Keywords

1 Introduction

Taiwan is facing the dual challenges of quickly becoming a “super-aged society” with more than 20% of the population aging over 65 in 2025 [1], while it also battles a rising epidemic of diabetes. As the population with diabetes grows, it is increasingly important to have sustainable chronic disease self-management programs in place that can contribute to minimize days with poor blood glucose control. Technology holds great promise for ubiquitous monitoring of critical health factors, and effective intervention can lead to reducing health care utilization among highest risk groups , such as old adults.

Technology is ubiquitous across Taiwan with nearly everyone using mobile phones as part of their daily life. Based on a 2017 government survey, percentage of internet access decreased rapidly after age 65 (age 50–59 group is 83.3%, age 60–64 group is 62.0%¸ age 65 and above is 28.3%). [2, 3] Internet access via Wi-Fi or 4G is generally affordable and common, and offers an opportunity for internet-based health management interventions. But for older adults will be a challenge.

Through focus group method and content analysis, the study collects the participants’ health status, disease adaptive process and experience of diabetes management before and during the use of a custom-built diabetes self-management application. The purpose of the study is to explore obstacles and facilitators of diabetes older adults using a new internet-based technology intervention for their health management.

2 Study Description

The Intergenerational Mobile Technology Opportunities Program (IMTOP) was a diabetes self-management program conducted by the Suzanne Dworak-Peck School of Social Work, University Southern California (USC) affiliated with one of Medical Center in Taipei and Shih Chien University. This program conducted an eight-week program in health education and custom-built diabetes self-management application (IMTOP app) practice for older adults who had type II diabetes.

IMTOP app has three major functions: first is to integrate records of disease management and health behaviors, such as blood sugar record, blood pressure, medication behavior, diet behavior, water in-take record, and daily exercise behavior. Secondly, IMTOP app will provide graphic-chart report for users and medical professionals. Thirdly, IMTOP app can record user’s mood to detect whether there is depression tendency or symptom.

IMTOP app is designed with two aims. First of all, to encourage those with diabetes to actively monitor their health condition, control their diet and maintain regular medication schedule by using the app. Secondly, to provide data for researchers on the app utilization behaviors of older adults. Inevitably IMTOP app is a handy tool with specific design for older adults to management their diabetes, user friendly with effective information, and adding some interesting games for encouragement.

This study is one of the qualitative results related to the IMTOP project. The purpose of the study is to collect and analyze obstacles and motivations of utilizing the IMTOP app for Taiwanese type II diabetes older adults. Focus groups and content analysis are applied. The concepts used in this study come from collected keywords which were drawn out from numerous verbatim transcripts. Concepts are then put into grouping systems, next, by putting these system into natural situations, these concepts become more meaningful and are placed in time order, enabling us to analyze related events and characters. The study explores how participants managed their chronic disease - diabetes, and the experiences from using IMTOP app to fit in their health behaviors

3 Sample Selection

3.1 Selection Criteria

All participants met the criteria of IMTOP, thus they must have type II diabetes, been receiving treatment at sample hospitals for at least 6 months, age 55–75, normal cognition, literate in Chinese, able to complete 6 out of 8 weeks of health educational course and willing to accept three half-year following interviews. IMTOP had ended at the end of 2016, and 237 samples were collected from one medical centers’ metabolism outpatient in north city (Taipei) and one district hospital in east-coast rural area (Hualien) in Taiwan.

3.2 Sample Description

A total of 8 separate focus groups were organized, 4 in Taipei and 4 in Hualien. At each location, two groups were focused on those who rarely used IMTOP app and were labeled “Low user group”, with 36 participants across all groups. On the other hand, there were 37 participants who were grouped in the “High user group”. In total, 73 participants among the 237 older adults completed IMTOP courses were selected in this study. Discussion was conducted for one and half to two hours on each focus group in order to gain enough information. The study linked their qualitative responses to back-end system records, based on the last two weeks of the app usage frequency before holding focus groups, and divided participants into high and low user categories. The definition of two levels of app utilization is as follow:

  1. A.

    High-level IMTOP app users were defined as those in the 50th percentile or higher in terms of the number of days they used the app.

  2. B.

    Low-level IMTOP app users were defined as those in the 25th percentile or lower, which meant they did not use the app on their own outside of the class.

