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 Table of Contents  
Year : 2016  |  Volume : 2  |  Issue : 4  |  Page : 149-156

Evaluation of motivation and attitude for Telehomecare among caregivers of elderly patients affected with congestive heart failure

1 Center of Telemedicine and Telepharmacy, School of Pharmacy, University of Camerino, Camerino, Italy
2 Department of Cardiology, “U. Sestili” Hospital, INRC-IRCCS, Ancona, Italy

Date of Web Publication3-Mar-2017

Correspondence Address:
Milica Kaladjurdjevic
School of Pharmacy, University of Camerino, Camerino
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/digm.digm_40_16

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Background: The development of telemedicine has become a solution to provide healthcare service to the elderly while they remain in their homes. The unit of cost of healthcare service provided at home is lower than the unit of cost of Institutional Healthcare Service. The healthcare users' attitude and motivation are a fundamental factor for the acceptance of technology and behavior change. Still, motivation and attitude toward telemedicine, especially among elderly and their caregivers is not satisfactory. Objectives: The object of this study is to investigate the utilization of Telehomecare and its effect on user's attitude and motivation among caregivers of elderly population who are affected by chronic heart failure. Materials and Methods: Observational trial and quasi-experimental design with duration of 6 months were adopted. Intervention with the telemedicine platform that supports multispecialty teleconsultation and questionnaire for evaluating the effect of intervention “Use and attitude of current technology” were used. Results: The results after 6 months showed that expectations and attitude were improved, and the user's opinion about barriers was positive. Conclusion: We evaluated readiness and responsiveness of naïve user before and after 6 months during observational trial. The trial has demonstrated a unified user's opinion that the barriers to telemedicine's use are not so high that they cannot be overcome.

Keywords: Caregivers, congestive heart failure, elderly patients, Telehomecare

How to cite this article:
Kaladjurdjevic M, Antonicelli R. Evaluation of motivation and attitude for Telehomecare among caregivers of elderly patients affected with congestive heart failure. Digit Med 2016;2:149-56

How to cite this URL:
Kaladjurdjevic M, Antonicelli R. Evaluation of motivation and attitude for Telehomecare among caregivers of elderly patients affected with congestive heart failure. Digit Med [serial online] 2016 [cited 2023 Mar 29];2:149-56. Available from: http://www.digitmedicine.com/text.asp?2016/2/4/149/201267

  Introduction Top

The healthcare service system in near future will face a problem of accessibility and delivery, mostly because of rapidly growing percentage of people over 65 years of age who are affected by chronic diseases. The prevalence of chronic disease is rising; however, in many countries, a disability rate is decreasing. The Theory of Fries [1],[2] suggested a possibility of compression of morbidity in future, explained as more healthy years of life while the disease and disability will be postponed until the end of the life. Still, the chronic diseases – mainly cardiovascular disease, cancer, chronic respiratory diseases, and diabetes – were estimated to cause more than 60% (35 million) of all deaths in 2005.[3] Disability is associated with aging and the correlation between age and disability shows that 32% people aged 55–64 are disabled, and 44% people aged 65–74 are disabled; with older population, the percentage is higher, 60% people aged 75–84 are disabled, and up to 70% people for those aged 85+.[4] The fastest growing old age population is those over 85+, with an expected increase of 300%.[5]

The possibility to “age-in-place” is less costly and beneficial for the mental and physical health of older persons. Still, the complexity of healthcare system service and lack of technology skills and technology discomfort of user is the reasons for lower usability of home care solutions. The innovation implementation and its adoption have to succeed in five attributes (relative advantage, compatibility, trialability, observability, and complexity) in order that the decision maker – user will perceive it as worthy to accept.[6]

Although the gerontechnology [7] can both reduce caregiver workload and reduce demands on the healthcare system, the economic benefit and relative advantages of home-based solution are not perceived as that, because of the technology discomfort of the users. The technology discomfort comes with new Information and Communications Technology (ICT) devices.

