Bridging the Digital Divide: The Impact Of Computer Training, Internet and Email Access On Levels of

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Bridging the Digital Divide The Impact Of
Computer Training, Internet and E-mail Access On
Levels of Cognition, Depression and Social
Functioning In Older Adults Residing In Long-Term
Care

• Brenda Hage, MSN, CRNP
• Assistant Professor, Nursing
• College Misericordia
• Dallas, PA

Funded by the US Administration on Aging
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Statement of Purpose

• This research project is focused on addressing
  the digital divide which separates older adults
  from technology. Computer training and access to
  the Internet and e-mail was provided for
  long-term care (LTC) residents aged 55 or
  greater.
• We examined the impact of this intervention on
  levels of social isolation, depression and
  cognition. Throughout this process, we sought to
  develop a cost-effective, replicable model of
  technology training for LTC residents.

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Background and Significance

• It is estimated that the number of Americans aged
  65 and older will reach 70 million with one in
  five persons aged 65 or above by the year 2005
  (Healthy Aging, 2003).
• The US has experienced an explosion in the
  diffusion of technology. Through an improved
  ability to communicate and get information and
  services via the Internet, individuals can access
  resources that can improve health and quality of
  life (Burdick Kwon, 2004).

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Computer Access

• The Internet offers the potential opportunity to
  provide enhanced social support and psychological
  well being (White et al., 1999).
• However, according to the Pew Internet the
  American Life Project, just 27 of those aged 60
  and over have access to computers at home or at
  work, while some 78 of those under the age of 30
  have the same access, (2000).

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The Digital Divide

• The Haves and the Have Nots.
• Ageism
• Stereotyping

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Quality of Life

• Though many institutionalized older adults lack
  computer or Internet access, research suggests
  that those who do experience a positive effect on
  their quality of life McConatha et al, 1994
  Malcom et al, 2001 White et al, 2002).

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Depression/ Loneliness

• White et al., found a trend toward improved
  psychological well-being and decreased loneliness
  with the implementation of a computer based
  intervention for older adults in a retirement
  community spanning independent living, assisted
  living and LTC (1999).

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Social Isolation

• Social isolation has been defined as being
  ..characterized by feelings of exclusion from
  the socio-cultural environment (McConatha, 2002,
  p.25). Many LTC residents experience reduced
  social contact when such contacts are reduced
  through retirement and death, and family and
  friends may no longer live nearby making contact
  difficult and expensive.

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Social Isolation

• The Internet has been cited as a means of
  overcoming barriers to social interaction for the
  elderly (Post, 1996 Kubeck et al., 1997White et
  al., 2002 Bradley Poppen, 2003).

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Social Isolation

• Others posit that use of technology to further
  privatize entertainment, obtain information, and
  conduct commercial transactions may decrease
  contacts with the outside world (Rathbone-McCuan
  Hashimi, 1982 Kraut et al., 1998).

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Social Isolation Technology

• In considering this paradox from the perspective
  of a LTC resident or the home bound individual in
  the community who may have limited opportunities
  for meaningful social interaction, use of
  technology and the Internet can offer a new means
  of reaching out to the world.

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Older Adults Computers

• Older adults are open to learning about computers
  (Czaja, 1996), however, they have been found to
  experience a decline in cognitive and processing
  abilities such as related computer task errors,
  and required longer time to perform on the
  computer (Kelley Charness, 1995 Czaja, 1996
  Morrell Echt, 1996 Rogers et al, 1996).

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Older Adults Computers

• Subjects success at initial computer training
  was the most important predictor of continued
  computer use in older adults using an electronic
  bulletin board (Kelley et al.,1999).
• Use of active, self-paced computer training
  programs appear to be the most successful for
  older adults (Charness et al., 1992 Czaja et
  al., 1986). A self-paced format was used with
  the ACTION Curriculum, a low literacy computer
  training curriculum developed by the Coalition of
  African, Asian European, and Latino Immigrants of
  Illinois available at
• http//www.caaelii.org/downloads.htm

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Research Questions

• What is the effect of the intervention on
  subjects levels of depression?
• What is the effect of the intervention on
  subjects levels of cognition?
• What is the effect of the intervention on
  subjects levels of social isolation?
• What is the effect of the intervention on
  subjects perceptions of their general health
  status (as measured by subscales of bodily pain,
  general health, vitality, and social
  functioning)?

