Background
Methods
Study design
Study participants and settings
Data collection
Data analysis
Results
General information
Characteristics | P a (n = 29) |
---|---|
Gender, n (%) | |
Male | 19 (66) |
Female | 10 (34) |
Age (years), mean (SD) | 70.6 (6.4) |
Education status, n (%) | |
Primary school and Below | 7 (24) |
Middle school | 10 (34) |
High school | 8 (28) |
Higher education and Above | 4 (14) |
Disease classification b, n (%) | |
GOLD I | 5 (17) |
GOLD II | 11 (38) |
GOLD III | 6 (21) |
GOLD IV | 7 (24) |
Disease duration, n (%) | |
< 10 years | 12 (41) |
≥ 10 years | 17 (59) |
Group | |
PeR group c | 10 (34) |
FtF group d | 10 (34) |
Regular group e | 9 (31) |
Characteristics | D a (n = 8) | N b (n = 11) | PT c (n = 4) |
---|---|---|---|
Age (years), mean (SD) | 44.4 (8.0) | 32.5 (5.0) | 41.5 (10.5) |
Gender, n (%) | |||
Male | 6 (75) | 0 | 2 (50) |
Female | 2 (25) | 11 (100) | 2 (50) |
Degree, n (%) | |||
Bachelor | 5 (63) | 8 (73) | 3 (75) |
MSc d | 2 (25) | 3 (27) | 1 (25) |
MD e | 1 (13) | 0 | 0 |
Working duration, n (%) | |||
< 10 years | 2 (25) | 5 (45) | 1 (25) |
≥ 10 years | 6 (75) | 6 (55) | 3 (75) |
Position, n (%) | |||
Head | 5 (63) | 3 (27) | 2 (50) |
None | 3 (38) | 8 (73) | 2 (50) |
Training experiences | |||
Yes | 5 (63) | 6 (55) | 4 (100) |
No | 3 (38) | 5 (45) | 0 |
Experience with PeR f | |||
Yes | 4 (50) | 6 (55) | 2 (50) |
No | 4 (50) | 5 (45) | 2 (50) |
Main results
Themes | Sub-themes |
---|---|
1. Faced with a vast amount of online health information | 1.1 Health-related information that older patients contemplated 1.2 The understanding of health-related information available to older patients |
2. Essential competencies and personality traits ensuring older patients’ participation and sustained use | 2.1 Basic personal competencies of older patients for accessing telehealth and online health information 2.2 Confidence of older patients 2.3 Personal inertia of older patients 2.4 Health responsibility of older patients |
3. User experience with the use of technology | 3.1 Novel feeling of technology in older patients 3.2 Feeling superior to other older people 3.3 Feeling of distance between the patient and HCP during remote interaction 3.4 Users’ scepticism of the accuracy of remote diagnosis 3.5 Perceived advantages of using telehealth and online health information by users |
4. Being in a complex social context | 4.1 Social prejudice against the internet 4.2 People’s resistance to the telehealth service model 4.3 The reliance on offspring 4.4 The persuasive power of speech 4.5 Health resources to be improved |
Faced with a vast amount of online health information
Health-related information that older patients contemplated
“COPD is really my concern … I gasp even getting dressed. I often search to see if there is any good solution or ‘wonder drugs’. I also asked the COPD patients in WeChat group what medicines work ” (P6, PeR)
“We Chinese people care a lot about health maintenance. People my age should go online to learn more about health care, such as acupressure... This is good both for ourselves and our families” (P22, Regular)
“If I sensed an illness, I would definitely baidu (a google-liked Chinese search engine) which hospital is the best for the treatment and rehabilitation of it ... and what’s the most conveniently way to get there ” (P21, Regular)
“Everything COVID-related is my biggest concern now ... for example how to properly wear a mask.” (P21, Regular)
Some patients reported that a lack of information led them to search for COPD-related health information online.“Mostly I go online to see if there is a ‘wonder medicine’ for COPD” (P25, Regular)
However, a minority of patients reported that frequent exposure to negative disease-related online news caused their own psychological discomfort and they were reluctant to access disease-related health information online.“I wanted to know what to pay attention to in general (for COPD patients). At the hospital, the doctors were too busy to talk about these stuff. I had to look it up on the internet myself. It was said that tai chi could be good for COPD, so I have tried it.” (P24, Regular)
“I don't want to go online because a lot of people there say that COPD is a disease that can't be cured … negative views like that make me feel uncomfortable.” (P13, FtF)
The understanding of health-related information available to older patients
“I knew something about COPD like it can’t be cured. So when I saw some medicine claiming to cure COPD, I knew it’s a lie. ” (P26, Regular)
However, some older patients were more likely to “take online information out of context” and made health decisions that were detrimental to their own health. Some HCPs argued that this tendency interfered with the delivery of their health services.“There is a lot of useful health information online ...... I went online and found out that people with chronic obstructive pulmonary disease should get a flu shot every year to prevent colds. I get a flu shot every year and it is working” (P7, PeR)
“I have searched online ... Although some said smoking is bad, others said it has benefits ... so I choose to stay with smoking” (P25, Regular)