Then, two groups of high-level app users, and two groups of low-level app users were selected in both Taipei and Hualien. In total, there were 8 focus groups with 73 participants among the 237 older adults who completed the IMTOP course.

3.3 Data Collection and Ethic Issue

The focus groups were hosted at a Taipei and Hualien Hospitals where the educational component of the course took place. A consent form [4] was signed. A questionnaire related to participants’ health behaviors was collected before each focus group in order to have more information on diabetes history, family history, caregiver support, prior and after program diabetes blood sugar recording habits, some subjective feelings related to their severity of diabetes before and after IMTOP courses, ability to use the app, and ability on using 3C equipment (i.e. computer, communication and consumer electronic: smart phone, internet…etc.).

The principal discussion prompts were:

  1. A.

    Briefly describe your diabetic history and health management related to this disease.

  2. B.

    What is your motivation to use IMTOP app after IMTOP course

  3. C.

    Do you use the app to record blood sugar and health behaviors after IMTOP course? Tell me about your experiences.

  4. D.

    Do you have any health behavior changes after use the app?

  5. E.

    Pros and cons of using the app. Any suggestion for the app software design.

  6. F.

    Any barriers when you use the app.

  7. G.

    Pros and cons of IMTOP education course

  8. H.

    Any suggestion for current and future support group.

Follow-up questions were open-ended and started with “tell me more about…” to get a more detailed response. Probing questions such as “please tell me more” were used to elicit more detailed responses.

3.4 Participant’s Coding

In order to identify each participant and their text in transcription of focus groups, the following personal coding was created.

  • First letter - district: Taipei (T), Hwalien (H)

  • Second code - focus group number, A = first group, B = second group, .etc.

  • Third code - participant number in groups

  • Fourth code - gender: M = male F = female

  • Fifth code - frequency of usage: L = low user H = high user

  • Sixth code - line number from focus group transcription

  • [TD01ML: 133-193] means that Taipei, forth focus group, number one participant, Male, low user: line 133 to 193

3.5 Data Analysis Tool

The recorded discussions were transcribed verbatim and analyzed without revealing the identity of interviewees by using the Dedoose software. A multi-stage coding process included an initial open coding effort to identify major theme, axial coding in which categories and concepts were linked using inductive and deductive thinking, and selective coding. The most frequently mentioned words or phrases were marked with a colorful highlight, extracted into a separate document and labeled with a code. Through a process of comparison across the transcripts a system of similar codes were combined into concepts that could be used for analysis. Concepts were grouped by similarity, first at the most abstract level and then at the theoretical level, where themes and categories were finalized and the coding scheme standardized. A total of 490 quotes were coded and categorized using this scheme.

We used the bottom-up/data-driven approach described in the grounded theory in which identified concepts from a group of random transcripts informed the initial coding process. We also used the top-down/concept-driven approach to base our coding on ideas found during our literature review. The coding scheme is shown in the Table 1. Chronic disease management stages are divided into four stages: adjustment stage, exploring stage, control stage, and stable stage.

Table 1. The themes for data coding
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3.6 Reliability and Validity

The study relied on several tests of reliability including the Relevant test method (triangular test). The study used the pre-questionnaire basic information, post-test data and interview information to confirm the authenticity and consistency. Furthermore, the researchers consulted the instructor and USC research team to ensure the results match with their understanding and observation by tracking participants’ utilization records as well as three of their face-to-face follow-up interviews during one and half year after the course.

  1. A.

    Feedback method which led to the initial structure and concept map: The study extended to interview other health management app users in order to understand the logical and reasonable IT behaviors for older adults.

  2. B.

    Audit trail: The study held regular discussions with the study team in Taiwan and USC research team, including details of the methodology, process, and so on.

  3. C.

    Maximum variation: The study stratified participants to focus on levels of utilization, urban and rural areas, gender, education and other diversities. According to the variability, researchers can understand users’ behavior based on different background variations.

For validity, the discussion prompts were reviewed through reference reviews and research team discussions. Furthermore, during the process of coding the transcriptions, the study team went back and forth to recheck the contents and the meanings behind the participant intentions.

