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Services provided by governmental and the health sectors in Sweden are increasingly being digitalized. This includes use of information technology (IT) to search healthcare information, electronic booking for consultation and other health-related services. The use of health services is growing among the senior citizens and it is therefore important to investigate how electronic (e-health services) are used and how they are suited to the senior citizens. The objective of the study was to review the health related e-services and identify those that are for the elderly population. The study was divided into three phases. First a literature review was undertaken followed by a questionnaire in the second phase. Finally qualitative observations with focus on usability were carried out in the third phase. An overview of the available health related e-services is reported and those that are used by the senior citizens were identified. The result showed a large and growing use of health related e-services by internet savvy senior citizens. An increased and more varied use of the available services could be achieved with a targeted marketing. The investigated health related e-services were perceived as relatively user-friendly, nevertheless senior citizens and the patients in general would benefit from an enhancement and continuous review of the usability of the provided e-services. KEYWORDS: electronic health related services, senior citizens, usability 1. Introduction The use of information technology within the healthcare and the government sector has increased  and efforts still remains in order for the citizens to experience e-health services as user friendly and not as a burden. The number of internet users in Sweden is growing at a fast rate where almost all the young people use internet every day. Yet it is the senior citizens, 65-79 years, that stands for the largest increase from 29 percent to 39 percent in 2008 , . It is therefore important that the e-health services are designed from the need and users point of view. The study focuses on exploring on the e-health services that are in use today among other internet services  which are directly targeted to this group. Thereby depict on how the senior citizens encounter them and outline their usability. 2. Objectives Digitalization of e-services1 has become very common within the government sectors and even within the health services. This includes use of information technology (IT) to search healthcare information, electronic booking for consultation and other health services. The objective of the study was to survey health related e-services used within the Stockholm municipality by the senior citizens. The study examined the frequency of usage, its usability and its´ user-friendly. Out of the objectives, it was assessed important to carry out the study in three phases. The first phase entailed in giving a base on those e-health services that are within the Stockholm municipality. While the second phase was to outline the frequency in the usage of these services. Tests were implemented to evaluate on their usability in the third phase. The target group for this study included men and women aged 65 years and above that lived in Stockholm municipality and had some basic knowledge in computer.2 The term e-services in this context include telecommunication, information technology and radio. E-services are those services that are delivered electronically, i.e. electronic communication. 2 Basic computer knowledge here entails to that one is acquainted to the use of internet for mailing or searching of information. 3. Background Each municipality in Sweden is responsible for the delivery of healthcare services thus the welfare of its citizens. Other responsibilities are prevention of health problems not to mention the least, planning of growth of the municipality. The municipality is answerable and responsible in providing health- and hospital care to its citizens. This entails in meeting the needs and expectations of all the citizens at an individual level . The services should be built on scientific and tested experiences and thus practiced with high integrity and security . Within the Stockholm municipality there is a website `Vårdguiden` that provides medically reviewed information on illnesses and health, contact details of all the health care providers in the county, and Vårdguidens e-service `My Care Contacts` . With e-services in this website, entails, booking or un-booking of appointments with physicians, requests on physicians calling patients, prescription renewals, SMS-reminders and so on , . Other services have been implemented in order to enhance e-services offered to patients and to reduce the burden within the healthcare sector. These services include call-back, description of direction, information on diseases and injuries. Usability Usability methods have been defined by different authors in different ways and not the least by the international standard (ISO). According to the ISO, usability is the extent to which a product can be used by specified users to achieve specified goals with effectiveness3, efficiency4 and satisfaction5 in a specified context of use . Effectiveness in this concept of usability is about consumption of resources such as time and satisfaction with a comprehension on what users think about their interaction with a website. Other authors describe usability as the usefulness of focusing on users, where people use the system for efficiency, and connect with the product . It is the users that determine the ease of use of a website. There are different methods of using usability tests this includes the use of questionnaires, interviews observation and many others. There are pros and cons for the methods that are there today , , . The manner in achieving an assignment is accomplished. The degree and effort used in attaining the goal. 5 The degree of satisfaction and the positive feeling in using of a given product. 4. Material and Methods The study was divided into three phases with an effort to resolve the problems. The combination and the approach of using both quantitative and qualitative give a phenomenon from different perspective . Quantitative method was applied in the first phase of this study with the aim of research procedures that gives a description of human own writing or speech and observations . In this phase, it identifies and outlines the health related e-services that are used within the municipality of Stockholm. A search of literature in the internet based on well-known trustful publications and journals like PubMed, Google scholar were used . A measure of their validity, existence, owners and up-to-date websites was implemented . A demarcation of literature study was made based on the definition of e-health services in this study. Use of literature gives information on specific subject, which makes it more understandable of the study's subject . Inclusion and exclusion criteria were applied in order to concisely identify only Swedish publications, articles and reports published not earlier than 1995 . Consequently, phrases with inclusion criteria for men and women above 65 years of age were included thereby excluding other ages and none Swedish publications