The population is aging globally, resulting in a high demand for older adult care. Chronic diseases also represent a major financial and social burden in the United States and China. As of 2012, approximately one half of all U.S. adults—117 million individuals—had one or more chronic health conditions (Ward, Schiller, & Goodman, 2014). In the United States, chronic illnesses account for approximately 75% of total health care costs (Walls, 2013). Similarly, according to the State Council Information Office of the People's Republic of China, as of 2012, approximately 260 million Chinese individuals had chronic diseases that incurred 70% of total medical costs (“Chinese medical and health undertakings,” 2012). Another concern is the shortage of hospital beds and escalating health care costs associated with repeat hospitalizations (Organisation for Economic Co-operation and Development, 2013).
To reduce the number of costly and unnecessary hospitalizations, family caregivers are expected to provide more complex care to older adults living at home with chronic and comorbid health conditions. Family members may be ill-equipped to provide caregiving services and generally lack formal training in health care. Family members need access to credible information and easy access to health care providers so that they can better care for their older family members. Thus, developing effective ways to support lay caregiving is critical to the quality of care provided, both in developed (e.g., the United States, where more than 40 million individuals are age 65 and older) and developing (e.g., China, where 123 million individuals are older adults) countries (United Nations, 2013). Information transfer and communication with health care providers may be enhanced through strategic use of mobile communication devices.
The purpose of the current study was to examine the acceptance of a mobile device (i.e., tablet) and ability of operating an application (app) among middle- and old-age family caregivers in the United States and China who primarily take care of older adults in their homes.
Family Caregivers of Older Adults
In the United States, 43.5 million adult family caregivers care for individuals 50 and older and 14.9 million caregivers care for individuals with Alzheimer's disease or other dementias (Family Caregiver Alliance, 2012). Approximately 67% of family caregivers provide care for individuals 75 and older (Mendes, 2011). Parent care is the primary caregiving situation for mid-life caregivers, accounting for 70% of caregivers ages 50 to 64 (Wagner & Takagi, 2010). The average age of caregivers for individuals 65 and older is 63 years (Family Caregiver Alliance, 2012), suggesting spouses or siblings are also frequently involved in the caregiving process.
Caregiving issues are potentially even more serious in China. Based on a recent world population study by the Department of Economic and Social Affairs Population Division of the United Nations (2013), 123 million individuals (9% of the population) are considered older adults (age 65 and older), and China is expected to become the world's most aged society by 2030; there will be more than 40 million oldest-old individuals (age 80 and older). The rapid aging of the population results in a high demand for older adult care in China, where there is a tradition, reinforced by law (The 11th Standing Committee of the National People's Congress, 2012), that family members are the primary caregivers for older adults who are no longer independent. Caregiving in China is profoundly influenced by the notion of filial piety (i.e., respect for one's father, elders, and ancestors). In the United States and China, the majority of caregivers for older adults are adult children (e.g., sons/daughters, sons-/daughters-in-law) or spouses, who are typically 50 and older and still work to support the family (Li & Zhao, 2009; National Alliance for Caregiving, 2009).
Mobile health (mHealth) is defined as information technology provided through the use of mobile communication devices, such as mobile phones and tablet computers (e.g., iPad®), for health services and information (Cipresso et al., 2012). Research has found that communication problems with health care providers are associated with poor patient adherence, decreased patient satisfaction, diminished outcomes, reduced resource use, and higher risk of hospitalization (American College of Preventive Medicine, 2011; Flores, 2006; Haskard Zolnierek & DiMatteo, 2009). Evidence exists that the use of mHealth, especially among younger patients/caregivers, is effective in improving communication between patients/caregivers and providers and for promoting adherence to the recommended care of chronic disease (Hostetter, 2011; Khair & Holland, 2014). Although mHealth is at an early stage of development, the potential advantages and effect of adopting mHealth for caregivers of older adults include: (a) providing disease-specific information, reminder alerts (e.g., scheduled medication taking), instant guidance based on user-entered data, and links to specific social networks; and (b) enhancing communication links between health care professionals and patients. These functions support users' sense of competency, autonomy, and social relatedness, which many psychologists argue are essential to individuals' self-motivated and self-determined behaviors (Deci & Ryan, 2002). These functions may also contribute to better adherence and health outcomes.