4 Results 1: Demographic Information of Participants

There are total 73 participants with 50.7% high-app users, 47.9% living in Taipei, 65.2 average age, 12.9 years with diabetes, 72.6% having family history with diabetes, 34.2% having experiences taking care diabetes family members, 41.1% with college education or above, 80.8% willing to continue use the app (Table 2).

Table 2. Demographic characteristics
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5 Result 2: Analysis of Adaptation Stages for Chronic Disease Management

The study examined the data extensively based on the level of utilization, urbanization, gender, education, 3C ability, and other measurements. The emerged themes were: self-perceived the severity of diabetes, health beliefs, self-efficacy (health behaviors), self-efficacy (data recording), internet environmental factors, acceptance of technology, and interference of the IMTOP app.

5.1 Self-perceived Diabetes Severity & IMTOP app Utilization Behaviors

The study found that participants in different adaptation stages of chronic diseases have varied health management and IMTOP app behaviors. The study classified the adaptation stages into four stages: adjusting, exploring, controlling and stable stages.

  1. A.

    Adjusting stage

Participants in the adjusting stage of chronic disease will go through different emotion and behaviors while facing their diabetes, such as astonish, deny, depression, anxiety, lost and adjust to accept.

At first I really couldn’t accept it (diabetes), I thought then it’s like having myself sentenced to death. Because I think when I heard it was diabetes, I was a bit shock. And I’m afraid to tell my family that it was diabetes. [HE01FL: 4062-4119]

I couldn’t believe I had diabetes, I was healthy, the doctor told me to do a thorough health check, but then I escaped from my responsibility. [HH10ML: 5896-5938]

If I was told to take medication, then I do it, but I don’t control my diet at all, and I don’t exercise neither, I’m already fat. [TA03FH: 6326-6363]

I was unperturbed to accept the fact, I seen diabetes patients often. After going to the doctor, there has been a benefit, I have an excuse to quit drinking alcohol to others’ invitation. [HF08MH: 9415-9466]

For those who are at the beginning stage of diabetes, they do not feel that diabetes is an immediate health threat, usually lacking motivation to have active self-management to measure and record their blood sugar. In addition, they are used to recording their blood sugar and blood pressure on paper, so it’s easier for them to become low IMTOP app users.

I do not know if I really have diabetes. I am here because Dr. Guo told me: “You must go to class, you will benefit from being encourage by others in the class.” … But I did not exercise with friends, Before the class my blood sugar level was 130 and now it is rarely more than 100… Otherwise, I would also like to say my body is as strong as a cow. … I don’t know how to measure my blood sugar, when I go to the hospital they will check it for me. I feel I am healthy, I don’t need to record my blood sugar. [TD01ML: 133-19320]

I’m more like the lazy type, I’ve never used the tablet before, but I’ve been on some health websites. …I’m thinking that I don’t have to be so harsh on myself right now, maybe sometimes I didn’t control it well or have my glycosylated hemoglobin over 7, then I kind of reflect on myself. [TB01ML: 246-336]

I used to use a notebook, …, I know how to use an APP, but I’m just kind of lazy. [TB07ML: 7310-7484]

  1. B.

    Exploring Stage

For the second adaption stage of chronic disease, also called the “exploring stage”, the participants start to understand and more actively explore methods for diabetes management and health behaviors, such as discussing with health professionals and obeying their suggestions, searching for health information, accepting the status of diabetes.

Starting from then on, I followed the doctor’s orders completely, before and after both meals, before and after dinner, breakfast and lunch I took my medicine on a regular basis, I had a pretty good control over myself. Then I started to look on the internet and I found out that the complications of diabetes is very terrifying, it affects our body totally, we are like people that are soaked in sugar, so then I thought I must control my diet when I eat. [HG10FH: 6653-6778]

I haven’t stop taking my medication, I think of myself as a model student of diabetes, because first, I have never stopped exercising, and second, I changed my daily habit completely, I used to always go to bed at around 12 PM, but then throughout the 6,7 years, I insisted myself on sleeping at 10 PM, and I would automatically wake up at around 5:30 to 6:00 AM, I really think I improved a lot. [HG05MH: 2622-2770]

When we discussed about their utilization on IMTOP app, there are couple obstacles, such as afraid of self-injection and low self-efficiency in recording.

