Journal of Gerontological Nursing

Feature Article 

Perceptions of Mobile Technology for Heart Failure Education and Self-Management Among Middle-Aged and Older Adults

Valerie P. Tarte, DNP, MSN, RN; Karen A. Amirehsani, PhD, FNP-BC

Abstract

Mobile technology is a promising educational platform for chronic disease management. Patients with heart failure (HF) have high rates of hospitalization and complications. The goal of the current cross-sectional study was to determine if middle-aged and older adults were using or willing to use technology for HF education and self-management. A convenience sample of 37 patients with HF were recruited from an outpatient HF clinic. Participants were asked to complete a 23-item paper survey. Male participants comprised 59.5% of the sample and 54.1% of the sample reported being age ≥65. Most participants (60%) described using text messaging and Facebook®, 78.3% reported believing technology could help with HF management, and 70.3% of participants indicated willingness to use technology. Findings indicate that incorporating mobile technology into HF education and self-management is of interest to middle-aged and older adults. These findings have important implications for designing HF patient education programs. [Journal of Gerontological Nursing, 45(11), 30–38.].

Abstract

Mobile technology is a promising educational platform for chronic disease management. Patients with heart failure (HF) have high rates of hospitalization and complications. The goal of the current cross-sectional study was to determine if middle-aged and older adults were using or willing to use technology for HF education and self-management. A convenience sample of 37 patients with HF were recruited from an outpatient HF clinic. Participants were asked to complete a 23-item paper survey. Male participants comprised 59.5% of the sample and 54.1% of the sample reported being age ≥65. Most participants (60%) described using text messaging and Facebook®, 78.3% reported believing technology could help with HF management, and 70.3% of participants indicated willingness to use technology. Findings indicate that incorporating mobile technology into HF education and self-management is of interest to middle-aged and older adults. These findings have important implications for designing HF patient education programs. [Journal of Gerontological Nursing, 45(11), 30–38.].

Mobile technology is rapidly changing the way health care providers can interface with patients (Schaeffer, 2012). These technological devices are readily available as smartphones, tablets, and laptops and have the potential to enhance how individuals manage their overall health and participate in chronic disease self-management (Jacelon, Gibbs, & Ridgway, 2016; Schaeffer, 2012). The use of mobile technology can give providers immediate access to information needed to make treatment decisions, decrease patients' travel times, permit rural hospitals to use remote health care teams, and enable patients to obtain care near their families and primary care providers (Winkler & Ripton, 2016). Mobile technology also allows for remote monitoring in which patients can record their own health status and instantaneously transmit information to their health care team, potentially keeping patients out of the physician's office, and reducing health care costs by avoiding hospitalizations (Lopez, Seville, & Javitt, 2014). Furthermore, this type of technology can provide patients with disease-specific health information and reminders about self-management behaviors, such as taking medications, diet, and exercise, as well as early recognition of worsening signs and symptoms, or understanding when to contact their health care provider (Toukhsati, Driscoll, & Hare, 2015). There is an emerging role for mobile technology for managing chronic conditions (Bodenheimer, Lorig, Holman, & Grumbach, 2002).

Approximately 83% of U.S. adults use smartphones and many adults also use text messaging (Suffoletto, Calabria, Ross, Callaway, & Yealy, 2012). Due to the high penetration rate of mobile phones in society, this technological platform has the potential to be an ideal choice for reaching older adults (Joe & Demiris, 2013). Mobile technology could potentially be used as a platform for improving the health of older adults, particularly those with chronic diseases such as heart failure (HF).

In the U.S., HF affects >5.7 million people, with approximately 660,000 new cases diagnosed every year (American Heart Association [AHA], 2017; Division for Heart Disease and Stroke Prevention [DHDSP], 2016). It is anticipated that HF rates will increase 46% by the year 2030 (AHA, 2017; DHDSP, 2016). Older adults experience high rates of HF, and this expensive and preventable disease often results in hospitalizations, complications, and early mortality (AHA, 2017; DHDSP, 2016). When patients are diagnosed with HF, there is improvement initially, but long-term, all-cause mortality rates are high. Ineffective self-management contributes to many of the poor outcomes in patients with HF (Gardetto, 2011). The primary responsibility of self-management rests on patients and their personal support system. Complex diseases like HF require high levels of health literacy, knowledge, and abilities to make treatment decisions. Self-management of HF includes monitoring symptoms; following medication plans, diet, and exercise routines; recognizing health changes; and responding by modifying their behaviors or requesting assistance (Toukhsati et al., 2015). Empowering patients to engage in effective self-management of HF should be a goal for all providers (Ibrahim, Tawfik, & Abudari, 2016). The benefits of self-management include greater quality health care and improved health outcomes (Gardetto, 2011).

