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Journal of Evaluation in Clinical Practice ISSN 1365-2753
Public knowledge and perceptions of connected health Paul J. Barr MSc PhD,1* Shauna C. Brady MPharm,2 Carmel M. Hughes BSc PhD MRPharmS MPSNI3 and James C. McElnay BSc PhD FPSNI FRPharmS FACCP FBPharmacolS3 1
Research Fellow, 2Undergraduate Pharmacy Student, 3Professor, School of Pharmacy, Queen’s University Belfast, UK
Keywords health care surveys, health knowledge attitudes, practice, telemedicine Correspondence Professor James C. McElnay Clinical and Practice Research Group School of Pharmacy Queen’s University Belfast Belfast, Northern Ireland BT9 7BL UK E-mail: [email protected] * Present address: The Dartmouth Center, Hinman Box 7256, 37 Dewey Field Road, 4th Floor, Hanover, NH 03755, USA. Accepted for publication: 6 February 2014 doi:10.1111/jep.12118
Abstract Rationale, aims and objectives This study aims to examine the public’s knowledge and perceptions of connected health (CH). Methods A structured questionnaire was administered by face-to-face interview to an opportunistic sample of 1003 members of the public in 11 shopping centres across Northern Ireland (NI). Topics included public knowledge of CH, opinions about who should provide CH and views about the use of computers in health care. Multivariable analyses were conducted to assess respondents’ willingness to use CH in the future. Results Sixty-seven per cent of respondents were female, 31% were less than 30 years old and 22% were over 60 years. Most respondents had never heard of CH (92%). Following a standard definition, the majority felt CH was a good idea (≈90%) and that general practitioners were in the best position to provide CH; however, respondents were equivocal about reductions in health care professionals’ workload and had some concerns about the ease of device use. Factors positively influencing willingness to use CH in the future included knowledge of someone who has a chronic disease, residence in NI since birth and less concern about the use of information technology (IT) in health care. Those over 60 years old or who felt threatened by the use of IT to store personal health information were less willing to use CH in the future. Conclusion Increased public awareness and education about CH is required to alleviate concerns and increase the acceptability of this type of care.
Introduction The population of the world is ageing, which has been associated with the increased prevalence of chronic conditions such as cardiovascular disease and diabetes [1,2]. Coupled with improved life expectancy and projected shortages in health care staff, a significant strain will be placed on health care resources in the future [1,3–7]. The new challenges come at a time when worldwide health care costs are soaring and initiatives to reduce spending are being implemented [8,9]. Connected health (CH), a form of telemedicine, has been proposed as a way of partially alleviating these pressures. In CH, patients with chronic medical conditions are remotely monitored through the use of home medical devices, working in partnership with health professionals promoting selfmanagement/self-care of disease [10]. For example, patients with hypertension can use a home blood pressure monitor, the results of which can be automatically forwarded on to a health professional via the Internet. 246
Public awareness of, and opinion on, CH are unclear. Previous public surveys in the United States and Canada have highlighted a lack of awareness of telemedicine as only a minority (8.9–18.2%) of those surveyed were familiar with telemedicine [11–13]. Yet once explained, approximately 50% of those surveyed indicated that they would be willing to use telemedicine services as they could improve access to health services and quality of care, while potentially reducing health care expenditure [12]. Gagnon et al. also reported that those most willing to use telemedicine had knowledge of its applications, recognized its benefits, perceived fewer barriers associated with telemedicine and were more likely to be female [12]. Katz and Rice investigated the views of the public towards mobile health care technology, such as monitoring blood pressure through radio frequency identification devices [11]. They found that people who had strong interpersonal social support, higher levels of trust, higher levels of concern around privacy and those from a non-white ethnicity were more interested in using these services.
Journal of Evaluation in Clinical Practice 20 (2014) 246–254 © 2014 John Wiley & Sons, Ltd.
P.J. Barr et al.
However, the public are less likely to request or accept CH if they are unaware of its availability and health care providers are unaware of the public’s views and expectations regarding CH [14]. Furthermore, there have been few studies that have investigated the role of the pharmacist in CH provision, despite their widespread distribution in the community [10]. It has been argued that the community pharmacist could act as the ‘hub’ for CH provision [15].
Aim The main aim of the study was to gain a better understanding of the knowledge and perceptions of CH within the general public, in Northern Ireland (NI); as such, a survey was deemed the most appropriate research method. This is pertinent given the introduction of CH in NI for approximately 20 000 patients at the time the study was undertaken [16]. The objectives of the study were fourfold: (1) to assess the public’s knowledge about, and perceptions of, CH; (2) to identify the public’s preferred provider of CH and in particular to explore their views on the role of the pharmacist in CH provision; (3) to assess views of members of the public on the perceived benefits and concerns related to CH; and (4) to explore factors related to willingness to use connected health technology.
Methods Participants The study population chosen for the survey was an opportunistic sample of the general public in NI. Data were collected in shopping centres across NI via a face-to-face, intervieweradministered, structured questionnaire. People aged 18 years or older and who had lived in NI for 2 years or more were included in the study. A total sample size of 1000 participants was targeted, which provided a 95% probability of estimating the true public opinion to within ±3% (a confidence interval width of 6%). The survey was conducted in 11 shopping centres in provincial towns and cities across the region from January to August 2011. Shopping centre managers were contacted prior to the commencement of the study in order to gain their approval. Four interviewers were trained in the administration of the survey, with a maximum of two interviewers attending a particular shopping centre at any one time. Each centre was visited on at least two occasions and a minimum of 40 surveys was administered per centre. Ethical approval for the survey was granted from the Ethics Committee, School of Pharmacy, Queen’s University Belfast (QUB).