mHealth use is growing rapidly in the United States. A national survey conducted by the Pew Research Center and American Life Project of 3,014 adults living in the United States found that more individuals used apps to track or manage their health in 2012 (31%) than in 2010 (17%) (Fox & Maeve, 2012; Kwan, 2013). In the United States, surveys of family caregivers 18 and older have revealed valuable information regarding the current and potentially rapidly growing use of mHealth. A national survey conducted by Princeton Survey Research Associates International of 3,001 adult family caregivers reported 79% had access to the Internet using desktops and/or mobile devices (Fox & Brenner, 2012). Another online survey of 1,000 family caregivers with experience using computers and mobile devices found that 70% reported having searched the Internet for information related to caregiving, 47% used an electronic organizer or calendar to help with caregiving, 11% participated in a caregiving-related blog or online discussion, and 41% used a technology other than a standard computer or cell phone to help with caregiving. More than one half (53%) of technology-using caregivers who responded to the survey were younger than 50, 29% were ages 50 to 64, and only 18% were 65 and older (National Alliance for Caregiving, 2011). As the population ages, the typical age of caregivers using mHealth is predicted to increase.
Another factor of the growing use of health care software apps is their widespread adoption by health care providers. Hostetter (2011) found that approximately 80% of health care providers in the United States (N = 4,000) use smartphones capable of running apps—a far greater proportion than among the general public. Health care providers use mHealth to communicate with patients and other providers and to deliver care (Hostetter, 2011).
A recent pilot study was conducted by the U.S. Department of Veterans Affairs (2013) over 3 months involving 881 family caregivers in a treatment group receiving iPads and 3,620 caregivers in a control group. The treatment group received iPads loaned by the U.S. Department of Veterans Affairs loaded with nine different health care information apps to support caregivers and the needs of Veterans. Characteristics of caregivers that significantly predicted app use varied by individual app and included the relationship of the caregiver to care recipient, urban/rural living location, polytrauma care, diagnosis, age, and type of assistance provided (Frisbee, 2014; U.S. Department of Veterans Affairs, 2013). Participants were adult caregivers age 18 and older. No specific information was revealed about caregivers caring for older patients who were predominantly middle- or old-age.
Based on the current prevalence of mobile and Internet technology, the use of mHealth in China also has great potential. By the end of 2014, according to a China Internet Network Information Center survey of 76,000 residents, China had 649 million Internet users (age 6 and older) as well as 557 million mobile Internet users who accounted for 47.9% of the Chinese population. Individuals who navigated the Internet via mobile phones accounted for 85.8% of Internet users. Mobile Internet users ages 10 to 39 accounted for 78.1%, whereas those ages 20 to 29 accounted for 31.5% of 76,000 residents. However, middle- to old-age Internet users accounted for less than 15% of the sample. Mobile Internet users ages 50 to 59 accounted for 10.6% of the sample and were closely split between males (5.1%) and females (5.5%). Individuals 60 and older accounted for an additional 4.3% of the sample, similarly split between males (1.9%) and females (2.4%) (China Internet Network Information Center, 2015).
The Chinese mobile medical app market is growing rapidly. iiMedia Consulting (2013) found that the market value of Chinese mobile medical apps earned $3.1 billion in 2012, a 17.7% increase from the previous year. PricewaterhouseCoopers (2012) estimated that in 2017 the United States and China will have the largest mHealth markets, and the combined market will account for more than one third of the total worldwide market. Based on the current gaps in health care delivery and extrapolations of existing initiatives, mHealth revenues are expected to reach $23 billion globally by 2017 (PricewaterhouseCoopers, 2012). The two largest mHealth markets, the United States and China, are projected to reach $5.9 and $2.5 billion, respectively (PricewaterhouseCoopers, 2012).
The increasingly aging population has resulted in the need for more caregivers of older adults with comorbid chronic health conditions. In most cases, these caregivers are family members who are middle- to old-age. mHealth and mobile apps have been widely accepted by family caregivers in the United States and the market is growing rapidly in China. Although there are many potential advantages of adopting mHealth apps in supporting care for individuals with chronic disease, the majority of current mobile device users are younger caregivers. There is not a clear understanding of how well middle- and old-age caregivers would accept a mobile device to support their caregiving role and whether they would be able to use it effectively.