In addition, a small number of patients felt overwhelmed by the amount of information available. They reported that they were unable to distinguish what information was useful to them and gave up searching online and employing online health information.“Some older people misunderstood the information on the internet ... making our work more difficult” (D3)
“Information or services about COPD rehabilitation are available on WeChat, Today’s Headline and television ... It’s just too much. I don't know how to choose or which one to use. So I just quit and let the doctor decide.” (P23, Regular)
Essential competencies and personality traits ensuring older patients’ participation and sustained use
Basic personal competencies of older patients for accessing telehealth and online health information
Patients and HCPs described that older patients’ lack of literacy skills limited their ability to access written materials and communicate health information through text. Along the same lines, older patients with insufficient levels of Mandarin had difficulties in accessing audio materials and vocally communicating health information.“I’m too old to recognize the small size words on my cell phone” (P14, FtF)
Patients and HCPs also noted that some older patients with poor learning and memory skills struggled to quickly grasp how to use smart devices and software when engaging with telehealth interventions and online health information.“Some older patients did not even finish primary school. They can't read... write or type. It's hard for them to communicate with health care professionals through cell phone ... Most of the videos on health education for COPD are in Mandarin … they only speak the local dialect and do not understand Mandarin. ” (N1)
“We taught the older patients to use PeR to participate in chronic disease management for COPD ...some of them are slow to learn and quick to forget” (N8, PeR)
Confidence of older patients
“I'm afraid I can’t master it (to use a cell phone) ... so I quit. ” (P17, FtF)
Older patients and HCPs reported that experiences of success or failure with learning and/or using telehealth determined patients’ confidence and willingness to continue learning and participating in telehealth use and online health information use.“Some older patients found using PeR too difficult for them … gave up before they even started” (N6, PeR)
“I’ve learnt it before, for example, the play button... I’ve been following PeR for pulmonary rehabilitation before so I’ m experienced. I wanted to find breathing exercises, and found it within a few clicks.” (P5, PeR)
“I was not proficient with cell phone before. I was afraid I couldn't do it ... Now I can follow the videos on PeR to exercise on my own. I think I can master it … it’s a good tool and I will use it more often.” (P6, PeR)
“At first I was quite willing to learn. But after I learnt (how to search for health information online), I forgot it within a few days. So I learnt it again. I went back and forth for several times. It felt like I couldn't remember a thing and I couldn't learn. I lost my confidence and simply gave up.” (P28, Regular)
Personal inertia of older patients
“I haven't been paying much attention to rehabilitation information related to COPD on the Internet lately ... Sometimes when I'm just too lazy for that.” (P12, FtF)
“Some older people have inertia ... they are just too lazy to learn or look it up online” (N3)
Health responsibility for older patients
However, some older patients reported not having enough time and energy to participate in telehealth interventions and go online to access online health information.“My view is that we should be responsible for our own health, we can't rely on others completely ... should rely on ourselves. I can always go online to find out what I want to know and get advice. Now I do the breathing exercises I found on the internet every day” (P20, FtF)
A few patients reported that they would forward online health information to family members and close friends to maintain the health of others. However, there were also patients who were reluctant to forward health information to other patients online because they feared that their forwarded information would damage others’ health, especially health information concerning medications.“I'm usually too busy looking after my granddaughter and cooking … to have enough energy. How could I have extra time to search health information online? “ (P15, FtF)
“I forwarded some useful health information to good friends and family members ... that’s good for their health” (P26, Regular)
“I simply read but did not forward it. There are truths and lies on the internet. Forwarding health information to others may lead to unwanted results. Who should be responsible if their conditions worsen?” (P5, PeR)
User experience with the use of technology
Novel feeling of technology in older patients
“It's new and quite interesting. I'd love to try ... to search for information on common medications for COPD online. I like to follow the guidance of PeR to do rehabilitation exercises. Isn't that great?” (P5, PeR)
“They found it novel ... happy to participate in the chronic disease management of COPD with PeR “ (N5, PeR)
Feeling superior to other older people
“ I always keep up with the trends. When they [peers] saw that I could consult the doctor online on what to do about COPD, they would say ‘You’re so fashionable! This is awesome! Could you teach me?’ They wanted to be like me.” (P21, Regular)