Questionnaire The questionnaire was developed by the research team taking account of previous surveys investigating public knowledge and views of telemedicine [11,12,14] and surveys previously conducted on health care-related issues in NI [17,18]. Colleagues within the School of Pharmacy reviewed the questionnaire for face validity. The survey instrument was piloted with students and staff from QUB (n = 20), after which the survey instrument was further refined to produce the final version, with a total of 27 items. The survey took approximately 15 minutes to complete and consisted of seven main sections:
© 2014 John Wiley & Sons, Ltd.
Public views on connected health
1 prior knowledge of CH or related terms; 2 views on the potential providers and recipients of CH; 3 perceived benefits and concerns related to CH; 4 individual views of the use of computers in health care to store personal information; 5 the potential role of the community pharmacist in CH provision; 6 respondents’ medical history, demographics and experience of medical and information technology (IT) devices; and 7 willingness to use or recommend CH services The majority of responses were binary, yes or no, or on a Likert scale.
Data collection Members of the general public were approached in the shopping centres and, if they met the inclusion criteria, were asked whether they would like to take part in a survey about health care. They were asked if they had heard of CH or related terms (which included telehealth, telemedicine, telemonitoring and telecare). Following this, to help ensure consistency in understanding across the survey population, each participant was given the definition of CH (Fig. 1); their views of CH were assessed throughout the remainder of the survey. No reference was made to the School of Pharmacy during the interviews to reduce the possibility of response bias. Participation was voluntary and all participants were informed that information would be dealt with anonymously, remain confidential and be used for research purposes only. Consent was implied if the member of the public agreed to participate in the interview; this approach was viewed as being acceptable in previous studies carried out by members of the research team [17].
Data analysis Descriptive analyses were conducted for all key variables, which included demographic information, prior experience with health care technology and current views of the use of computers in health care (Tables 1 & 2). Parametric and non-parametric testing, as appropriate, were also conducted between the main outcome of interest (participant’s willingness to use CH if he or she currently suffer, or in the future suffered, from a long-term health condition) and the key variables. Multiple logistic regression analyses were conducted to identify factors associated with the main outcome. The response was categorized as 0, ‘no/not sure’, or 1, ‘yes’. A further analysis was conducted with the outcome ‘would you be happy for community pharmacists to be involved in the provision of a CH service’. Robust standard errors for estimates were used to account for clustering of respondents’ characteristics within the different recruitment sites [19]. All analyses were conducted using the STATA 11.2® statistical package [20] and significance was set a priori at P < 0.05.
Results A total of 1003 people were interviewed; however, incomplete surveys were recorded for 12 of these respondents, who, due to lack of time, did not complete the interview. Approximately 33% of those interviewed were male (n = 326), 30.5% of participants were aged 18–30 years old (n = 304), 247
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Table 2 Characteristics of respondents*
Table 1 Characteristics of respondents* Item Demographics Sex Male Female Age (years) 18–30 31–40 41–50 51–60 >60
N
N%
326 672
32.7% 67.3%
304 140 168 165 221
30.5% 14.0% 16.8% 16.5% 22.1%
Education Primary/Secondary Tertiary (University) National Statistics Socio-Economic Classifications† Managerial/professional Intermediate occupations Routine and manual occupations Unemployed Student Retired
573 418
57.8% 42.2%
56 305 209 77 96 215
7.1% 38.7% 26.5% 9.8% 12.2% 21.4%
Live alone? Yes No
185 813
18.5% 81.5%
Lived in NI entire life? Yes No
890 106
89.4% 10.6%
Do you suffer from a medical condition? Yes No
466 528
46.9% 53.1%
Have you ever used a home medical device Yes No
319 677
32.0% 68.0%
If yes: type of home medical device (n = 319) BP Glucose monitor
208 92
65.2% 28.8%
Do you know someone who suffers from a medical condition? Yes No
849 146
85.3% 14.7%
*Some cells do not match total due to uncompleted survey items. † National Statistics Socio-Economic Classifications. BP, blood pressure; NI, Northern Ireland.
whereas 22.1% were over 60 years old (n = 221), with the remainder evenly distributed across the other age categories (Table 1). The majority of respondents (85.3%) knew, or had known well, someone who suffered from a chronic medical condition and over half of the respondents themselves suffered from a medical condition that required the use of medication. The majority of the sample reported having access to computers (83.7%), the Internet (79.4%) and mobile phones (87.8%), of which 39% were defined as smart phones (Table 2). Fewer respondents over 60 years of age had Internet access (49.8%) in comparison to those less than 30 years of age (95.1%) and 30–60 years of age (83.9%). 248
Use of home technology Do you use any of the following technology at home? Computer Internet Mobile phone Games console Use of computers in health car The storage of personal information on computers of health care professionals is a threat to personal privacy Agree Neither agree or disagree Disagree Health care providers ask for too much personal information Agree Neither agree or disagree Disagree People should have more control over the personal information held on computer health records Agree Neither agree or disagree Disagree
N
N%
840 796 881 334
83.7% 79.4% 87.8% 33.3%
262 126 610
26.3% 12.6% 61.1%
144 122 732
14.4% 12.2% 73.4%
529 153 316
53.0% 15.3% 31.7%
*Some cells do not match total due to uncompleted survey items.