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Theoretical Framework

• Research suggests that lack of information for
  cognitive processing, a structured living
  environment, lack of variation in environmental
  design, space restriction and decreased number of
  people encountered on a daily basis may results
  in decreased problems solving, thinking and
  memory (Langer, 1985).

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Theoretical Framework

• Seligman posited than an anti-depressant effect
  could be achieved by changing the environment of
  depressed individuals for the better and
  enhancing their sense of control (1991).
• A psycho-educational model was used to frame the
  study. This model addresses factors related to
  psychological well-being, learning , and
  cognition, by increasing opportunities for
  rewarding and pleasant day to day activities and
  decreasing unpleasant activities (Antonuccio,
  Lewisohn, Steinmetz, 1995).

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Hypotheses

• The following hypotheses are offered
• 1. Computer training, Internet and Email use will
  be associated with a decreased in depression
  levels in older adults in this study.
• 2. Computer training, Internet and Email use are
  associated with a change in cognition levels in
  older adults in this study.
• 3. Computer training, Internet and Email use are
  associated with a change in level of social
  functioning in older adults.

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Methodology

• Institutional Review Board approval was obtained
  from College Misericordia and approval was also
  obtained from the Department of Health, Division
  of Long-Term Care.
• Funding for the project was obtained from a grant
  by the US Administration on Aging.

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Methodology

• A quasi-experimental, pre-test/post-test design
  was used. The study population consisted of LTC
  residents aged 55 or older in two counties in
  northeastern Pennsylvania.
• Inclusion criteria included age gt 55 years a
  Mini-Mental State Exam (MMSE) (Folstein,
  Folstein, McHugh,1975) score of 24 or greater,
  the ability to read a computer screen either with
  or without magnification and ability to use an
  input device such as a track ball or mouse and
  computer or onscreen keyboard.

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Methodology

• Participants were recruited from three LTC
  facilities in two counties. Two of the
  facilities were for-profit, one was
  not-for-profit. A convenience sample was
  utilized.
• Informational meetings were held in each facility
  and residents who wished to participate completed
  an informed consent.
• Those meeting the inclusion criterion completed
  pre-testing.

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Sample

• 27 subjects were recruited
• 23 were enrolled
• 3 subjects were lost due to mortality and
  attrition
• 4 additional subjects were lost prior to
  pre-testing due to  early patient discharge after
  completion of short-term rehab and discharged
  prior to training
• Final n16

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Measures

• Measurement tools used included
• Mini-Mental State Exam (MMSE) (Folstein,
  Folstein, McHugh, 1975)
• Geriatric Depression Scale-Short Form (Yersavage,
  Brink, Rose et al, 1983)
• SF-36 Short-Form Survey (Ware, 1990).

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MMSE

• The Mini-Mental State Exam is a test of cognitive
  function and consists of two main parts, which
  assess orientation, memory, and attention with a
  maximum score possible of 30 (Folstein, Folstein
  McHugh, 1975).

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GDS

• The Geriatric Depression Scale-Short Form
  (GDS-SF) is a 15-item self-report measure
  composed of a yes/no format with good
  sensitivity and positive predictive values for
  diagnosing mild to moderate depression in older
  adults (Anderson, Michalak, Lam (2002).

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SF-36

• The Short Form Health Survey (SF-36) is composed
  of 36 questions and measures individuals
  self-reported perceptions about their physical
  and mental health. The tool is further subdivided
  into an eight-scale functional health profile to
  provide ..psychometrically-based physical and
  mental health summary measures and a
  preference-based health utility index (Ware,
  2002, p.1). The tool has been well validated in
  the literature.

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SF-36

• The following SF-36 subscales were used
• Bodily Pain
• General Health
• Vitality
• Social Functioning

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SF-36

• To avoid confounding data, subscales of Role-
  Emotional Mental Health were not used.
• Subscales of Physical Functioning, and
  Role-Physical were also eliminated secondary to
  their inappropriateness for LTC residents.