When patients with HF are discharged from the hospital, the discharge instructions can be overwhelming and the educational materials may be lost or never consulted again (Athilingam et al., 2016). In a society full of technology and illnesses, additional ways to support patients with understanding their discharge education and their efforts to strive for healthier outcomes can be provided. Promoting patient self-care and early problem detection is important (Paul, 2008). According to Bui and Fonarow (2012), not all patients can participate in HF programs due to geographic barriers, socioeconomic constraints, or other obstacles. Therefore, using technology to support patients' self-management skills is important and has potential to improve quality of life and effectiveness of HF care (Gardetto, 2011). Another potential bonus for technology is increased patient engagement in their health care.

To date, prior interventions using technology include the use of smart homes for health monitoring, videophones for telehealth applications, and sensors for detecting patient falls (Demiris & Hensel, 2008; Jacelon & Hanson, 2013; Nahm et al., 2008). However, to promote the use of this technology, patients need adequate training, access to internet connectivity, and belief that this technology could be improving their quality of life. In a meta-review by Jones, Lekhak, and Kaewluang (2014) on the use of mobile phones and short message services (SMS) for self-management of chronic conditions, SMS messaging was found to significantly increase patients' adherence for keeping appointments, taking HIV antiretroviral therapy, engaging in diabetes self-management behaviors, achieving smoking quit rates, and improving blood pressure and asthma control. However, among the 11 systematic reviews included in this meta-review, data on the use of mobile phones and SMS messaging among adults with HF were lacking as well as the use among older adults (Jones et al., 2014). The authors identified a need for research to identify who is more likely to use mobile technology as part of self-care to target populations and tailor interventions.

Nundy et al. (2013) reported promising results in a study using text messaging with lower income, urban-dwelling African American patients who had been readmitted for acute decompensated HF. Participants received text messages providing self-care reminders and patient education on diet, symptom recognition, and health care navigation for 30 days after hospital discharge (Nundy et al., 2013). As a result of the use of text messages, participants in the study experienced a reduction in missed pills, decreased salt intake, and an increase in health maintenance and management. A barrier identified by research participants was lack of access to mobile phones (Nundy et al., 2013). Limitations of Nundy et al.'s (2013) study included its small sample size (N = 15) and high attrition rate, as only six participants completed the post-intervention survey. Furthermore, the mean age of participants was 50 (range = 23 to 69 years); thus, information related to older adults was limited.

In a pilot study aimed at understanding how a mobile health (mHealth) system could successfully support patients with HF after transitioning home from the hospital, researchers found high levels of user satisfaction with the mobile system and improvement in patients' quality of life (Alnosayan, Chatterjee, Alluhaidan, Lee, & Houston-Feenstra, 2017). In this study, eight patients (mean age = 61.5 [SD = 9.3 years]) and nurses regularly used the system for 6 months and were able to successfully identify eight health deteriorations, which were heart rate, blood pressure, weight, glucose, shortness of breath, high-risk heart attack, and two flu emergency cases. Five of these health deteriorations were completely managed remotely and included heart rate, blood pressure, weight, glucose, and shortness of breath (Alnosayan et al., 2017). Participants reported using the mHealth system assisted in recording biophysical markers and identifying and treating problems sooner. In addition, participants articulated improved communication with their health care team and receiving needed reassurance and encouragement. Suggested improvements described by participants for using technology for HF management included having technical support easily available and more personalized messages (Alnosayan et al., 2017).

Although evidence is available supporting the use of mobile technology for chronic disease management, the data typically are from studies with small sample sizes, limited inclusion of adults aged ≥65, chronic diseases other than HF, and lack of information on participants' perceptions of using technology for self-management. Research is needed to better understand patients' willingness to learn, acceptability of, and belief in mobile technology to improve patient self-management and health outcomes in chronic disease management, particularly among older adults with HF.