The majority of respondents had never heard of CH (n = 924, 92.1%), or any of the related terms, prior to the survey. However, following the provision of a definition of CH (Fig. 1), 89.1% of respondents’ felt that it was a ‘very good idea’ or ‘good idea’ to monitor health ‘from information sent by a patient from their home’. In addition, 91.9% of those surveyed felt it was a very good or good idea to alert patients about potential health problems.
Provision of CH Participants believed that CH could be very helpful or helpful for people with diabetes (95.3%), heart disease (94.8%) and asthma (88.4%). However, participants were equivocal as to whether this service would be helpful for patients with dementia or Alzheimer’s disease (52.6%); a number of participants suggested that the latter would only be appropriate if a carer was available to assist. Other conditions suggested by respondents for which CH could possibly be used included cancer, cystic fibrosis, mental illness, epilepsy, renal disease, multiple sclerosis, stroke, thyroid conditions and blindness. In addition, some people mentioned the potential use of CH during pregnancy. The majority of participants (n = 808; 80.6%) felt that within a CH service, if a concern about the patient’s condition was raised, for example, via home monitoring, the health professional could send an alert to the patient about their condition via the Internet or mobile phone (or both). The remaining respondents (n = 194; 19.4%) preferred a mix of landline calls, face-to-face visits or mailing feedback to patients. Of those respondents who reported having a medical condition themselves, 25% would prefer a means of contact other than the Internet or mobile phone, compared to only 15% of respondents without a current medical condition (P < 0.001). © 2014 John Wiley & Sons, Ltd.
P.J. Barr et al.
Public views on connected health
Connected health can be described as a way of connecting a person with a long term-illness, for example, high blood pressure, diabetes or asthma, from their own home to the health professional (doctor, pharmacist or nurse) looking after them. This involves people regularly monitoring their illness (e.g., daily) from their own home using a medical device, for example, a blood pressure or blood sugar monitor. This information is then sent to their health professional automatically, for example, through the Internet or via the mobile phone network. If the person’s condition begins to get worse, the health professional can be automatically sent an alert and they can then contact the patient to recommend a course of action, for example, a change in medication. Just to repeat – a person uses a device in their own home to monitor control of their illness, the results go directly to a health care professional’s computer, via the Internet or mobile phone network. The healthcare professional can offer advice as required. In other words, the patient is connected in to the health care system – hence the term Connected Health. Figure 1 Definition of connected health as used during the face-to-face interview.
In terms of who would be in the best position to provide a CH service, participants were asked to rank health professionals from 1 (best position), to 5 (worst position). General practitioners were considered to be in the best position to provide the service, with a mean rank of 1.6 [standard deviation (SD) 0.9] (ranked first 627 times), followed by nurses, 2.7 (SD 1.2) (ranked first 115 times), hospital doctors, 3.0 (SD 1.2) (ranked first 83 times), community pharmacists, 3.25 (SD 1.3) (ranked first 83 times), and hospital pharmacists, 4.32 (SD 0.91) (ranked first 11 times). When asked why they felt their chosen health professional was in the best position, several themes emerged, the most common of which were as follows: familiar with the patient history (40%), health professional was appropriately educated/trained (11.9%), better access to the chosen health professional (9.9%), they would have more time to deliver the CH service (8.6%) and are community-based (7.4%).
Benefits of and concerns about CH The interviewees were provided with a number of statements and asked to indicate their opinion about the potential benefits and concerns that could arise with CH. Overall, respondents agreed with the range of possible advantages of CH (Fig. 2), although respondents were more equivocal regarding the potential of CH to reduce health care professionals’ workload (59.2% strongly agreed/agreed). In terms of perceived concerns, the responses were more variable. The respondents appeared to be most concerned about devices being difficult to use (Fig. 3). Interestingly, older respondents (over 60 years) seemed less concerned regarding difficulty of device use (5% very concerned) compared to other age groups, for example, less than 30 years (11.2%) and 30–60 years (11.3%),
© 2014 John Wiley & Sons, Ltd.
P < 0.001. Respondents who reported suffering from a medical condition compared to those who did not, and those who had received only primary or secondary education versus tertiary education, were also less likely to be ‘very concerned’ regarding difficulty of device use (6.7% versus 12.1%, P < 0.001; 6.5% versus 13.7%, P = 0.003, respectively). Overall, the respondents were much less concerned with the potential reduction in face-toface contact between patients and health providers and the possible inconvenience to patients of using a remote monitoring device (Fig. 3). In addition, most respondents did not feel that storage of personal information on the computers of health care professionals threatened their privacy (61.1%) and did not feel that health professionals asked for too much personal information (73.4%) (Table 2).