and articles. In phase two of the study, qualitative method was applied thereby utilizing the results of the first phase onto the second phase. The aim of the second phase was to depict the relevant e-health services among the senior citizens and also their usability. The approach used in selecting the respondents was through the society for the senior citizens. The inclusion criteria entailed that respondents were members of one of these societies/clubs. This include; SeniorNet, SPF Pension and PRO. The strategy used in sampling of respondents in this phase was through a non-random approach. Out of this, individual respondents were approached through the clubs website, where the interested club members were given a link to get to the questionnaires. The inclusion criteria in this phase entailed to that the respondent had basic computer knowledge since the questionnaires were online. The approach taken in using e-health services and website as the base to formulating the questionnaires  was from the findings of phase1. The data was collected by use of online questionnaires that consisted of 16 objective questions with multiple choices. They were formulated in a simple and comprehensive manner to the respondents understanding. The questionnaires were first tested by a pilot group of three people before exercising them on the respondents. The aim of testing the questionnaires on the pilot group was to increase its validity and reliability . The third phase focused on combining observations and usability tests that were conducted individually , . The two methods allowed the numerical calculations with an extension of the qualitative part of phase I. This aimed on contemplated phenomena in different perspectives, with a high reliability thus relevant and trustworthy. The criteria applied in the this phase was the relevancy of website in regard to healthcare related e-services, the frequency of visited website and the frequency of the e-health services used or searched. Data was collected through use of paper-based questionnaires and planned observations . A similar strategy of approaching the respondents was applied to the third phase as in the second phase. What differed on the approach in this phase was that usability tests were carried out on different sites. Consequently were respondents asked to answer a paper questionnaire after they had completed usability test. The key points were the user tests and the questionnaires. This was to measure user satisfaction in using of the e-health services thus the method based on openness towards the respondents. Further measurements of the respondent's usability were made whereby a comparison was made in relevance to different definitions of usability and users expectations. This explains how well the user expectations are fulfilled and the results achieved in integrating with the website , . 5. Results Since the study was divided into three different phases, it was considered appropriate to show the results in those three phases. The results from phase I, outlines health related e-health services within the municipality of Stockholm. The table shows an outline of those e-services that were found within the Stockholm municipality. The literature findings, showed the most used e-services and the websites that had the highest activity in relation to health related e-services that are there today. Consequently these findings were used as a base in the second phase thereby reflecting on the e-health services offered, by use of different functions. Table 1. Overview of the relevant e-health services and their functions FUNCTIONS Address and telephone number to healthcare centers Road map with guideline PURPOSE OF THE E-HEALTH SERVICE Practical information related to a health provider Health questions and health guidelines through the internet Follow-up of operation availability time and queuing period Films describing how examination and treatments are done Booking appointment with physicians on the internet Renewal of prescription Facts on diseases, injuries, examinations, treatment, medicine and dental care Links with more specific and relevant information on e-health services Order of certificate or healthcare equipment Healthcare updates and news Health related information Information related to a clinical intervention Self-booking service Self-management of treatment Health related information that are factual Guided external resources discovery Self-ordering Keeping the citizen updated The results from the second phase shows a summary of those health related services within the healthcare and the healthcare centers. There were 26 out of 30 requested respondents that answered the questionnaires. This was considered viable to evaluate the outcome of the collected data since the targeted populations´ response was 76% thus perceived eligible to base our evaluation on it. Out of the 26 respondents, the analyses show that 84.6% use telephone contact while 46.2% use healthcare center website and 3.9% e-mail. There was an overlap of those that use both the telephone and the internet e-health services. Table 2. Channels to communicate with healthcare providers. Type of communication channel for healthcare Website Automatic telephone services Telephone services E-mail Procent (number) 46.2% (12) 0.0% (0) 84.6%(22) 3.9%(1) In third phase a total of 12 respondents went through a usability test. The test was based on usability methods with the testers being around the respondents. They interacted with a website that was perceived to have the highest frequency of users in addition to the highest number of health related e-services. Besides the usability tests, the respondents were requested to answer 5 formulated questions with a scale of five. These questions were based on the usability interactions they had gone through. This included navigation, information retrieval, functionality and coherence of the terms among others. The figure below gives an illustration of the tasks in respect to the time used for each individual task and for respective respondents. The results indicate that most of the respondents took more time to complete the first task in respect to the second task. One can discern that some of the tasks were experienced to be more difficult than others. A correlation of the time taken to complete some task was observed in relation to the respondents´ computer background and familiarity to the website. Figure 1. Time spent for each task shown by participant. The average time taken to complete a task for respective respondents is shown in figure 2. It was observed that no respondent succeeded in completing the final task (task 5) within the allocated time frame. Some disappointments were observed and many of the respondents quit even before the allocated time had elapsed. One can contemplate that most of the respondents took time in the beginning of the task performance, and gradually became acquainted to the website. Nevertheless a lot of time was consumed and many steps were undergone in completing the last task. Figure 2. Average time needed by the participants to complete respective task. The figure below illustrates time used to answer the questions and the steps undergone to complete each task. The findings show no correlation between the time spent and