The current study was guided by a framework modified from Caboral-Stevens, Whetsell, Evangelista, Cypress, and Nickitas' (2015) U.S.A.B.I.L.I.T.Y. (Use of Technology for Adaptation by Older Adults and/or Those with Limited Literacy) framework originally developed to determine potential usability of health websites by older adults. The Figure depicts the unique individual factors, such as age, education attainment, culture, and socioeconomic demographic factors, that influence older adults' user behavior through usability. Perceived user experience is the experience and perceived usability of using the tablet and is measured by Brooke's (1996) System Usability Scale (SUS). Learnability is “the ability to perform well” (Grossman, Fizmaurice, & Attar, 2009, p. 651), and efficiency is the ability to do things correctly (Pennsylvania State University, 2006). Learnability and efficiency are measured as performance in the current study. The endpoint (i.e., intent to use) is measured by an open-ended question.
Adapted from Caboral-Stevens, Whetsell, Evangelista, Cypress, and Nickitas (2015).
Study Design, Settings, and Sample
A descriptive cross-sectional study was conducted in one midwestern U.S. region and in an eastern China province. A volunteer sample was used to select individuals who met the following inclusion criteria: age 55 or older, a primary caregiver for an older adult, able to speak the native language, and not a professional health care provider. The study was approved by the University of Wisconsin–Milwaukee's and Shanghai Jiatong University's institutional review boards and conducted from May 2014 through March 2015. An information sheet/invitation letter describing the project's goals and inclusion criteria was distributed to potential participants by the researchers (H.T., L.W.) in public communities and churches to invite caregivers to participate. Individuals who responded to the initial invitation to participate were contacted by telephone. One hundred caregivers who met inclusion criteria agreed to participate and provided written consent.
Questionnaires. The short survey questionnaire included a demographic section and seven items asking about caregivers' past experiences or openness in using the mobile device. The first four questions used a multiple choice format and asked:
Have you used the following devices in the past 2 weeks?
How often do you use the device(s)?
What do you do when you use the device(s)?
Did you ever use some of these devices 2 weeks ago?
Questions five to seven used a 5-point Likert scale (where 1 = strongly disagree and 5 = strongly agree) and asked: “Do you feel confident using a smartphone/tablet/other? Please specify.” English and Chinese versions of the survey were confirmed to be equivalent by the two bilingual and doctoral-prepared nurse scientist researchers (H.T., L.W.) who have many publications in English and Chinese.
A one-dimension Brooke's (1996) SUS was used to assess perceived usability of the tablet. SUS comprises 10 5-point Likert items; however, because the goal of the survey was to obtain subjective assessments of usability of the tablet (and not of a system or study software), four items were omitted to avoid confusion (e.g., “I found the various functions in this system were well integrated,” “I thought there was too much inconsistency in this system.”). During analysis, these items were given a neutral score. SUS versions in English and Chinese have been widely adopted. Cronbach's alpha for the six items was 0.775.
Performance. In the current study, performance is a measure of the caregiver's ability to complete essential tasks needed to use a tablet app, such as turning on/off the device and selecting a specific app, typing a simple message, and following written or graphic directions (i.e., screen prompts) to complete a task by moving one finger onscreen toward a direction. Three performance criteria were used to score performance as high, medium, or low: (a) manual assistance delivered, (b) requests for assistance, and (c) self-resolution of mistakes. Criteria given for a high score corresponded to no required intervention from the researcher and no more than three observed instances of self-resolved issues, such as ineffective onscreen sliding or self-corrected mistakes. Pauses that did not require intervention were not counted as issues. Asking for help more than three times to continue the required task resulted in a low score. All individuals who asked for help three times or less to complete the task were given a medium score. To assure interrater agreement (Graham, Milanowski, & Miller, 2012) between observers, the following rater agreement activities were completed: (a) review, discussion, and agreement on the observation protocol and rating criteria; and (b) walkthroughs using mock participants. Two volunteer caregivers were videorecorded performing different versions of the observation study activities, in which they varied their behavior to simulate different potential skill levels. These behaviors included adding pauses, asking questions, making mistakes, ineffective onscreen sliding, or completing tasks smoothly. The two researchers viewed the videos and rated the performances independently and then compared and discussed their coding until a consensus was reached. Interrater reliability achieved was considered good by multiple measures; the interrater correlation was 0.901 and Cohen's kappa was 0.844.