Purpose

Given the growing population of adults with HF and the fact that many older adults have access to mobile technology, understanding patients' perceptions of using technology as part of HF self-management is important. The purpose of the current pilot study was to survey middle-aged and older adult patients with HF who received care in an outpatient health care setting to assess their current use of mobile technology and identify if they believed technology would be helpful in learning more about HF and if they were willing to use mobile technology for HF education and self-management. Findings from the current study may be used to develop or modify outpatient HF education programs to improve the care this population receives and prevent unnecessary hospitalizations or complications.

Method

Study Design, Sample, and Setting

The current study was a cross-sectional, descriptive quantitative study with a convenience sample of patients with HF recruited from an outpatient HF clinic in the southeastern United States. Inclusion criteria were age ≥18; able to speak, read, and write in English; and self-reported diagnosis of HF. Anyone participating in another HF research study was excluded from the current study.

This geographic area of the United States has one of the highest rates of cardiovascular disease (CVD) in the nation (DHDSP, 2017). The HF clinic is a tertiary center and provides a full range of cardiac care services, including high-level diagnostic tests, professional evaluation from qualified specialists, service for heart devices, and progressive cardiac treatment options for participants in urban and rural settings. Patients receiving care from this clinic either live in medium metropolitan areas or in the surrounding rural communities, as defined by the U.S. Census Bureau (2018). It was anticipated that some patients may drive a distance to receive cardiac specialty care. Most of this geographic area has been designated as medically underserved areas (MUAs; Health Resources and Services Administration [HRSA], 2019).

Recruitment and Data Collection

Prior to the start of the current study, a letter of support was obtained from the Institutional Review Board (IRB) Coordinator of the HF clinic giving permission to recruit participants, and the study was approved by the University of North Carolina at Greensboro's IRB. Patients being seen in the outpatient HF clinic were provided with an information sheet and flyer explaining the purpose of the current study by the first author (V.T.).

Potential participants were informed that participation was voluntary, they could discontinue study participation at any time, skip any survey questions they did not wish to answer, and their choice to participate or not in the study would not be communicated to the health care team or affect in any way the services they receive from the HF clinic. A full explanation of the current study and survey was given to participants by the first author and all questions were answered. Information sheets, rather than signed consent forms, were used as the study was determined to be low risk by the IRB. Each participant was given a copy of the information sheet for his/her personal records. There were no incentives for participating in the study.

Participants completed the self-administered written survey in a private room in the HF clinic with the first author present in case anyone had questions. The survey took approximately 5 to 10 minutes to complete and no personal identifiable information was collected. Upon completion, surveys were stored in a secure location. Survey data were entered into password protected electronic files and stored on a secure network system and only accessible by the study authors (V.T., K.A.).

Survey Instrument

A 23-item survey designed by the authors was used and contained demographic questions and questions pertaining to preferred methods of receiving health education, current use of mobile technology, and beliefs and willingness to using mobile technology for HF education and self-management. The questions were developed based on information learned from the literature and desired knowledge for creating a technology-based HF intervention for older adults. The paper and pen survey was designed with larger font size in anticipation of having older adults participate in the study. The response options comprised dichotomous or multiple-choice options or a 5-point Likert scale comprising definitely yes, probably yes, might or might not, probably not, and definitely not. The survey was reviewed by two nurse practitioners experienced with the geriatric population for content and ease of use and was pilot tested in the current study.

Data Analysis

Data analysis was conducted using SPSS version 25.0. Data entry was verified for accuracy. Descriptive statistics were used to analyze the data. Categorical variables were described using frequencies and percentages.

Results

A total of 48 adults with HF were interested in participating in the current study. Eleven people were ineligible as they were participating in another HF study. The final sample comprised 37 adults and most participants were men (59.5%), and 54.1% of participants self-identified as being age ≥65 (Table 1). More than one half (56.7%) of the sample described having some college education or having completed college. All participants lived in MUAs (HRSA, 2019) and most participants (57%) were from rural communities, whereas 43% lived in medium metropolitan areas (U.S. Census Bureau, 2018). Approximately one quarter of participants disclosed traveling 31 to 61 miles one way to be seen at this tertiary outpatient HF clinic for care and 46% of the sample lived within 10 miles of the clinic (Table 1 and Table 2).