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Demographics

• Demographic information included age, gender,
  occupation before retirement, level of education,
  and whether subjects had prior experience with
  computers, the Internet or Email.

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Procedures

• Following pre-testing with the MMSE, GDS-SF and
  SF-36, subjects received computer training in
  three to five self-paced sessions with a trained
  research assistant. Tracking forms were used to
  capture time spent on the computer outside of
  training and types of computer activities
  performed.

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Technology SpecificationsHardware

• Technology specifications for hardware components
  included computers equipped with a 2.53 GHz
  Intel Celeron processor, 40 Gigabyte hard drive,
  256 megabytes of random access memory (RAM).
• Input device were Microsoft EZ Ball, Kensington
  Expert Four Button Trackball, Hewlett Packard
  optical mouse, Visi-Key enhanced visibility
  Internet keyboard ( QWERTY key layout) and Big
  Keys LX (QWERTY alpha key layout) keyboard input
  devices. Subjects also had the option to use a
  standard QWERTY keyboard and mouse.
• Output devices consisted of a 17 inch cathode
  ray tube (CRT) monitor and a networked color
  printer and speakers. Magnifier overlay screens
  were also used.

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Assistive Devices
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Software Components

• Senior Net IBM Web Accessibility Tool
• Windows XP home edition operating system with
  accessibility tool for enlargement of type, audio
  reader and graphics modifications
• Internet Explorer version 6.0 web browser
• Generations Online software application

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Generations Online (G-oL)

• The software features e-mail, ability to engage
  in inter-generational dialogue with elementary
  school children and a simplified search engine
  with colors and graphics that address human
  factors concerns of the older adult. G-oL is
  available for a nominal fee for those who
  administer services in areas providing congregate
  housing for the older adults. http//www.generatio
  nsonline.org
• Developed by Tobey Dichter.

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Generations Online
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Intergenerational Dialogue
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Email
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Search Engine
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Elder Focused Web Sites
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Instructional Materials Visual Reminders
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Gender
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Age
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Educational Level
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Occupation before retirement
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Used a computer before?
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Used Internet or email before?
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Assistive Devices
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Pre SF 36 Q1
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Pre SF 36 Q1
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Post SF 36 Q1
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Post SF 36 Q1
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Pre SF 36 Q2
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Pre SF 36 Q2
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Post SF 36 Q2
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Post SF 36 Q2
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Pre SF36 Q6
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Pre SF36 Q6
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Post SF 36 Q6
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Post SF 36 Q6
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Pre SF 36 Q7
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Pre SF 36 Q7
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Post SF 36 Q7
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Post SF 36 Q7
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Pre SF36 Q8
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Pre SF36 Q8
65
Post SF 36 8
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Post SF 36 8
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Recoded Pre-SF Q7 8- Bodily Pain Subscale
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Recoded Pre-SF Q7 8- Bodily Pain Subscale
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Recoded Post-SF Q7 8- Bodily Pain Subscale
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Recoded Post-SF Q7 8- Bodily Pain Subscale
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Assumptions Study Limitations

• Threats to validity
• Subjects had multiple co-morbidities with some
  experiencing a medical decline.
• GDS reliable for diagnosing mild to moderate
  depression but not for severe depression.
• Convenience sample
• Small n
• One of the study sites underwent a major
  remodeling project which limited subjects access
  to the computer.

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Next steps

• Hypothesis testing in progress.
• To remove skewness, data will be
• transformed using mathematical
• computation (square root, logarithmic or
• inverse transformation).

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Implications thus far

• We need to be concerned with the capabilities
  and limitations of people and use of this
  scientific knowledge about human behavior to
  specify design and use of a human-machine (or
  human-environment) system (Fisk et al., 2004). 
• Unfortunately, older adults have not been
  considered a major market factor in this design
  process.  This paradigm must shift to emphasize
  the importance of 'older adult friendly' design
  in order to meet the better meet the needs of our
  aging society. Manufacturers must be encouraged
  to produce these products in order to make 
  technology use a reality for older adults.

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Future research directions

• Examination of websites for senior friendly web
  design.
• NIA
• DOTTIE Guidelines
• AARP

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Questions..