Open-Ended Question. After completing the usability test, an open-ended question was asked: “If you have a tablet, would you like to use a caregiving support app that requires similar performance as you just did in supporting your caregiving role? If yes, please specify what support you need.”
To avoid response bias, no health or caregiving content was included before the final open-ended question. Thus, caregivers responded only on the basis of their acceptance of the tablet when completing the usability test.
Surveys and performance testing were anonymous and occurred in a variety of quiet settings following participants' preferences. Setting options included the caregiver's home, researcher's office, public book stores, a quiet corner in a church, or hospital room. Before starting the short survey, caregivers were first seated comfortably so as to minimize interruptions and distractions.
Following completion of the first short survey, a tablet with a preloaded, simple game intended for use by a broad audience was introduced. A researcher provided seven step-by-step instructions on how to use the provided tablet and how to interact with a computer game during a 30-minute introductory practice session:
Turn on the tablet.
Move finger on screen to find specific app.
Open the app.
Log in with a preregistered name and password.
Read the app instructions.
Follow screen prompts to complete tasks.
Turn off the tablet.
Participants were not asked to use the software to play the game. Caregivers were permitted to ask questions and start over as many times as needed during this introductory practice session. After the practice session, the researcher restored the tablet. The next step involved an observation of independent use of the tablet. Caregivers were asked to complete the seven steps on their own and their performance was scored based on the predefined scoring criteria (i.e., high, medium, or low) by one of two researchers.
Participants then completed the six-item SUS-based survey to assess their perceived usability of the setup using the tablet. Finally, an open-ended qualitative question was asked regarding caregivers' attitudes toward and their need of using a tablet app to support their caregiving.
A double-entry procedure was used for analyzing the questionnaires. Continuous variables were expressed as mean (SD), whereas categorical data were summarized as frequencies and percentages. Independent t tests were used to examine the mean difference of continuous variables, such as age and SUS scores, between the United States and China. Chi-square tests were used for comparison of categorical variables, such as gender, educational attainment, and performance, between the two regions. Finally, a stepwise multiple regression and an ordinal logistic regression were applied to explain what factors may influence SUS scores and performance. Data analysis was performed using SPSS 17.0.0 at 0.05 alpha levels. Answers to the open-ended question were analyzed using content analysis methodology (Elo & Kyngas, 2008).
One hundred caregivers (50 from each region) 55 and older completed the study. The mean age of caregivers was 64.5 years (SD = 7.5 years, range = 55 to 88 years). Table 1 presents descriptive results with a comparison between the United States and China. The majority of caregivers used a smartphone (82% in the United States versus 68% in China), and more used tablets in the United States (62%) than China (36%). Most caregivers used mobile devices every day. U.S. caregivers were, on average, 4 years older, more highly educated, and more likely to use a tablet or mobile device for browsing the Internet and online shopping, but less likely to chat online, than their Chinese counterparts.
Description and Comparison of Sample Demographics, Performance, Use, and Confidence
Table 2 compares responses to items measuring perceived usability in the United States and China. Caregivers from both regions thought they “would like to use the tablet,” “the tablet was easy to use,” “most people would learn to use the tablet very quickly,” and “felt very confident using the tablet.” The average score of each SUS item was >3 (range = 0 to 4), except for Chinese participants' scores for the item, “I think I would like to use the tablet.” Also, Chinese caregivers scored lower for every individual item than their U.S. counterparts, except for “I felt very confident using the tablet,” but the difference was not significant. Scores for “I found the tablet is unnecessarily complex” and “I think I would need the support of a technical person to be able to use the tablet” were statistically significantly different between groups. Total SUS scores for perceived usability were significantly higher for U.S. than Chinese caregivers (68.2 versus 57.9).
Comparison of Responses to Perceived Usability Items in the United States and China
Betas for all factors were statistically significant and the model predicted 52% of variance in perceived usability of tablets (SUS scores) (Table 3). SUS scores were, on average, six points higher for U.S. than Chinese caregivers. Actively using devices for texting or browsing the Internet increased SUS scores by approximately 10 points. However, individuals with an educational attainment of at least a bachelor's degree tended to score 5 points lower when controlling for region and mobile activities. The overall test of the model was statistically significant (F(4,95) = 25.660, p < 0.001; R2 = 0.519).