The pharmacist Approximately 55% of those who responded visited the community pharmacist on a weekly or monthly basis. Respondents were asked about the potential role of the community pharmacist in the provision of CH. A high percentage of respondents strongly agreed/agreed that it would be beneficial if the community pharmacist could check whether patients had taken their medication (86.5%) and remind patients (e.g. text message) to take the medication (88%), via the use of a CH service. However, only 53.4% of respondents strongly agreed/agreed with the pharmacist making an adjustment to patient medication in response to information sent. In general, however, respondents believed that the community pharmacists could help with the provision of a CH service (94.6%) and were happy for them to do so (93.4%). A multiple logistic regression analysis was conducted, where each variable was analysed while controlling for the effect of all 249
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Figure 2 Perceived benefits regarding connected health.
Figure 3 Perceived concerns regarding connected health.
other variables. Female respondents, compared to male respondents [odds ratio (OR) 2.30; 95% confidence interval (CI) 1.44– 3.65; P < 0.01], respondents who disagreed with the statement that health professionals ask for too much personal information, compared to those who did not (OR 2.53; 95% CI 1.57–4.08; P < 0.01) and those who received primary or secondary education, compared to those who had a tertiary education (OR 2.15; 95% CI 1.22–3.82; P = 0.01) were all more than twice as likely to be ‘happy’ for the community pharmacists involvement in the provision of CH.
Who would use CH? Upon survey completion, 91.8% strongly agreed or agreed that CH was a ‘good idea’, 87.2% indicated that they would be willing to 250
use CH services if they currently suffered from or developed a long-term health condition and 86.1% would recommend CH to a family member or friend with a long-term health condition (Table 3). Logistic regression analyses were conducted to identify the key characteristics of respondents who expressed a willingness to use CH, if they had, or were to develop, a long-term health condition (Table 4). Following an unadjusted analysis, an analysis was conducted to identify the independent relationship of each variable with willingness to use CH in the future, adjusted for all other variables in Table 4. The respondents who expressed most willingness to use CH in the future were those resident in NI their entire lives (OR 2.40; 95% CI 1.45–4.00; P < 0.01); those with family or friends who had a chronic disease (OR 2.25; 95% CI 1.48–3.41;
© 2014 John Wiley & Sons, Ltd.
P.J. Barr et al.
Public views on connected health
Table 3 Views of connected health Would you use connected health in the future if you developed a chronic disease? Yes No Don’t know Would you recommend connected health to family or friends if they developed a chronic disease? Yes No Don’t know Do you think connected health is a good idea? Yes No Don’t know
865 48 79
87.2% 4.8% 8.0%
858 28 110
86.1% 2.8% 11.0%
913 28 54
91.8% 2.8% 5.4%
P < 0.01), respondents who disagreed that the storage of personal information on the computers of health professionals was a threat to personal privacy (OR 1.92; 95% CI 1.65–4.93; P < 0.01), disagreed that health professionals asked for too much personal information (OR 2.85; 95% CI 1.65–4.93; P < 0.01) and who agreed that patients should be allowed more control over medical records (OR 2.01; 95% CI 1.07–3.76; P = 0.03). In comparison, people aged over 60 years (OR 0.51; 95% CI 0.29–0.90; P = 0.02) and those who agreed that IT in health care was a threat to personal privacy (OR 0.50; 95% CI 0.30–0.85; P = 0.01) were less willing to support the CH approach.
Discussion The majority of the public had never heard of CH, similar to survey findings in North America [11,12]. However, most respondents provided positive views of CH following an explanation of the approach. The actual proportion supporting the concept of CH was much larger in NI, that is, almost 90% indicated that they would be prepared to use CH, when compared with approximately 50% of those surveyed regarding telemedicine in Quebec, Canada [12]. Lack of awareness has been identified as a barrier to implementation of telemedicine [14]. The higher levels of acceptance of CH in NI may be a temporal effect, as the survey in Quebec was conducted almost a decade ago. IT is much more integrated in today’s society, for instance, the proportion of people in the UK with access to the Internet has steadily increased from 61% in 2007 to 77% in 2011, similar to the levels reported in the current project, 79.4% [21]. Respondents felt that GPs were in the best position to provide CH. Given the GP’s role as the main gatekeeper to hospital services in the UK, this is not surprising. The primary reason behind the choice was the GP’s familiarity with the patient and their condition, lending support to the belief that trust and a good rapport with a health professional can facilitate the uptake of CH [22]. The greatest perceived benefit of CH was its potential to make patients feel more secure at home, a finding common across other studies, particularly when the monitoring is conducted by a trusted health care professional [22,23]. It had been suggested that patient concern regarding reduced face-to-face contact with a health care
© 2014 John Wiley & Sons, Ltd.
provider could be a major barrier to the implementation of remote monitoring technologies [24]. However, this was not a major cause of concern among the current respondents. Respondents were less certain about the potential of CH to reduce the workload on health professionals. In a recent systematic review of barriers and facilitators to telemedicine implementation, 11 studies identified telemedicine as time saving compared to 30 studies where it was perceived as time consuming or as increasing the workload for the health professional [25]. Particular concerns have been raised about the loss of treatment time due to the initial implementation and learning phases of new IT and telemedicine programmes in health care [25–28]. The review also highlighted ease of use as a major barrier to the introduction of telemedicine and IT technologies in health, that is, similar to the current study [25]. Privacy and confidentiality of information were also common concerns. However, they have been viewed as both facilitators and barriers to CH implementation [25]. Some consider remote patient monitoring as a protector of privacy by allowing people to be monitored from home, therefore offering patients more independence, while others argue that it impinges upon individual privacy and are opposed to providing personal information over the Internet [11,22].