the steps undergone to complete the whole task. One can observe that there was a pattern regarding time spent with an average of 20 minutes for the total performed tasks. The number of steps undertaken varied between 33 and 84 steps with time spent between 16 and 19 minutes respectively. It was ascertained that most respondents spent more time with the first two tasks and the last task too. Figure 3. Shows the time and steps needed each participant to complete the tasks After the usability tests, each respondent gave remarks on the website they hade interacted with. These included interoperability, functionality, and consistency, user friendly and general impression. Half of the respondents experienced the website to be average on it´ interoperability while one respondent experienced it to be inoperable. Its´ functionality was expressed as helpful by half of the respondents and unhelpful by others. The terminologies used were incoherent; this was experienced to be inconsistent by half of the respondents while the rest expressed it to be consistent. The majority of the respondents experienced the website to be user-unfriendly and it was consequently the general impression too. 6. Results and discussion The aim of this study was to survey the healthcare related e-services, thereby analyzing in which extension these e-health services were used in reflection to their usability and user friendly for the senior citizens. From the phase I results, one can contemplate that the most widely used e-health services within healthcare are; information, enlightening, booking of healthcare services and links to other web pages. A comprehensive usage of e-health services in the second phase denoted the types of communication channels for the health related e-services. This substantiated in which extension these services are used. The telephone services were highly used which can be expressed useful under emergency situation thereby contemplated to be simple and at hand. A large number of the senior citizens have time to stay on line thus consider it less complicated than the e-services. The senior citizens perceive telephone services to be friendly, since they get instant feed back unlike the e-services. Respondents use e-health services on the basis of getting fact on diseases, addresses and telephone numbers to healthcare centers. This shows that the senior citizens find it apparent to use e-health services in search of those services. Some of the respondents conceive e-health services as to be for the sick and thereby irrelevant as long as they are healthy. This showed that some respondents lacked the knowledge of the existences of e-services. This established a reason to carry out usability tests in the third phase with an aim of ascertaining on their use and usability. The results displayed no correlation between the time and number of stages used in performing the tests. The variation of time and the number of stages used by the respondents perceived to be the computer back ground. Another explanation can be that the respondent had visited this website before which he was well acquitted with. It was observed that those with high computer background used less time but many stages. This was due to the fact that they were unfamiliar with the website and its usability thereby attempting different ways of interacting with the website. This group revealed a pattern in the beginning of the test where more time was spent thereby showing unfamiliarity of the website. Those that had less computer background used both more time and many stages. It was evident that there was a difference between those that had more computer exposure and those that had less. Another difference was seen between those that had visited the website before and those that had not. This made it indisputable that in order to be able to quickly interact with this website, one needs to visit it many times. Apparently there was no respondent that was able to fulfill the last task in linking to another website. This opened a discussion on whether it was intentionally designed in order to keep the users on the website or was it a design problem. This concludes that the website was not comprehensive enough and raised questions on its usability and user-friendly. Methodological considerations There were both pros and cons to the method used in the first phase. It gave detailed knowledge as a comprehensive base to work from. But on the other hand the use of phrases and key words to search information may have limited the data collected. Although it was considered essential to make restrictions in order to avoid irrelevant data, it may have its consequences in missing data that might have been of considerable importance. With predetermined multiple choices gave the respondents limited options to chose from. In contrast to the open questions, the procedures took less time to process and analyze data. Based on the open questions that is more explorative gives results in broader perspective in comparison to multiple questions. A combination of both qualitative and quantitative methods used in this phase was considered to be appropriate in attaining to the results. The advantage of this limited study is that a more in-depth data collection has been completed, which is of an advantage to a pilot study. For more generalizable results, the study should be conducted in broader extent with a larger sample. 7. Conclusion From the results of this study, it was noted that many of the senior citizens prefer to use the telephone for their healthcare chore to the e-services. This can be due to the complexity of e-health services and the unwillingness to change the old habits or lack of need for healthcare related e-services. In comparison to other health related website, the website used in this study was observed to be more frequently visited. This can be due to the wide selection of information within one website. It is evident that many of the respondents prefer to have information at a glance and in a simplified form. The senior citizens do not optimize in the use of health related e-health services like they do with other websites. This can be due to the fact that they relate e-health services to diseases and thereby lacking the need. The study showed a difference on the test results which was due to computer background the respondents had. This gives a good reason in educating the senior citizens on IT. Another variation was noted between those that had visited the website and those that had not. This shows the need to design for all and make it user friendly thereby increase the usage of the e-health services among this group and optimize on information utilization. This in turn would lead to prevention of some diseases and enhance the welfare of this group. An offload of the healthcare sector would be considered positive with the senior citizens being self reliant on their well being. Out of the usability tests, we deduce that health related e-health services that we tested were relatively user friendly thereby many senior citizens would benefit from. There is apparently room for developments towards usability for future optimization of usage by all.
Bio-Algorithms and Med-Systems – de Gruyter
Published: Jan 1, 2012
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