“My friends said I was good at this (using telehealth) … asked me to help him find hospitals and buy medicine online ... I think I am better than them on this matter” (P16, FtF)
Feeling of distance between the patient and HCP during remote interaction
“Smart devices are not people … not human enough to replace us ” (N9, PeR)
“Spacing out through cell phone makes people feel distant from each other … better to communicate in person” (P23, Regular)
“It's not just the exchange of disease information ... eye-contact and a gesture from a doctor or a nurse will give the patient a lot of psychological comfort, which is very difficult to achieve on a mobile phone.” (D4)
Users’ scepticism of the accuracy of remote diagnosis
“How can doctors conduct a follow-up consultation online? ...without listening by a stethoscope and tapping by fingers. Just saying a few words ... without a physical examination, there must be something wrong with the diagnosis” (P12, FtF)
HCPs also felt that there were problems with the accuracy of remote consultations.“Looking, listening, questioning and feeling the pulse are important in Traditional Chinese Medicine. If doctors don't see the patient, the diagnosis must have been faulty “ (P24, Regular)
“I think online consultations are more limited ... are not as accurate as face-to-face consultations” (D4)
Perceived advantages of using telehealth and online health information by users
“The system and device (for telehealth) must be simple and practical. The older person will only learn to use it if they find it’s easy to learn” (D2)
“...notes on COPD ... more convenient to look up online.” (P24, Regular)
HCPs also reported that they recommended telehealth to patients because of its economic cost and lack of potential for cross-infection.“I don't have to go to Shanghai if I want to see a specialist ... I can consult a doctor at home anytime through PeR without going to the hospital. I think this form of telehealth is great and I will continue to use it in the future” (P2, PeR)
Both patients and HCPs also noted that COVID-19 pandemic advanced the use of telehealth among older people with COPD.“The cost of transport for patients to visit doctors is reduced with remote communication ... no risk of cross-infection. We would like to recommend it to patients” (D8, PeR)
“During the pandemic, it was very inconvenient for older patients to go to the hospital. We created a WeChat group to facilitate COPD patients' consultation and communication. Many older patients were very active in the group ... asking about information on diet, medication ...” (N4)
Being in a complex social context
Social prejudice against the internet
“There are too many scammers online … often scamming money through fake health management platforms. So I won't try it.” (P29, R)
“I don't go for online rehab exercises ... a few clicks might give your privacy away.” (P13, FtF)
“Online rehab exercises for COPD ... I would consider whether it would be good for my health. If so, I would like to follow it ... If online health information said I needed to take medication, I would be more cautious… looking it up on the internet to check or asking my doctor. What if I took the wrong medication and messed up my body” (P19, FtF)
Patients and HCPs emphasised that better regulation of information by government departments was the only way to change people’s prejudices about the internet.“Some older patients came to me and asked if they could take a medicine that they learned about online” (N3)
“Unless it is regulated by the government … only this can prevent fraud and information leakage. Then people can trust the internet” (P29, Regualr)
“It’s up to the relevant departments of the state to do a good job of standardization.” (N6, PeR)
People’s resistance to the telehealth service model
“We all know that telehealth is the future” (P5, PeR)
“We all know for accepting the change in the healthcare model hardly to happen in a short term ... A shift of mindset is even harder. We have become accustomed to the original face-to-face delivery of health care ... It takes time to change our work mindset and procedure “ (D6, PeR)
Some patients also expressed a feeling of being forced to use telehealth and were concerned that the traditional model of healthcare delivery would be completely replaced by telehealth in the future.“We all know that older people are relatively conservative … identify with tradition … find it difficult to change … to accept new models of healthcare.” (D1)
“If telehealth is as common as e-payment, I’ll have to use it even if I don't like it” (P11, FtF)
Some HCPs believed that primary care and telemedicine services are complementary. However, there were also HCPs who believed that telemedicine services are not needed if there are well-established primary care services.“I am really scared that I will have to use telehealth in the future” (P27, Regular)
“Primary care services and telemedicine services should be complementary to each other.” (PT2, PeR)
“Is there a need for internet healthcare to exist? Now the country is vigorously developing primary care and the hierarchical diagnosis and treatment system. If the community health service centres can solve all the patients' problems, why do we need online medical care?” (D2)