Sample Characteristics (N = 37)

Table 1:

Sample Characteristics (N = 37)

Current Technology use and Preferred Methods of Education by Age Group (N = 37)Current Technology use and Preferred Methods of Education by Age Group (N = 37)

Table 2:

Current Technology use and Preferred Methods of Education by Age Group (N = 37)

The top preferred methods for receiving HF management education identified by participants age ≥65 (i.e., older adults) were face-to-face discussion (85%) and paper handouts (15%; Table 2). Participants age ≤64 (i.e., middle-aged adults) also preferred face-to-face discussion (52.9%) as their top choice for learning; however, 23.5% of this age group reported preferring learning electronically, 11.8% by paper handouts, and 5.9% by watching videos. When older adults were asked to select their second top preferred method for receiving HF education, 45% chose paper handouts, 20% electronically, 15% by watching videos, and 10% each for demonstration or face-to-face discussion; among middle-aged participants, the second most preferred method for receiving educational information comprised videos (35%) and demonstrations (17.6%). One quarter (25%) of older adults and 29.4% of middle-aged participants reported using their electronic medical record portal system to educate themselves about HF.

High rates of cellular phone (60% of older adults; 47% of middle-aged adults) or smartphone (25% of older adults; 76.5% of middle-aged adults) use were reported with more smart-phone use noted among the middle-aged group. Both age groups described using a variety of electronic devices including laptop and desktop computers, smartphones, tablets, and iPads®. Forty percent of older adults and 64.7% of middle-aged adults disclosed finding the internet easy to use. Approximately one quarter of middle-aged adults and 40% of older adults, however, reported not using the internet. Among participants who reported using the internet, 35% of older adults and 35.3% of middle-aged adults described using the internet ≥6 hours weekly and 20% of older adults and 29.4% of middle-aged adults used the internet 1 to 5 hours weekly. Among older adults, 45% reported using Facebook and 35% used text messaging. Five persons age 70 to 79 years reported text messaging use and five persons age 70 to 79 years along with two persons age 80 to 89 years reported using Facebook. Middle-aged adults reported using multiple types of social media with most using text messaging (88.2%), followed by Facebook (76.5%), Instagram® (17.6%), LinkedIn® (17.6%), and Twitter® and Snapchat® (5.9% each) (Table 3).

Attitudes About Technology by Age Group (N = 37) (Middle-Aged Group [≤64 Years] N = 17; Older Adult Group [≥65 Years] N = 20)

Table 3:

Attitudes About Technology by Age Group (N = 37) (Middle-Aged Group [≤64 Years] N = 17; Older Adult Group [≥65 Years] N = 20)

A series of questions were asked to better understand participants' attitudes toward technology (Table 3). Most older adults (70%) and middle-aged adults (88.2%) reported believing that technology can definitely or probably positively effect health care. In addition, most participants believed that technology could help them improve HF self-management (70% older adults; 88.3% middle-aged adults) and help educate about heart disease (75% older adults; 94.1% middle-aged adults). High levels of willingness to use technology for HF education were reported by older adults (60%) and middle-aged adults (82.4%). Many older adults (60%) and middle-aged adults (94.1%) reported believing that training would allow them to better use technology. One half of older adults and 70.6% of middle-aged adults described wanting training on using technology for education and to self-manage their HF condition.

Discussion

`Among the current sample of middle-aged and older adults, technology is already being used for day to day activities. Such devices as cellular phones, smartphones, computers and tablets, and social media platforms, such as Facebook and text messaging, were reportedly used by all age groups. These findings are comparable to the study by Anderson and Perrin (2017) in which 85% of adults who owned a cellular phone were aged ≥65 and 42% of persons aged ≥65 owned a smartphone. Previous research indicates that mobile phones and text messaging technology have the potential to support chronic disease self-management (Jones et al., 2014).