CH and the pharmacist Community pharmacists are the most frequently contacted health professionals in the UK and the results of the current survey indicated public support for their involvement in CH provision [29]. Some contend that the community pharmacist could act as the ‘hub’ for a CH service [15]. Such integration of services provided by different health professionals could help with the successful implementation of CH [23]. Interestingly, females (compared to males) and respondents with primary or secondary education (compared to tertiary) were happier for the pharmacist to be involved in the provision of CH, and upon further analysis, it was shown that both groups visited the pharmacist more often than their comparators. This reinforces the importance of patient familiarity with the health professional providing CH services [22].
Willingness to use CH In comparison to younger age groups, those aged over 60 years expressed less willingness to use CH in the future. Respondents over 60 years were also less likely to have Internet access (49.8%); however, access among respondents was higher than official figures of those aged 65 or older in the UK (40%) and the United States (41.5%) [30,31]. Previous studies have suggested that older people may find the use of IT-related technology both complicated and confusing, leading to low self-efficacy in terms of utilizing a new technology [32,33]. However, Irizarry et al. believed that this is simply a ‘transitional issue’ as IT has become integrated in the home, work place and educational settings in recent years [34]. Lack of training of older adults in the use of IT has been identified as a key barrier to the implementation of IT devices and it is therefore important that CH devices are user-friendly, particularly for older patients who may have less experience with IT [35,36]. Knowing someone with a chronic disease was associated with an increased willingness to use CH in the future. This observation 251
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Table 4 Factors influencing the willingness to use connected health in the future* Variable
Unadjusted odds ratio (95% CI)
P-value
Adjusted odds ratio (95% CI)
P-value
Demographic Male (%) Female
Gender (Reference: Male) 0.91 (0.64–1.29)
0.58
0.86 (0.60–1.24)
0.43
Age (Reference: 60 years
1.06 (0.66–1.72) 1.03 (0.68–1.56)
0.81 0.88
0.89 (0.43–1.84) 0.51 (0.29–0.90)
0.76 0.02
Education (Reference: Primary/secondary) Tertiary
0.85 (0.55–1.30)
0.44
0.81 (0.47–1.41)
0.46
Socio-economic classification (Reference: Intermediate) Professional/managerial 0.80 (0.44–1.44) Routine/manual 0.67 (0.46–0.95) Student 1.68 (0.77–3.67) Unemployed (not including retired) 3.77 (0.54–26.3) Retired 1.40 (0.80–2.44)
0.45 0.03 0.19 0.18 0.24
0.70 0.83 1.35 3.40 2.33
(0.34–1.44) (0.59–1.17) (0.49–3.70) (0.41–28.0) (0.86–6.31)
0.34 0.28 0.56 0.25 0.10
Live alone (Reference: No) Yes
0.73 (0.52–1.03)
0.08
0.73 (0.52–1.02)
0.06
Live in NI entire life (Reference: No) Yes
2.25 (1.4–3.38)
Journal of Evaluation in Clinical Practice ISSN 1365-2753
Public knowledge and perceptions of connected health Paul J. Barr MSc PhD,1* Shauna C. Brady MPharm,2 Carmel M. Hughes BSc PhD MRPharmS MPSNI3 and James C. McElnay BSc PhD FPSNI FRPharmS FACCP FBPharmacolS3 1
Research Fellow, 2Undergraduate Pharmacy Student, 3Professor, School of Pharmacy, Queen’s University Belfast, UK
Keywords health care surveys, health knowledge attitudes, practice, telemedicine Correspondence Professor James C. McElnay Clinical and Practice Research Group School of Pharmacy Queen’s University Belfast Belfast, Northern Ireland BT9 7BL UK E-mail: [email protected] * Present address: The Dartmouth Center, Hinman Box 7256, 37 Dewey Field Road, 4th Floor, Hanover, NH 03755, USA. Accepted for publication: 6 February 2014 doi:10.1111/jep.12118
Abstract Rationale, aims and objectives This study aims to examine the public’s knowledge and perceptions of connected health (CH). Methods A structured questionnaire was administered by face-to-face interview to an opportunistic sample of 1003 members of the public in 11 shopping centres across Northern Ireland (NI). Topics included public knowledge of CH, opinions about who should provide CH and views about the use of computers in health care. Multivariable analyses were conducted to assess respondents’ willingness to use CH in the future. Results Sixty-seven per cent of respondents were female, 31% were less than 30 years old and 22% were over 60 years. Most respondents had never heard of CH (92%). Following a standard definition, the majority felt CH was a good idea (≈90%) and that general practitioners were in the best position to provide CH; however, respondents were equivocal about reductions in health care professionals’ workload and had some concerns about the ease of device use. Factors positively influencing willingness to use CH in the future included knowledge of someone who has a chronic disease, residence in NI since birth and less concern about the use of information technology (IT) in health care. Those over 60 years old or who felt threatened by the use of IT to store personal health information were less willing to use CH in the future. Conclusion Increased public awareness and education about CH is required to alleviate concerns and increase the acceptability of this type of care.