Factors Predicting Perceived Usability of Tablets (Stepwise Procedure)
Finally, an ordinal logistic regression was conducted to determine whether perceptions about usability, experience using a mobile device to browse the Internet, level of education, or country of origin were associated with tablet performance (Table 4). Higher perceived usability, having experience using a mobile device to browse the Internet, and having a higher education level (i.e., at least a bachelor's degree) all increased the likelihood of performing better. However, controlling for average SUS scores, educational attainment, and prior Internet use, U.S. caregivers tended to perform worse than their Chinese counterparts. The overall test for the model was statistically significant (chi-square = 85.926, p < 0.001).
Factors Predicting Tablet Performance
In addition to the quantitative results, all participants answered “yes” to whether they would use a caregiving support app to support their caregiving role if they had a tablet. Specifically, the following types of supports were rated as most needed: obtaining relevant medical knowledge to help caregiving, tracking personal health records, communicating with professional caregivers, administrating medication, and easily finding useful information for a concerning health problem.
The Mobile Device
The majority of caregivers used a smartphone, but more used tablets in the United States than China. However, even in China, the number of individuals now using tablets is significant. The difference in the current use of tablets in the two regions may be explained by the underlying economic inequality. According to a 2013 Pew Research Center's survey on Americans' use of the Internet (N = 2,252), one third (34%) of adults owned a tablet (Zickuhr, 2013). Individuals living in households earning at least $75,000 per year and those who were college graduates were more likely to own a tablet compared to those who earned less or were less educated (Zickuhr, 2013).
Perceived Usability and Performance
There was a significant difference in perceived usability between the two regions. Based on Sauro's (2011) review of 500 different usability evaluations using SUS, the average SUS score was 68. In the current study, scores from the U.S. region would thus be considered above average and scores from China below average.
Contradictory results were found between the regressions in terms of individuals with higher educational attainment (i.e., having at least a bachelor's degree). When region and mobile activities were controlled, individuals with at least a bachelor's degree tended to rate usability as lower by five points, but were more likely to be rated higher for their performance by a factor of five compared to those without a degree. This apparent contradiction might indicate that higher-educated caregivers did not perceive their tablet's usability but actually performed better than those who had less education.
Similarly, when controlling for perceived usability score, educational attainment, and whether prior mobile activity included Internet navigation, U.S. caregivers tended to perform at a lower level than their Chinese counterparts (i.e., if two participants [one from each region] had the same educational attainment, used a mobile device for Internet navigation, and gave the setup the same overall SUS score, the participant from China was more likely to have performed better). This unexpectedly higher performance level suggests that if caregivers from China were given sufficient training, their performance with a tablet would improve, suggesting great potential for the future.
Acceptance of the Tablet
Caregivers were not only willing to use the tablet as a tool to support their caregiving role but were also eager to obtain supportive informational apps for the sake of their own health. These findings may suggest that tablet-based mHealth would be more acceptable and welcomed than use of the tablet alone. The explanation is likely to be twofold: first, when individuals reach middle-age, their concern for personal health generally increases (Li et al., 2002; McFadden et al., 2008) and, second, family caregivers, regardless of their current health, are more likely to expect that they will need similar care in the future (Henning-Smith & Shippee, 2015).
The current study has several limitations. First, the regions used as settings in the United States and China and use of convenience sampling can limit generalizability of the findings. Second, the self-report questionnaire might cause possible response biases. Third, performance criteria were created based on the experience of computer science experts and the researchers, and content validity was not tested.
As cited previously, the Groupe Speciale Mobile Association estimated that in 2017 the United States and China will have the largest mHealth markets, and the combined market will account for more than one third of the total worldwide market (PricewaterhouseCoopers, 2012). The current study suggests family caregivers might be a significant part of the increase in Internet users, as they increasingly take care of their older family members and, at the same time, are concerned about their own health conditions. However, lack of economic parity and persistence of low education attainment may be a barrier to promoting effective use of needed tools for caregiving and may contribute to the persistence of health disparities.
Lack of economic parity and persistence of low education attainment exists not only in China but also in the United States. Research reported by the National Alliance for Caregiving (2011) examining 1,000 U.S. family caregivers' receptivity to technology revealed that the most prevalent perceived obstacle to trying these devices is the perception that they would be expensive. Educational disparity also exists in the United States. According to the U.S. Census Bureau (2014), educational attainment of high school or less than high school was 51.1% for Black individuals. Thus, mHealth designers must consider cost of devices and literacy of intended users to increase accessibility and usability of their products. In addition to good design and an appropriate interface for a target population, training must be reinforced and ongoing support should be provided.