While receiving healthcare service through standard telephone does not require additional technology skills, the tablet, computers, and other hardware that are utilized in home monitoring solutions usually require additional (sometimes complex) technology skills. A previous study [8] found that main technology discomfort includes using devices with widgets (unskilled on the use of a smart phone or a computer), other barriers found are multiple screen transitions to complete a task, menu bars that contain several layers or inappropriate size of a smart phone (too big or too small).[9] The easy perceivable design of hardware and simple commands of software application are important in patient's decision-making of hardware, and simple commands of software application are important about technology use. Congruence between individual and environment that surrounds him depends on objective attributes, perception, and individual needs, and therefore, the level of congruence of relationship between individual and environment will produce success or failure.[10] The perception and needs of individual user have to be understood to better optimize design and improve gerontechnology utilization.[11] Motivation represents a fundamental factor for use of technology and is funded on felt need and perceived benefits.[12]

This paper presents a home-based telecardiology intervention designed to improve caregiver skill in the management of high-risk patient affected with chronic heart failure after their discharge from the hospital during the vulnerable period. The high-risk patient is defined according to the New York Heart Association (NYHA) Class (III), age (85 years age), and vulnerability (discharge period) and rate of the previous hospitalization (3 hospitalization in the last year). The rationale for intervention, a description of innovative intervention and patient's characteristics and results from the questionnaires at base visit and at last visit are presented.

  Materials And Methods Top


The patient affected with congestive heart failure (CHF) during discharge period is more prone to rehospitalization and mortality. Heart decompensation and hospitalization result from a number of factors, such as lack of knowledge regarding the illness, nonadherence to medication and diet, inability to recognize changes in signs and symptoms, and inability to access healthcare providers.[13] Chronic diseases are a pathology that requires constant and continuous primary and secondary care, in case of exacerbation patient is admitted to tertiary care. For chronic disease care, important objectives are to prevent further deterioration of disease and to maintain the patient as long as possible in independent active state. On the other hand, we are witnessing a rapid spread of information technology through all spheres of citizen's life.

The given possibility of information technology is in more accessible healthcare consultation and healthcare monitoring.

Information technology development in the last decades has a great impact on the civil society behavior, way of living, and work. Nevertheless, older population has been left marginalized from information technology values and benefits. Most of the hardware and software used in information technology have been designed for the need of young and working population. Today, we have a wide variety of application for entertainment, games, social networks, and software for different professional's need. Most of devices have been designed for young Dexter population while the older and less able population has been left a part. The increasing population over 65 years of age is having an impact on the information technology industry. The information technology industry is realizing that elderly population is become important share of consumers, and they need software and hardware fitted for their ability and limitations. The elderly responsiveness and readiness for new technology is limited for a variety of reasons. Elderly population is more familiar and comfortable with human interactions, instead of artificial communication and interaction. The information technology industry has not recognized elders as potential consumers as the ICT industry offers inadequate software and hardware design for elderly use.

Pilot trial

Cardiology pilot project for CHF-affected patient, combined with health education courses, addressed to both the patient and their caregiver, with weekly telemonitoring of population over 86 years of age, who are assisted or living with caregivers.

Intervention and technology used

To participate in the study, every caregiver and patient were required to undergo the training of using telemedicine devices. A structured brochure containing all major information regarding telemedicine device was given to every patient and caregiver. Every patient has received a list with telephone and E-mail contacts of responsible person who should be contacted in case of technical or other problems. A telemedicine platform supporting specialty teleconsultations and telehomecare was used. The software was developed to be used by people without medical skills, such as patients and caregivers. The technical system platform has to be configured at the moment of deployment to the user.