Introduction The population of the world is ageing, which has been associated with the increased prevalence of chronic conditions such as cardiovascular disease and diabetes [1,2]. Coupled with improved life expectancy and projected shortages in health care staff, a significant strain will be placed on health care resources in the future [1,3–7]. The new challenges come at a time when worldwide health care costs are soaring and initiatives to reduce spending are being implemented [8,9]. Connected health (CH), a form of telemedicine, has been proposed as a way of partially alleviating these pressures. In CH, patients with chronic medical conditions are remotely monitored through the use of home medical devices, working in partnership with health professionals promoting selfmanagement/self-care of disease [10]. For example, patients with hypertension can use a home blood pressure monitor, the results of which can be automatically forwarded on to a health professional via the Internet. 246
Public awareness of, and opinion on, CH are unclear. Previous public surveys in the United States and Canada have highlighted a lack of awareness of telemedicine as only a minority (8.9–18.2%) of those surveyed were familiar with telemedicine [11–13]. Yet once explained, approximately 50% of those surveyed indicated that they would be willing to use telemedicine services as they could improve access to health services and quality of care, while potentially reducing health care expenditure [12]. Gagnon et al. also reported that those most willing to use telemedicine had knowledge of its applications, recognized its benefits, perceived fewer barriers associated with telemedicine and were more likely to be female [12]. Katz and Rice investigated the views of the public towards mobile health care technology, such as monitoring blood pressure through radio frequency identification devices [11]. They found that people who had strong interpersonal social support, higher levels of trust, higher levels of concern around privacy and those from a non-white ethnicity were more interested in using these services.
Journal of Evaluation in Clinical Practice 20 (2014) 246–254 © 2014 John Wiley & Sons, Ltd.
P.J. Barr et al.
However, the public are less likely to request or accept CH if they are unaware of its availability and health care providers are unaware of the public’s views and expectations regarding CH [14]. Furthermore, there have been few studies that have investigated the role of the pharmacist in CH provision, despite their widespread distribution in the community [10]. It has been argued that the community pharmacist could act as the ‘hub’ for CH provision [15].
Aim The main aim of the study was to gain a better understanding of the knowledge and perceptions of CH within the general public, in Northern Ireland (NI); as such, a survey was deemed the most appropriate research method. This is pertinent given the introduction of CH in NI for approximately 20 000 patients at the time the study was undertaken [16]. The objectives of the study were fourfold: (1) to assess the public’s knowledge about, and perceptions of, CH; (2) to identify the public’s preferred provider of CH and in particular to explore their views on the role of the pharmacist in CH provision; (3) to assess views of members of the public on the perceived benefits and concerns related to CH; and (4) to explore factors related to willingness to use connected health technology.
Methods Participants The study population chosen for the survey was an opportunistic sample of the general public in NI. Data were collected in shopping centres across NI via a face-to-face, intervieweradministered, structured questionnaire. People aged 18 years or older and who had lived in NI for 2 years or more were included in the study. A total sample size of 1000 participants was targeted, which provided a 95% probability of estimating the true public opinion to within ±3% (a confidence interval width of 6%). The survey was conducted in 11 shopping centres in provincial towns and cities across the region from January to August 2011. Shopping centre managers were contacted prior to the commencement of the study in order to gain their approval. Four interviewers were trained in the administration of the survey, with a maximum of two interviewers attending a particular shopping centre at any one time. Each centre was visited on at least two occasions and a minimum of 40 surveys was administered per centre. Ethical approval for the survey was granted from the Ethics Committee, School of Pharmacy, Queen’s University Belfast (QUB).
Questionnaire The questionnaire was developed by the research team taking account of previous surveys investigating public knowledge and views of telemedicine [11,12,14] and surveys previously conducted on health care-related issues in NI [17,18]. Colleagues within the School of Pharmacy reviewed the questionnaire for face validity. The survey instrument was piloted with students and staff from QUB (n = 20), after which the survey instrument was further refined to produce the final version, with a total of 27 items. The survey took approximately 15 minutes to complete and consisted of seven main sections:
© 2014 John Wiley & Sons, Ltd.
Public views on connected health
1 prior knowledge of CH or related terms; 2 views on the potential providers and recipients of CH; 3 perceived benefits and concerns related to CH; 4 individual views of the use of computers in health care to store personal information; 5 the potential role of the community pharmacist in CH provision; 6 respondents’ medical history, demographics and experience of medical and information technology (IT) devices; and 7 willingness to use or recommend CH services The majority of responses were binary, yes or no, or on a Likert scale.
Data collection Members of the general public were approached in the shopping centres and, if they met the inclusion criteria, were asked whether they would like to take part in a survey about health care. They were asked if they had heard of CH or related terms (which included telehealth, telemedicine, telemonitoring and telecare). Following this, to help ensure consistency in understanding across the survey population, each participant was given the definition of CH (Fig. 1); their views of CH were assessed throughout the remainder of the survey. No reference was made to the School of Pharmacy during the interviews to reduce the possibility of response bias. Participation was voluntary and all participants were informed that information would be dealt with anonymously, remain confidential and be used for research purposes only. Consent was implied if the member of the public agreed to participate in the interview; this approach was viewed as being acceptable in previous studies carried out by members of the research team [17].