High levels of positive beliefs about technology and the willingness to use technology to assist with improving HF knowledge and self-management were found among the current sample of predominately older adult patients with HF. This finding has important implications for addressing the needs of patients with HF. Increasing patient and support system access to knowledge or receiving technology-based self-care reminders may improve HF self-management and avoid emergency department visits and/or prevent hospitalizations. Furthermore, this mode of support may increase patients' and family members' self-efficacy and engagement in self-care decision making. Increasing patients' confidence and self-care abilities is important because so much of the success of HF management is dependent on the patient (Gardetto, 2011). Using mobile technology as part of HF self-management may improve access to care among the current study's sample, many of whom are older adults and may have transportation barriers for follow-up care or live in rural areas. Evidence reported by Nundy et al. (2013) indicates that sending text messages to patients with HF can reduce the number of missed pills, decrease salt intake, and increase health maintenance and management behaviors. However, research evaluating the effectiveness of the use of mobile technology as part of HF education and self-management among larger sample sizes that include older adults is needed.

In addition, another important finding from the current study was that middle-aged and older adults believed training would allow them to improve their use of technology and most participants expressed a desire for training on technology use to better care for their HF condition. Therefore, as HF patient education programs are designed for older adults, incorporating mobile technology and including training for patients and their support system would be important. Programs could incorporate the use of Facebook, text messaging, and videos as these are platforms older adults are already using or want to learn how to use and can be accessed from devices such as smartphones and tablets.

Nurses have a critical role to play in designing HF programs that incorporate mobile technology for older adults and assisting them in feeling confident to use this technology to improve their health. Designing mHealth HF programs using bold colors, large font sizes, simpler illustrations, and blinking boxes may assist older adults to navigate through content (Fletcher & Jensen, 2015). Embedding short educational videos that can be easily accessed from a smartphone or tablet without requiring navigation to multiple windows may facilitate ease of use. Developing training and practice sessions for patients and their support person on navigation of the HF program and providing step-by-step directions with photos and screen shots would be important along with education on how to reduce glare from display screens and enlarging font size on their devices (Fletcher & Jensen, 2015). Demonstrating how mobile technology can personally benefit the individual and assist in self-care would be important in overcoming acceptance barriers.

Limitations

The current study had several limitations. First, it was a cross-sectional, descriptive study with a convenience sample from one HF clinic, thus limiting the generalizability of results. High levels of education and access to technology were found among the sample along with willingness in using technology for HF education and self-management; however, these views may be different from other patients with HF who chose not to participate in the study or who have lower educational levels and/or access barriers to mobile technology.

When designing the survey, e-mail communication was overlooked and not included as a possible response option to the question on social media use even though e-mail is the most pervasive e-communication technology (Weaver, Lindsey, & Gitelman, 2012). Including e-mail may have provided additional useful information. Lastly, the survey questionnaire did not provide a description of cellular phones for respondents to distinguish between cellular phones with text messaging and social media capabilities versus older mobile flip phones without these capabilities. Not providing descriptions of the different types of cellular phones may have caused confusion for participants.

Conclusion

Technologies have the potential to increase access to health information and enhance how individuals self-manage their health and care for chronic diseases (Jacelon et al., 2016). Findings from the current study indicate that older adults are already using technology and have positive attitudes about using technology as part of HF management. These study findings can inform the development or modification of outpatient HF education programs, potentially improving HF self-management practices.

Although not every patient embraces technology, for those willing, having a designated portal for the HF clinic may transform the way education and self-management are viewed and followed by patients. Designing and implementing technologically based HF management and education programs would be an excellent opportunity to reach this growing population. Future research is needed to assess the use and effectiveness of mobile technology as part of HF self-management among older adults.