One concern that has yet to be addressed by current research is the consistency with which caregivers would continue to use mHealth tools over time. New apps will not be effective if they are tried and abandoned (because of defects in design or flagging motivation), which might make using an mHealth tool seem like yet another task for a busy caregiver. Long-term studies are needed to assess the significance of this problem. In the future, the current authors intend to examine whether, why, and how soon flagging use might become an issue and also explore the impact of alternative designs on preserving the motivation of caregivers to use a tool over time. In addition, further research should explore more comprehensive predictors for gaining confidence in using these devices to receive caregiving help.
Pew Research Center and other market-based studies consistently find increasing use and acceptance of mobile technology and Internet among a broad range of population groups, especially in the United States and China. mHealth software is among the most promising, yet still seems to be underused by individuals who might benefit most: family caregivers. Although new investment in health software might be justified, success will depend on addressing barriers in physical ability or attitudes among the target population. The current study contributes to this effort by assessing perceived usability and user performance with existing mobile technology among typical family caregivers caring for older adults in their homes in the United States and China. The study found a willingness and ability to adopt tablet-based software, but also found some participants (especially those from China) were worried about the complexity of tablets and software even when their level of performance was sufficient for success. It is recommended that new mHealth efforts for family caregivers be pursued, but that software designs and training prior to use should be sensitive to these persistent caregiver concerns.
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Description and Comparison of Sample Demographics, Performance, Use, and Confidence
|Variable||United States, n (%)||China, n (%)||Chi-Square||p Value|
|Female||36 (72)||29 (58)||2.154||0.142|
| Less than high school||5 (10)||21 (42)||27.641||<0.001|
| High school||9 (18)||18 (36)|
| Some college||14 (28)||7 (14)|
| Bachelor's degree or higher||22 (44)||4 (8)|
|Smartphone||41 (82)||34 (68)||2.613||0.106|
|Tablet||31 (62)||18 (36)||6.763||0.009|
|Use every day||46 (92)||43 (86)||2.244||0.691|
|Experience (game)||16 (32)||15 (30)||0.047||0.829|
|Experience (text)||36 (72)||27 (54)||3.475||0.062|
|Experience (Internet)||44 (88)||19 (38)||26.813||<0.001|
|Experience (chat)||7 (14)||24 (48)||13.511||<0.001|
|Experience (shopping)||17 (34)||8 (16)||4.32||0.038|
| Low||9 (18)||10 (20)||0.697||0.706|
| Medium||20 (40)||16 (32)|
| High||21 (42)||24 (48)|
|Age (mean, SD)||66.36 (7.139)||62.50 (7.481)||2.639||0.01|
|Confidence using smartphones (mean, SD)||4.76 (0.537)||4.57 (0.778)||1.218||0.227|
|Confidence using tablets (mean, SD)||4.56 (0.732)||4.17 (1.581)||1.158||0.253|
Comparison of Responses to Perceived Usability Items in the United States and China
|Item||Country||Mean (SD)a||t Statistic||p Value|
|Like to use||China||2.72 (1.617)||1.126||0.263|
|United States||3.04 (1.195)|
|United States||3.5 (0.735)|
|Easy to use||China||3.08 (1.275)||0.845||0.4|
|United States||3.26 (0.803)|
|Need supportb||China||1.2 (1.325)||7.267||<0.001|
|United States||2.98 (1.116)|
|Learn quickly||China||3.18 (1.119)||0.196||0.845|
|United States||3.22 (0.91)|
|United States||3.28 (0.927)|
|Perceived usability scorec||China||57.9 (13.47)||10.3||<0.001|
|United States||68.2 (9.56)|
Factors Predicting Perceived Usability of Tablets (Stepwise Procedure)
|Variables||B||Beta||t Statistic||p Value|
|Education (Bachelor's degree or higher)||−5.484||−0.197||−2.378||0.019|
Factors Predicting Tablet Performance
|Variable||Beta||Wald||Odds Ratio||p Value|
|Perceived usability score||0.126||21.848||1.134||<0.001|
|Education (Bachelor's degree or higher)||1.518||6.52||4.563||0.011|