The user interface has been developed to take into account the simplicity of using the mandatory characteristics. The software allows in real time, the storage and sending data without data loss, also in the case of lack of connectivity. It integrates different types of medical devices tailored for the patient. Every kit contains medical device (blood pressure device, oxygen saturation device, weight control device, electrocardiogram (ECG) – 12 leads, and electronic stethoscope) [Figure 1] and tablet with software.
Figure 1: Telemedicine kit

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The telemedicine kit is very easy to use. After an internet connection, the software application opens instantly and displays 4 images representing access to separate pages of 4 vital signs measurement (saturation, blood pressure, weight, and ECG). The value of measurement is automatically transferred from the device to the application at the hardware (tablet) and appears as a measurement already inserted in corresponding window at tablet display. Patients may control the data transmitted on tablet to control that the medical device measured the corresponding data. This procedure was repeated for 4 measurements. Data were then transmitted directly to the cardiology division, and every patient (user) received a confirmation message that measurement had been sent successfully. The commands required for successful operation are next access to the application (only one at tablet display) with one click, selection of measurement, and confirmation of measurement. After data have been confirmed by the patient as accurate according to measure displayed at medical device, the application will send automatically data to the cardiology department. The stability of the internet connectivity is secured with USB internet device.

Study population

The study consists of patients diagnosed with of CHF and frequent rehospitalizations (at least three re-hospitalization in the last year), over the age of 80 years, living at home, in a self-sufficient manner, or assisted by a caregiver or a family member.

Inclusion criteria were as follows: at least three rehospitalization with primary diagnosis of heart failure within last year, ≥80 years of age; II–III Class NYHA; HF of different etiology (ischemic, valvular, hypertensive); presence of one or more of the following comorbidity: diabetes, renal insufficiency, hypertension, anemia; assisted by caregiver, (formal or informal) who have basic level of information technology use; internet access at home.

Participants were excluded from the study according to the following exclusion criteria: age <80 years; recent acute myocardial infarction; severe dementia; severe renal insufficiency (glomerular filtration <20); chronic dialysis; cancer with short life expectancy (<1 year); and absence of a caregiver (formal or informal). After screening conducted during patient's hospital stay, every patient and caregiver had to sign informed consent before enrollment at the study. [Table 1] represents a summary of patient characteristics.
Table 1: Patient characteristics (n=8)

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Statistical analysis

This was an observational study lasting for 6 months. The study intervention included as follows: a health education course (1st day) and weekly telemonitoring of vital signs starting from the 3rd day.

Intervention questionnaire

We used the questionnaire titled “Use and attitude for current technology.” The questionnaire is divided into seven areas: knowledge and use of technological devices, self-assessment of technical skills and joint technology, knowledge and interest, familiarity with telemedicine and telemedicine devices, expectations and attitude, and motivation and limitations.

  Results Top

We assessed caregivers and elderly population attitude toward ICT technology before and after the trial. [Table 2] presents the summary of results collected before and after the trial. The questionnaire “Use and attitude of current technology” was used to collect data and its template is presented in [Appendix I [Additional file 1]].
Table 2: Results from questionnaire “use and attitude of current technology” collected before and after the trial

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Use and familiarity with technological devices part

Most of the caregivers have answered that they are familiar with technology and they use it on everyday basis: phone, mobile phone, TV, remote commander, PC, the Internet. Just one caregiver has answered that he is not familiar with PC and the Internet. Two caregivers answered that they are not familiar with the medical devices (blood pressure measurement devices). After 6 months of the trial and standard training that caregivers received, all caregivers became familiar with PC, the internet and medical devices used in the trial.

Self-evaluation of common technological skills

All patients have responded that they have technological skills for phone, cell phone, TV, and remote telecommander (questions: 3.1; 3.2; 3.3, 3.4) [Appendix 1], and overall responses on questions 3.5; 3.6; 3.7 have a lower score before the trial. Following the training module given to caregivers initially and utilization of telemedicine platform during the trial, the responses on questions 3.5; 3.6; and 3.7 [Appendix 1] had a higher score at the end of the trial. This is very satisfactory, considering that technology discomfort is one of the major barriers to the wider use of telemedicine.