“I did not dare to test on my own, unless at the clinic. The nurse can help you prick the skin with less pain. My family gave me 2 sets of blood sugar tests, but I did not dare to use them, … and then I dare not test my own blood sugar, but I can measure my own blood pressure, exercise and monitor my own diet and feel pretty good.” [HH03FL: 1943-2244]

At that time, I focused more on my eating habits…, by eating this way, I controlled my blood sugar at around a little bit more than 100….before going to class, I would note the level of my blood sugar down randomly, when I had more starch, my blood sugar goes up and then I don’t feel too well. … yes, I do feel it…, then I recall what I had in the last meal, and think about what kind of food causes the uncomfortableness, then I paid more attention to it. [TD08FL: 5153-5507]

To sum up, conscious action awareness, willingness to measure health variables and record data (except for blood sugar because of the pain of the needle prick) with consistency for one’s own health are the obstacles for older adults to use the app as a tool to manage their diabetes.

  1. C.

    Controlling Stage

For the third adaptation stage of chronic disease, called the “controlling stage”, participants gradually understand their status of health, know how to control their diet, drinking and exercises. Meanwhile, they might have more active recording of their blood sugar as well as blood pressure.

“I have to eat whole wheat toast, because it helps my blood sugar control. When I first started, I was very careful with measuring my blood sugar. After a while, everything was under control, I ate same things every day, then I started to prolong the period of blood sugar test and recording.” [HE01FL: 4732-4874]

In this stage, participants are seeking more efficient tools to assist them to understand their health status.

  1. D.

    Stable Stage

For the fourth adaptation stage of chronic disease, called the “stable stage”, the patients have self-efficiency health management, can control blood sugar level and glycosylated hemoglobin well. On the other hand, they will fix their health management behaviors and pay less attention to the new tool - IMTOP app.

I had a more stable status, I control my own eating diet, normally I wouldn’t be measuring this frequently, I measure it once for around 4–5 days, this is my normal situation. If today I felt that I have less appetite or sleep, special situations like this, then I will measure it, sometimes I would measure it in the morning and also at night, but if I’m having a stable condition, then I measure it once every 4–5 days. [HH01FL: 619-802]

In this stage, the new tool (IMTOP app) may not provide enough drives for them to use because of paper recording habits, being familiar with their health behaviors. Obstacles on using tablet and IMTOP app include testing cost, recording habits and the consumption of time.

Normally I measure it twice or three times a week, I don’t record it in the app, but each year I have a notebook, there’s the date on it, I will note down the time and whether it was right or left hand. If I had a bigger meal (for instance, family reunion dinner), then I would measure it the next day and note it down to see if there is a difference. To be honest, the test paper is very expensive as well, if I measured it before and after every meal daily, then I would need a few bottles a month, one bottle costs 900 NTD, for now I use around one bottle every three months. … I am used to noting things down in a notebook, …I know how to use the app, but I’m kind of lazy to use it. [TB07ML: 6992-7484]

I think this app has a very good design, you can draw graphs on it and you can take pictures with it, but I still think this has to do with habit, I am still used to using notebook, as for the tablet, you have to turn it on and off, and it runs out of battery around 2–3 days…and also the test paper is expensive. [TB06FL: 8019-8360]

5.2 Obstacles on IMTOP App Utilization Behaviors

Self-perceive the severity of diabetes and chronic disease stages impact the health management behaviors as well as the utilization behaviors on IMTOP app, other obstacles have to be concerned as well. Even though there are incentives for attending the program such as: a given tablet with 6-month free internet access, an 8-week course learning about health information and IT skills, obstacles for low frequency utilization on IMTOP app includes: 3C beginner, not matching with their life-style and hardware problems.

  1. A.

    For 3C beginner

This tablet is pretty difficult to use, to be honest, I don’t really know how to use it, there are some symbols on it, sometimes maybe I click the wrong place or something, it is gone, and I don’t really know how to bring it back. [HH01FL: 964-1020]

Before coming to class, I seldom use 3C products, and don’t really know how to. I’m pretty old, I would forget not long after my daughter has taught me. [HH02ML: 7991-8027]

I asked the student volunteers, they operate it very quickly, I didn’t have enough time to look at how it was used, and didn’t have enough time to take notes. … for my cellphone, I use it simply to receive phone calls, add new contact information, record, and use LINE, I have a lot of LINE groups, just using my cellphone takes up a lot of my time. [TB04FL: 2711-2958]