Data analysis Descriptive analyses were conducted for all key variables, which included demographic information, prior experience with health care technology and current views of the use of computers in health care (Tables 1 & 2). Parametric and non-parametric testing, as appropriate, were also conducted between the main outcome of interest (participant’s willingness to use CH if he or she currently suffer, or in the future suffered, from a long-term health condition) and the key variables. Multiple logistic regression analyses were conducted to identify factors associated with the main outcome. The response was categorized as 0, ‘no/not sure’, or 1, ‘yes’. A further analysis was conducted with the outcome ‘would you be happy for community pharmacists to be involved in the provision of a CH service’. Robust standard errors for estimates were used to account for clustering of respondents’ characteristics within the different recruitment sites [19]. All analyses were conducted using the STATA 11.2® statistical package [20] and significance was set a priori at P < 0.05.
Results A total of 1003 people were interviewed; however, incomplete surveys were recorded for 12 of these respondents, who, due to lack of time, did not complete the interview. Approximately 33% of those interviewed were male (n = 326), 30.5% of participants were aged 18–30 years old (n = 304), 247
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Table 2 Characteristics of respondents*
Table 1 Characteristics of respondents* Item Demographics Sex Male Female Age (years) 18–30 31–40 41–50 51–60 >60
N
N%
326 672
32.7% 67.3%
304 140 168 165 221
30.5% 14.0% 16.8% 16.5% 22.1%
Education Primary/Secondary Tertiary (University) National Statistics Socio-Economic Classifications† Managerial/professional Intermediate occupations Routine and manual occupations Unemployed Student Retired
573 418
57.8% 42.2%
56 305 209 77 96 215
7.1% 38.7% 26.5% 9.8% 12.2% 21.4%
Live alone? Yes No
185 813
18.5% 81.5%
Lived in NI entire life? Yes No
890 106
89.4% 10.6%
Do you suffer from a medical condition? Yes No
466 528
46.9% 53.1%
Have you ever used a home medical device Yes No
319 677
32.0% 68.0%
If yes: type of home medical device (n = 319) BP Glucose monitor
208 92
65.2% 28.8%
Do you know someone who suffers from a medical condition? Yes No
849 146
85.3% 14.7%
*Some cells do not match total due to uncompleted survey items. † National Statistics Socio-Economic Classifications. BP, blood pressure; NI, Northern Ireland.
whereas 22.1% were over 60 years old (n = 221), with the remainder evenly distributed across the other age categories (Table 1). The majority of respondents (85.3%) knew, or had known well, someone who suffered from a chronic medical condition and over half of the respondents themselves suffered from a medical condition that required the use of medication. The majority of the sample reported having access to computers (83.7%), the Internet (79.4%) and mobile phones (87.8%), of which 39% were defined as smart phones (Table 2). Fewer respondents over 60 years of age had Internet access (49.8%) in comparison to those less than 30 years of age (95.1%) and 30–60 years of age (83.9%). 248
Use of home technology Do you use any of the following technology at home? Computer Internet Mobile phone Games console Use of computers in health car The storage of personal information on computers of health care professionals is a threat to personal privacy Agree Neither agree or disagree Disagree Health care providers ask for too much personal information Agree Neither agree or disagree Disagree People should have more control over the personal information held on computer health records Agree Neither agree or disagree Disagree
N
N%
840 796 881 334
83.7% 79.4% 87.8% 33.3%
262 126 610
26.3% 12.6% 61.1%
144 122 732
14.4% 12.2% 73.4%
529 153 316
53.0% 15.3% 31.7%
*Some cells do not match total due to uncompleted survey items.
The majority of respondents had never heard of CH (n = 924, 92.1%), or any of the related terms, prior to the survey. However, following the provision of a definition of CH (Fig. 1), 89.1% of respondents’ felt that it was a ‘very good idea’ or ‘good idea’ to monitor health ‘from information sent by a patient from their home’. In addition, 91.9% of those surveyed felt it was a very good or good idea to alert patients about potential health problems.
Provision of CH Participants believed that CH could be very helpful or helpful for people with diabetes (95.3%), heart disease (94.8%) and asthma (88.4%). However, participants were equivocal as to whether this service would be helpful for patients with dementia or Alzheimer’s disease (52.6%); a number of participants suggested that the latter would only be appropriate if a carer was available to assist. Other conditions suggested by respondents for which CH could possibly be used included cancer, cystic fibrosis, mental illness, epilepsy, renal disease, multiple sclerosis, stroke, thyroid conditions and blindness. In addition, some people mentioned the potential use of CH during pregnancy. The majority of participants (n = 808; 80.6%) felt that within a CH service, if a concern about the patient’s condition was raised, for example, via home monitoring, the health professional could send an alert to the patient about their condition via the Internet or mobile phone (or both). The remaining respondents (n = 194; 19.4%) preferred a mix of landline calls, face-to-face visits or mailing feedback to patients. Of those respondents who reported having a medical condition themselves, 25% would prefer a means of contact other than the Internet or mobile phone, compared to only 15% of respondents without a current medical condition (P < 0.001). © 2014 John Wiley & Sons, Ltd.