The reliance on offspring
“Searching, consulting doctors ... No matter what difficulty I met, my son would teach me. My son is very filial, which makes me very happy … many friends envy me.” (P21, R)
“ It is their sons and daughters who should be teaching them. ‘Raising a child for old age’. If they want to learn, their children should teach them” (P19, FtF)
“There is no point in talking too much to older patients. In China, older adults always discuss things with their children, and they rely on their children to maintain their rights and health. In fact, by teaching their children, things (remote CDM for COPD) will be twice as easy, and older patients can just ask their children for help when they have problems” (D4)
“It is known that older people are slow learners … have poor memory and are not as skilled as younger people in using electronic devices. If they want to participate in remote CDM, they definitely need someone to help. Their children are definitely the first choice ... On-site training for patients and families on how to use PeR ... to ensure the effect of CDM … and to reduce our work pressure.” (D8, PeR)
Patients and HCPs reported that some older patients were dependent on their children and did not practice telehealth themselves. (P23, R) Some older patients reported their experiences of learning and trying to use telehealth by themselves with the guidance and assistance of their children. (P21, R) Some patients experienced lack of help from their children. (P20, FtF)“ It is known that older patients have poor self-care skills and need their children to accompany and look after them ... Their children are the target group for health education. Videos are usually for their family members … and communication in person for patients “ (N1)
“I didn’t consult my doctor online … my daughter did it all. I didn’t have to learn and use it myself” (P23, R)
“They (children) are always in a hurry. My son taught me several times, but he spoke too fast for me to follow” (P20, FtF)
The persuasive power of speech
“The young lady (doctor) didn't talk fast. What she said was easy to understand. She spoke in a fine voice like my granddaughter. I was just willing to listen to and follow what she said (… participating in CDM for COPD using PeR)” (P9, PeR)
The use of rhetorical devices (such as analogies, proverbs), motivational or praising words, assertions and repetition was reported to enhance the expressive effect of speech and to reinforce the patient’s self-confidence in learning and participating in telehealth.“The person in my ward was also an older patient with COPD. He told me how he searched the internet for information about COPD … clearly and vividly … as if he was telling a story … easy to understand. I liked to learn from him” (P18, FtF)
“‘It’s never too old to learn.’ was how we all encouraged him” (N7, PeR)
“‘You are not that old ... PeR is much easier than playing mahjong. It's a piece of cake for you’. The doctor describing it in such a humorous way made me at ease. It's no big deal … just try to learn and use it ” (P6, PeR)
Both older patients and HCPs noted that older patients were more likely to follow the advice of trusted HCPs or listen to the instructive language of authoritative HCPs to use telehealth.“The older people should be told ‘you can do it!’ repeatedly and emphatically. Compliment the person after he/she has done it. The older people will then have the confidence to apply PeR well to manage their illness.” (N9, PeR)
“The APP (the telehealth CDM APP) recommended by director in the Respiratory Department must be good. I trust the doctor who work in tertiary hospitals. I will use it for sure.” (P10, PeR)
Some HCPs suggested that HCPs be trained in conversational speech before carrying out remote CDM.“I have done exercises on PeR almost every day, because the doctor emphasized ‘you must follow PeR exercises and make sure to practice at least 3 days a week’ ” (P8, PeR)
“Healthcare professionals should also be trained in a uniform way before carrying out remote chronic disease management … it is crucial to train people on wording and making medical terminology easy to understand.” (N9, PeR)
Health resources to be improved
HCPs pointed out that the motivation of HCPs to use telehealth was linked to incentives.“The amount of time I devoted to telehealth can be described as a drop in the bucket. I was too busy with my work and life, and I didn’t have extra energy ... to give timely feedback to patients’ online questions. So patients’ experience may not be as good and levels of satisfaction not as high” (D2)
HCPs emphasised that the charge system, legislation and regulations, and matching information systems for telehealth needed to be improved.“In order to promote telehealth services for health care professionals … People will be motivated if there is a moderate pay rise … or a higher possibility of promotion for the telehealth work they perform.” (D2)
“We should develop matching software information systems to support the development of telehealth ... develop and improve laws and regulations to address medical liability issues. Such telehealth services should not be free of charge … the corresponding pricing system and health care payment system should be updated” (D6, PeR)