References

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Sample Characteristics (N = 37)

Variablen (%)
Gender
  Male22 (59.5)
  Female15 (40.5)
Age (years)
  ≤597 (18.9)
  60 to 6410 (27)
  65 to 692 (5.4)
  70 to 7910 (27)
  ≥808 (21.6)
Education level
  High school or less16 (43.2)
  Some college14 (37.8)
  College or higher7 (18.9)
Miles driven one way to the clinic
  0 to 1017 (46)
  11 to 202 (5.4)
  21 to 306 (16.2)
  31 to 403 (8.1)
  41 to 616 (16.2)
  Missing data3 (8.1)

Current Technology use and Preferred Methods of Education by Age Group (N = 37)

Variablen (%)
Middle-Aged Group (≤64 Years) (n = 17)Older Adult Group (≥65 Years) (n = 20)
Types of phones owneda
  Cellular phone8 (47)12 (60)
  Smartphone13 (76.5)5 (25)
  Does not own a mobile phone0 (0)1 (5)
Types of electronic devices used
  Smartphone13 (76.5)5 (25)
  Laptop computer11 (64.7)10 (50)
  Desktop computer7 (41.2)5 (25)
  Tablet7 (41.2)2 (10)
  iPad®4 (23.5)2 (10)
  Does not use electronic devices2 (11.8)5 (25)
Use of text messaging and social media
  Text messaging15 (88.2)7 (35)
  Facebook®13 (76.5)9 (45)
  Instagram®3 (17.6)0 (0)
  LinkedIn®3 (17.6)0 (0)
  Twitter®1 (5.9)0 (0)
  Snapchat®1 (5.9)0 (0)
  Does not use social media4 (23.5)11 (55)
Do you use your electronic medical record portal system to educate yourself about your disease?
  No12 (70.6)15 (75)
  Yes5 (29.4)5 (25)
Do you use the educational paper handouts given to you by your physician's office or the hospital to educate yourself about your disease?
  Yes12 (70.6)20 (100)
  No4 (23.5)0 (0)
  Missing data1 (5.9)0 (0)
Top preferred method to receive educational information about managing HF disease
  Face-to-face discussion9 (52.9)17 (85)
  Electronically4 (23.5)0 (0)
  Paper handouts2 (11.8)3 (15)
  Videos1 (5.9)0 (0)
  Demonstration0 (0)0 (0)
  Missing data1 (5.9)0 (0)
Second top preferred method to receive educational information about managing HF disease
  Videos7 (35)3 (15)
  Demonstration3 (17.6)2 (10)
  Face-to-face discussion2 (11.8)2 (10)
  Paper handouts2 (11.8)9 (45)
  Electronically2 (11.8)4 (20)
  Missing data1 (5.9)0 (0)

Attitudes About Technology by Age Group (N = 37) (Middle-Aged Group [≤64 Years] N = 17; Older Adult Group [≥65 Years] N = 20)

Question and Variablen (%) Per Each Age Group
Definitely YesProbably YesMight or Might NotProbably NotDefinitely Not
Do you believe technology has a positive effect on health care?
  ≤64 years10 (58.8)5 (29.4)2 (11.8)0 (0)0 (0)
  ≥65 years12 (60)2 (10)4 (20)2 (10)0 (0)
Do you believe technology can help you better self-manage your heart failure?
  ≤64 years7 (41.2)8 (47.1)1 (5.9)1 (5.9)0 (0)
  ≥65 years5 (25)9 (45)5 (25)1 (5)0 (0)
Do you believe technology can help educate you about your heart disease?
  ≤64 years10 (58.8)6 (35.3)1 (5.9)0 (0)0 (0)
  ≥65 years9 (45)6 (30)4 (20)1 (5)0 (0)
Would you be willing to use technology to educate yourself about heart failure (e.g., using a smartphone, tablet, or e-reader)?
  ≤64 years9 (53)5 (29.4)3 (17.7)0 (0)0 (0)
  ≥65 years5 (25)7 (35)2 (10)2 (10)4 (20)
Do you believe training will allow you to better use technology?
  ≤64 years12 (70.6)4 (23.5)1 (5.9)0 (0)0 (0)
  ≥65 years8 (40)4 (20)1 (5)1 (5)6 (30)
Authors

Dr. Tarte is Lecturer, School of Nursing, College of Health and Human Services, University of North Carolina at Wilmington, and Dr. Amirehsani is Assistant Professor, School of Nursing, University of North Carolina at Greensboro, North Carolina.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Valerie P. Tarte, DNP, MSN, RN, Lecturer, School of Nursing, University of North Carolina at Wilmington, 601 South College Road, Wilmington, NC 28403; e-mail: tartev@uncw.edu.

Received: March 02, 2019
Accepted: July 29, 2019

10.3928/00989134-20191011-05

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