These recording functions still seem pretty difficult to me, because I have never used it before, when I take it home, I couldn’t figure it out by myself, so then I put it away. I’m most familiar with YouTube, that’s all, you can choose songs on YouTube, and because I like to sing, I find some songs to sing. And with the Facebook now, I don’t get it at all, don’t know how to use it, I hope to improve these skills, and keep on taking classes. [HH07FL: 11057-11192]

  1. B.

    For 3C experienced users

The tablet runs out of battery every 2–3 days, I charge it all the time. [TB06FL: 8080-8111]

To be honest, I seldom use it, just for looking at the information, like the blood sugar and blood pressure, I measure it every day, but I don’t record it every day. I don’t always take a photo of what I’m eating, mostly I just control it by myself. Maybe because I’m a little lazy, I guess. I use the computer and cellphone every day, but having to key in all those information seems repetitive and weird. [TD04ML:17669-17914]

For example, if I’m having lunch, and I take my pill, I take it before my meal, and after my meal I still have to turn this on, I would say I couldn’t do it, I have to do this too frequently, and I’ll have to always have my tablet with me, I can’t do it. … I would say there are some blind spots with the app, it doesn’t have supervision from the hospital, nor immediate reminders or suggestions… [HE03ML:19724-20641]

  1. C.

    Environmental Factors

Furthermore, the environment plays a very important role in determining whether or not older adults use IMTOP app; it could be a supportive or an obstructive environments to use IMTOP app.

“It’s not easy to get the data signal at home”… [HH08ML: 11215-11307]

Since the tablets relies on a 3G cellular signal, the strength of the signal could vary across the city and within a home depending on barriers which include cement walls and areas far from the cellular towers. Asking for help was often a determining factor of tablet use as well. For example:

“I would like to ask my wife, but I do not know how to ask when she is at work, Saturday we worship, rest, sometimes I will use the tablet, and sometimes I will not want to use it.” [TD02ML: 18937-19000]

While the study intended the tablet to be used by an individual alone, older adults may in fact be demotivated by using it alone, and more likely to use it when another person is present for advice or encouragement. Of course, competing priorities may have also been a serious issue.

“In fact, during the class time I used the APP a lot, after graduation I was not forced to use it, and I didn’t because I have to do volunteer all the time, recording data was not my priority.” [TB09ML: 11247-11365]

Bearing in mind many participants volunteer for hospitals, they may find their priorities focused on the opportunities they have to be among others and feel their work is of service, rather than focus their attention to their own health concerns. That said, the IMTOP app did help some consider their disease management more actively.

“In this course, you will feel that you should keep a record every day, then you have to record it and you cannot lie to yourself. Then you have to actively think about what you eat.” [TA05MH: 21409-21482]

“I used this tablet after I finished the course, meanwhile when I visited doctors, I will show it to them. I mostly just write the data on paper, but the tablet has automatic guidance and electronic recording function, it is very good.” [TC03FH: 13423-13500]

The app may play an important role in enhancing self-efficacy.

“The doctor used to say he had to pay attention to my health data… because I had no way to accumulate records. Now I can make a return visit a week later and show my records to the doctor. I can ask if I can eat more of this or that… I also learned to play games on this computer, to take group pictures,… before this, all I heard was what to eat or not to eat, but there is no actual control, and now there is this tablet,… It can help me review what kind of food isn’t suitable for us to eat, what kind of food is suitable for us to eat, if you eat a certain kind of food then my blood sugar would soar, so I can try to avoid those things…. like this is more effective than the dietitian, nutritionist, out of this classroom, I do not remember what they say, they told me how many calories are in a bowl of rice, a bowl of fruit, but how can I remember that? Very few people can remember that. But the APP helps me out” [TA08MH: 14502-15628]

One of the primary interests in this study is to understand the barriers that stopped older adults from using IMTOP app effectively.

“I went to the tablet shop to ask them for help. If I don’t know I will ask, it’s no big deal. Whatever problem I have when using the tablet, I will go ask the tablet shop. As long as I can figure out how to use it, I don’t mind asking. …You have to learn if you want to use it, there is no other way.” [TC09MH: 17294-17528]

“I struggle with this software, I go back to ask my wife for help, she helps me input the data. Or I will call IMTOP manager or office for help.” [HF04MH: 12893-13359]

5.3 Accelerators: Support System in IT Technology and Social Network

The IMTOP course seemed to play a key role in enabling many to feel comfortable with IMTOP app. Throughout the study, those who have easy access to technology and having positive social support are more likely to overcome the complexity of data input and beome frequent users. Otherwise, they will be less motivated to use the app.

