development, require a higher level of R&D talents, and have high manufacturing costs. Small companies also find it difficult to enter this industry due to technical and financial problems, making it difficult to achieve scale effects, which leads to the problem of high prices of smart home products, and many users also indicated during the survey that purchase cost is one of the main considerations [37].

The good health skills group had a larger urban population, and place of residence was also a significant influencing factor on smart home use, with urban use better than rural. According to the survey, 84.2% of urban students in the Washington State school district reported being able to use reliable broadband to watch instructional videos, while only 67.5% of rural areas agreed [38]. In China, the Internet gap between urban and rural areas is gradually decreasing, but there is still a 24.1% difference in penetration rates [39]. Smart homes are built on the internet, rural Internet infrastructure is weaker than urban areas, and the digital divide is a barrier to the spread of digital health in rural areas [40, 41], which is one of the reasons for the low utilization rate of smart homes in rural areas. In addition to this, there are differences in access to health information between rural and urban residents, with rural residents having less access to health related information from sources such as specialists, magazines and less frequent use of search engines than urban residents [42], which may contribute to rural residents not knowing enough about digital health and smart home.

Although there are many differences in the smart home uses among different health skills groups, they also show similarities: men have a significantly higher purchase rate for VR glasses, body sensing cars, body bracelets, smart medicine cabinet, smart sockets, and temperature and humidity sensors than women, but women have a significantly higher utilization rate for smart clothes hanger than men. This is mainly determined by lifestyle, income, and subjective willingness. Currently, men generally have higher incomes than the income of women [43, 44], which determines that men have stronger purchasing power for higher-priced smart homes. Secondly, men and women have different household lifestyles; women take on more household chores [45, 46] and maybe more interested in smart clothes hanger related to household chores, while men have more leisure time at home and purchase more entertainment products. In addition, research has shown significant differences in the technology acceptance between men and women, with men showing a stronger intention to use technology [47, 48], while women are more interested in fashion products during consumption [49] and maybe more interested in daily protection of clothing closely related to fashion.

Looking at the three broad smart home categories, smart TVs have the highest utilization rate in the category of entertainment, with VR glasses and body sensing cars having lower utilization rates. This is related to the high frequency of use and usefulness of TVs as traditional homes [50], while VR glasses and body sensing cars may show lower utilization because our sample includes middle aged and elderly people, who are limited by their age and physical mobility [51] to use such exercise products. In the category of functional, smart washing machines and smart air conditioners were used more frequently, while electric curtains, smart clothes hangers, smart mosquito repellents and smart robots were used less frequently. This is related to the influence of the early use of washing machines and air conditioners that are widely used and highly practical, while electric curtains, smart clothes hangers and mosquito extinguishers are less practical and cost-effective, and smart robots are narrowly used, expensive and technically immature, with most of the experiencers expressing a neutral attitude [52]. In the health category, the utilization rate of sports bracelets, body fat scales and air purifiers were high, while the utilization rate of temperature and humidity sensors, hazard buttons, smoke sensors and smart medicine cabinets was low. This is related to the development of supporting facilities such as the Internet, the popularity of sports bracelets, body fat scales and air purifiers, and their low prices. The rest of the products are not very cost effective or practical. And although there are some small manufacturers selling these products, the leading companies are not putting them into production. We could not find any information about these products on the official websites of the larger Chinese smart home manufacturers Xiaomi and Huawei, which may be difficult to trust with consumers.

Implementing a digital health strategy requires a concerted effort by product manufacturers and the government. As older people consume products with greater consideration for ease of use and practicality, manufacturers should pay more attention to the older market and simplify the steps and the interface design of their products. Studies have shown that user involvement in the product design can effectively improve the quality, relevance and prevalence of work [53, 54], and companies can recruit elders as the volunteers to participate in the design process as appropriate to the actual situation. Health products are of importance for aging [55], but the current smart home market has a small range of such products, so manufacturers need to implement the concept of digital health and increase the development, production and promotion of such products. Smart home also can provide better life support to the chronic disease and disabled population, promoting their standard of living and health [55‐58]. However, our research shows that the smart home use among the chronic disease and disabled population is poor compared to the healthy population. This may be related to the current types of smart homes, where current manufacturers are designing smart homes more from the perspective of the general population, but the vulnerability of chronic diseases and disabled people and the need for a forte for smart home has led to the fact that current smart home is still lacking in personalized and flexible design for people with disabilities [59], manufacturers should establish good customer relationships with these two types of users, understand their sense of use, pay more in-depth attention to the real device needs of people with disabilities and continuously improve their products. Because of the poor utilization rate of smart home among the elderly, low-income groups, rural residents and women, manufacturers should pay more attention to the positive and negative factors influencing their purchases and broaden the market for their products. The high production costs of companies lead to the high pricing of products, which is one of the major obstacles to people using smart home. The government can enhance policy guidance to attract investors and capital into the smart home market and reduce the production pressure on enterprises. In addition, the government should also encourage enterprises to invest in technology research and development to break through existing technical difficulties, thereby reducing the difficulty of product production and achieving lower product prices. Secondly, because there is also no unified industry standard specification for smart home in China [3], while different companies have different product compatibility [60], leading to the problem that elderly users feel more difficult to use in the process. The relevant authorities should formulate industry standards to address this issue and solve the problem of different product compatibility. At the same time, the government should simultaneously strengthen the network in rural areas to improve rural network coverage and ensure network stability. It is also important to strengthen the promotion of health knowledge in rural areas and to increase rural residents' understanding of high-tech developments in the health field by explaining health knowledge in an easy-to-understand way, such as through posters. Finally, the government should also pay attention to strengthening the health knowledge system of the residents and improving their health skills in general, thereby increasing their demand for using smart homes to manage their health and helping them to better promote it.

Previous studies have confirmed that the use of smart homes can promote health. At the same time, with the World Health Organization and the Chinese government focusing on promoting this technology, it is crucial to explore the factors that influence smart home use. Our study delves into the characteristics of smart home use among different populations, discusses the reasons for the differences between different populations and provides a theoretical basis for the promotion of smart home.

In summary, our study found that smart home use is better among people with good health skills. There are gender differences in the smart home usage categories, with rural populations and older people having worse smart home use. The government and smart home companies need to focus on people with poor smart home use in various ways to promote their utilization rate of smart home for personal health management.