Interest and knowledge

Before the trial, responses to the questions 7, 8 [Appendix 1] generated a low level of knowledge and interest among selected users.

The questions 7 and 8 enquired about the interest and knowledge of responders pertaining to technology used for elderly needs. After the trial, the responses were more positive and demonstrated a higher level of interest and knowledge than before the trial. The value addition of telemedicine is in its better accessibility to healthcare service. It is necessary to provide adequate knowledge to end user that will empower him to be more confident to use telemedicine.

Familiarity with telemedicine and telemedicine devices

As we expected, before the trial, all the caregivers responded negatively or with a lower score on question 11 [Appendix 1], but after the trial, responses on same question the answer were yes (1 score). With this, we can conclude that the initial training and 6 months of user practical experience with telemedicine platform have increased familiarity with telemedicine among caregivers who provide care for elderly citizens.

Attitude and expectation from telemedicine and innovative technology

We were surprised with the initial level of expectation and attitude. The initial response on questions 14.1, 14.2, 14.3, and 14.4 [Appendix 1] corresponded to highly agreeable answers among all respondents, except for one caregiver who was strongly disagreeable. After the trial, the strongly disagreeable responder changed his attitude to strongly agreeable for the same questions. This shows that the training and 6 months of utilization can influence and change expectation and attitude of the end user.


Before trial, the motivation was very high among caregivers. On questions 15.1, 15.2, 15.3, 15.4, 15.5, and 15.7, most of the patients have responded with “strongly agree.” Even though they did not “strongly agree” with 15.6 question almost all have responded that they “agree.” After the trial, their level of motivation remained almost the same.


Most of the responders did not agree with questions of this part. The questions from 16.1 to 16.7 have been answered with the response: “strongly disagree” and this opinion remained the same even after the trial.

  Discussion Top

In the other studies, users were more willing to adapt to technology if the technology kit included the familiar technologies as TV, radio. The education and training resulted in positive adoption of technology after users were given time to learn and technical support in the execution of technology tasks.[14] Familiarity with telemedicine and telemedicine devices can improve as demonstrated in our study after education and training. Therefore, benefit perceived from telemedicine with adequate training and education can improve motivation and attitude of individual user. Similar to our results, positive attitude toward telemedicine was observed in the trial about geriatric population, where 121 elderly patients were recruited.[15] Most of the patients in our trial disagree that telemedicine applications are difficult for utilization or that it can intrude their privacy or hamper their security. These results are confirmed with the previous trials,[16] where 98.3 patients were satisfied with telemedicine. In a previous trial,[17] it was demonstrated that intensive learning can lower the barriers and make users more responsive to telemedicine. In the meta-analysis conducted by Kraai [18] on the patients affected by chronic heart failure, it was demonstrated that the patients were overally satisfied with the telemedicine intervention that they had received. The objects added to the home have to be familiar to the user in order for them to be accepted. Therefore, in our trial, we used the devices the user is familiar with, which do not disrupt relationship with home environment. The systematic review of the previous trials on the attitude of the patients toward telemedicine has demonstrated that most elderly patients who are affected by chronic diseases are motivated to use telemedicine, and in most cases, find it easy to use and beneficial for the management of their health problems.

  Conclusion Top

Our pilot trial has its own limitations: it is represented by a small number of patients and lacks statistical analysis. Nonetheless, this pilot project confirms the results from the previous trials about the attitude toward telemedicine. Inadequate diffusion of the new application of telemedicine along with the necessity for educational training before telemedicine has been used, which may also be the limitations for a broader use of telemedicine application. The results of our pilot trial show that motivation and attitude are strongly correlated, with opportunity to acquire technology knowledge and skills necessary to execute disease management tasks, as well as familiarity of devices and their nondisruptive effect of individual environment relationship.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1]

  [Table 1], [Table 2]

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