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

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 .

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

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  1. 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

  2. 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. Property of Brenda Hage, MSN, CRNP. Do not reproduce or use without permission. 7/28/05

  3. 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). Property of Brenda Hage, MSN, CRNP. Do not reproduce or use without permission. 7/28/05

  4. 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). Property of Brenda Hage, MSN, CRNP. Do not reproduce or use without permission. 7/28/05

  5. The Digital Divide • The “Haves and the Have Nots”. • Ageism • Stereotyping Property of Brenda Hage, MSN, CRNP. Do not reproduce or use without permission. 7/28/05

  6. 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). Property of Brenda Hage, MSN, CRNP. Do not reproduce or use without permission. 7/28/05

  7. 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). Property of Brenda Hage, MSN, CRNP. Do not reproduce or use without permission. 7/28/05

  8. 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. Property of Brenda Hage, MSN, CRNP. Do not reproduce or use without permission. 7/28/05

  9. Social Isolation • The Internet has been cited as a means of overcoming barriers to social interaction for the elderly (Post, 1996; Kubeck et al., 1997;White et al., 2002; Bradley & Poppen, 2003). Property of Brenda Hage, MSN, CRNP. Do not reproduce or use without permission. 7/28/05

  10. 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). Property of Brenda Hage, MSN, CRNP. Do not reproduce or use without permission. 7/28/05

  11. 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. Property of Brenda Hage, MSN, CRNP. Do not reproduce or use without permission. 7/28/05

  12. 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). Property of Brenda Hage, MSN, CRNP. Do not reproduce or use without permission. 7/28/05

  13. 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 Property of Brenda Hage, MSN, CRNP. Do not reproduce or use without permission. 7/28/05

  14. 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)? Property of Brenda Hage, MSN, CRNP. Do not reproduce or use without permission. 7/28/05

  15. 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). Property of Brenda Hage, MSN, CRNP. Do not reproduce or use without permission. 7/28/05

  16. 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). Property of Brenda Hage, MSN, CRNP. Do not reproduce or use without permission. 7/28/05

  17. 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. Property of Brenda Hage, MSN, CRNP. Do not reproduce or use without permission. 7/28/05

  18. 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. Property of Brenda Hage, MSN, CRNP. Do not reproduce or use without permission. 7/28/05

  19. 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 > 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. Property of Brenda Hage, MSN, CRNP. Do not reproduce or use without permission. 7/28/05

  20. 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. Property of Brenda Hage, MSN, CRNP. Do not reproduce or use without permission. 7/28/05

  21. 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 n=16 Property of Brenda Hage, MSN, CRNP. Do not reproduce or use without permission. 7/28/05

  22. 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). Property of Brenda Hage, MSN, CRNP. Do not reproduce or use without permission. 7/28/05

  23. 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). Property of Brenda Hage, MSN, CRNP. Do not reproduce or use without permission. 7/28/05

  24. 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). Property of Brenda Hage, MSN, CRNP. Do not reproduce or use without permission. 7/28/05

  25. 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. Property of Brenda Hage, MSN, CRNP. Do not reproduce or use without permission. 7/28/05

  26. SF-36 • The following SF-36 subscales were used: • Bodily Pain • General Health • Vitality • Social Functioning Property of Brenda Hage, MSN, CRNP. Do not reproduce or use without permission. 7/28/05

  27. 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. Property of Brenda Hage, MSN, CRNP. Do not reproduce or use without permission. 7/28/05

  28. Demographics • Demographic information included age, gender, occupation before retirement, level of education, and whether subjects had prior experience with computers, the Internet or Email. Property of Brenda Hage, MSN, CRNP. Do not reproduce or use without permission. 7/28/05

  29. 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. Property of Brenda Hage, MSN, CRNP. Do not reproduce or use without permission. 7/28/05

  30. 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. Property of Brenda Hage, MSN, CRNP. Do not reproduce or use without permission. 7/28/05

  31. Assistive Devices Property of Brenda Hage, MSN, CRNP. Do not reproduce or use without permission. 7/28/05

  32. 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 Property of Brenda Hage, MSN, CRNP. Do not reproduce or use without permission. 7/28/05

  33. 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.generationsonline.org • Developed by Tobey Dichter. Property of Brenda Hage, MSN, CRNP. Do not reproduce or use without permission. 7/28/05

  34. Generations Online Property of Brenda Hage, MSN, CRNP. Do not reproduce or use without permission. 7/28/05

  35. Intergenerational Dialogue Property of Brenda Hage, MSN, CRNP. Do not reproduce or use without permission. 7/28/05

  36. Email Property of Brenda Hage, MSN, CRNP. Do not reproduce or use without permission. 7/28/05

  37. Search Engine Property of Brenda Hage, MSN, CRNP. Do not reproduce or use without permission. 7/28/05

  38. Elder Focused Web Sites Property of Brenda Hage, MSN, CRNP. Do not reproduce or use without permission. 7/28/05

  39. Instructional Materials & Visual Reminders Property of Brenda Hage, MSN, CRNP. Do not reproduce or use without permission. 7/28/05

  40. Gender Property of Brenda Hage, MSN, CRNP. Do not reproduce or use without permission. 7/28/05

  41. Age Property of Brenda Hage, MSN, CRNP. Do not reproduce or use without permission. 7/28/05

  42. Educational Level Property of Brenda Hage, MSN, CRNP. Do not reproduce or use without permission. 7/28/05

  43. Occupation before retirement Property of Brenda Hage, MSN, CRNP. Do not reproduce or use without permission. 7/28/05

  44. Used a computer before? Property of Brenda Hage, MSN, CRNP. Do not reproduce or use without permission. 7/28/05

  45. Used Internet or email before? Property of Brenda Hage, MSN, CRNP. Do not reproduce or use without permission. 7/28/05

  46. Assistive Devices Property of Brenda Hage, MSN, CRNP. Do not reproduce or use without permission. 7/28/05

  47. Pre SF 36 Q#1 Property of Brenda Hage, MSN, CRNP. Do not reproduce or use without permission. 7/28/05

  48. Pre SF 36 Q#1 Property of Brenda Hage, MSN, CRNP. Do not reproduce or use without permission. 7/28/05

  49. Post SF 36 Q#1 Property of Brenda Hage, MSN, CRNP. Do not reproduce or use without permission. 7/28/05

  50. Post SF 36 Q#1 Property of Brenda Hage, MSN, CRNP. Do not reproduce or use without permission. 7/28/05

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