6 Result 3: Cross Table Outcomes for Different Disease Management Stages Between High/Low Users

According to focus groups’ transcription for each participant, the study analyzed their perceived severity of diabetes and health management behaviors, and classified them into different stages of chronic disease management. Analyzing the high and low users of IMTOP app and disease management stages, there are 38.9% of low users in the exploring stage, comparing to high users who are more allocated in the control stage (51.4%) and stable stage (35.1%). Ordinary cross-table statistic was testified (Spearman = .25, p = .033 < .05). Disease stages might impact the utilization of the app (Fig. 1).

Fig. 1.
figure 1

Cross table between IMTOP app high/low users and disease management stages

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Furthermore, the study analyzed high/low user groups of IMTOP app and conducted cross verification with the levels of 3C ability (including Computer, Communication and Consumer Electronic; the more 3C products they use, the higher the level). Basically, low users have higher percentage in the low 3C ability (54.1%). Meanwhile, the high users have 52.8% and 19.4% in middle and high 3C ability (Spearman = −.241, p = .04 < .05) (Fig. 2).

Fig. 2.
figure 2

Cross table between high/low users of IMTOP app and levels of 3C ability

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Finally, the study analyzed high/low user groups of IMTOP app and conducts cross verification with levels of self-perceived diabetes severity. There are no difference between levels of self-perceived diabetes severity and utilization of IMTOP app (Spearman = −.009, p = .941) (Fig. 3).

Fig. 3.
figure 3

Cross table between high/low users of IMTOP app and self-perceive of disease severity

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7 Discussion and Conclusions

Chronic disease self-management refers to daily activities, such as health promotion, symptoms’ management, minimization of the impact of the chronic illness on functioning, handling of psychosocial sequelae [5]. The study tried to use custom-built diabetes self-management application (IMTOP app) to assist type-II diabetic older adults to understand, analyze and manage their health behaviors and disease symptoms. Different stages of chronic disease self-management and levels of technological comprehension might impact the acceptance and utilization of new technology (IMTOP app) among older adults. Those who used the app the most reported that the stage which took up the most of their time was respectively exploring-stage for low users and controlling-stage for high users. The self-perceived severity of disease is not related to the utilization of new technology (IMTOP app).

Furthermore, 3C ability is a fundamental competence for users to continue to use the tablet as a health management tool. Programs that teach self-management skills are more effective than information-only education in improving clinical outcomes [6]. Hence, IMTOP provided educational program with structural lectures for old adults to understand the meaning of health management, practice how to calculate and control their diet and learn how to use the tablet and app; also pairing up with young college students as volunteer assistants is a good strategy. Unfortunately, older adults need more time to adjust to the new technology.

Other important obstacles are perception of the environment (i.e. internet) and availability of social supports in the tablet and app consultation. Finally, how the app program embeds in users’ lifestyle and disease management behavior is also the key for older adults to become frequent users. Because adopting daily use of the new app is a major behavioral change. Thus, it is difficult for older adults to implement as a daily routine.

The study contributed that chronic disease self-management can be divided into different stages which will impact people’s health management behaviors and high technology utilization. For future studies, Technology Acceptance Model (TAM) [7] can be applied to explore system quality; perceived self-efficacy and facilitating conditions can be expected to predict older adults’ behaviors of chronic disease self-management in different stages of disease adaptation by using the app.

8 Limitations

There are a number of limitations that should be considered. First, all of the participants in focus groups have subjective experiences that could reflect on both their past experience with disease management as well as their knowledge and ability to use electronic devices based on earlier life experiences. We should also remember that many older adults may be grateful for their course experience and suggest they liked the app, despite their actual limited interest in it, in order to be polite. Also, some may have been motivated by the opportunity to socialize with others and get a free tablet. Finally, much of the experience was from one hospitals, different disease management support groups in hospitals might impact their use of the app. We also note that focus group interviews can result in “group effects”, which people tend to agree with others in the group.