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Public views on connected health
Connected health can be described as a way of connecting a person with a long term-illness, for example, high blood pressure, diabetes or asthma, from their own home to the health professional (doctor, pharmacist or nurse) looking after them. This involves people regularly monitoring their illness (e.g., daily) from their own home using a medical device, for example, a blood pressure or blood sugar monitor. This information is then sent to their health professional automatically, for example, through the Internet or via the mobile phone network. If the person’s condition begins to get worse, the health professional can be automatically sent an alert and they can then contact the patient to recommend a course of action, for example, a change in medication. Just to repeat – a person uses a device in their own home to monitor control of their illness, the results go directly to a health care professional’s computer, via the Internet or mobile phone network. The healthcare professional can offer advice as required. In other words, the patient is connected in to the health care system – hence the term Connected Health. Figure 1 Definition of connected health as used during the face-to-face interview.
In terms of who would be in the best position to provide a CH service, participants were asked to rank health professionals from 1 (best position), to 5 (worst position). General practitioners were considered to be in the best position to provide the service, with a mean rank of 1.6 [standard deviation (SD) 0.9] (ranked first 627 times), followed by nurses, 2.7 (SD 1.2) (ranked first 115 times), hospital doctors, 3.0 (SD 1.2) (ranked first 83 times), community pharmacists, 3.25 (SD 1.3) (ranked first 83 times), and hospital pharmacists, 4.32 (SD 0.91) (ranked first 11 times). When asked why they felt their chosen health professional was in the best position, several themes emerged, the most common of which were as follows: familiar with the patient history (40%), health professional was appropriately educated/trained (11.9%), better access to the chosen health professional (9.9%), they would have more time to deliver the CH service (8.6%) and are community-based (7.4%).
Benefits of and concerns about CH The interviewees were provided with a number of statements and asked to indicate their opinion about the potential benefits and concerns that could arise with CH. Overall, respondents agreed with the range of possible advantages of CH (Fig. 2), although respondents were more equivocal regarding the potential of CH to reduce health care professionals’ workload (59.2% strongly agreed/agreed). In terms of perceived concerns, the responses were more variable. The respondents appeared to be most concerned about devices being difficult to use (Fig. 3). Interestingly, older respondents (over 60 years) seemed less concerned regarding difficulty of device use (5% very concerned) compared to other age groups, for example, less than 30 years (11.2%) and 30–60 years (11.3%),
© 2014 John Wiley & Sons, Ltd.
P < 0.001. Respondents who reported suffering from a medical condition compared to those who did not, and those who had received only primary or secondary education versus tertiary education, were also less likely to be ‘very concerned’ regarding difficulty of device use (6.7% versus 12.1%, P < 0.001; 6.5% versus 13.7%, P = 0.003, respectively). Overall, the respondents were much less concerned with the potential reduction in face-toface contact between patients and health providers and the possible inconvenience to patients of using a remote monitoring device (Fig. 3). In addition, most respondents did not feel that storage of personal information on the computers of health care professionals threatened their privacy (61.1%) and did not feel that health professionals asked for too much personal information (73.4%) (Table 2).
The pharmacist Approximately 55% of those who responded visited the community pharmacist on a weekly or monthly basis. Respondents were asked about the potential role of the community pharmacist in the provision of CH. A high percentage of respondents strongly agreed/agreed that it would be beneficial if the community pharmacist could check whether patients had taken their medication (86.5%) and remind patients (e.g. text message) to take the medication (88%), via the use of a CH service. However, only 53.4% of respondents strongly agreed/agreed with the pharmacist making an adjustment to patient medication in response to information sent. In general, however, respondents believed that the community pharmacists could help with the provision of a CH service (94.6%) and were happy for them to do so (93.4%). A multiple logistic regression analysis was conducted, where each variable was analysed while controlling for the effect of all 249
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Figure 2 Perceived benefits regarding connected health.
Figure 3 Perceived concerns regarding connected health.
other variables. Female respondents, compared to male respondents [odds ratio (OR) 2.30; 95% confidence interval (CI) 1.44– 3.65; P < 0.01], respondents who disagreed with the statement that health professionals ask for too much personal information, compared to those who did not (OR 2.53; 95% CI 1.57–4.08; P < 0.01) and those who received primary or secondary education, compared to those who had a tertiary education (OR 2.15; 95% CI 1.22–3.82; P = 0.01) were all more than twice as likely to be ‘happy’ for the community pharmacists involvement in the provision of CH.
Who would use CH? Upon survey completion, 91.8% strongly agreed or agreed that CH was a ‘good idea’, 87.2% indicated that they would be willing to 250
use CH services if they currently suffered from or developed a long-term health condition and 86.1% would recommend CH to a family member or friend with a long-term health condition (Table 3). Logistic regression analyses were conducted to identify the key characteristics of respondents who expressed a willingness to use CH, if they had, or were to develop, a long-term health condition (Table 4). Following an unadjusted analysis, an analysis was conducted to identify the independent relationship of each variable with willingness to use CH in the future, adjusted for all other variables in Table 4. The respondents who expressed most willingness to use CH in the future were those resident in NI their entire lives (OR 2.40; 95% CI 1.45–4.00; P < 0.01); those with family or friends who had a chronic disease (OR 2.25; 95% CI 1.48–3.41;
© 2014 John Wiley & Sons, Ltd.
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Public views on connected health
Table 3 Views of connected health Would you use connected health in the future if you developed a chronic disease? Yes No Don’t know Would you recommend connected health to family or friends if they developed a chronic disease? Yes No Don’t know Do you think connected health is a good idea? Yes No Don’t know
865 48 79
87.2% 4.8% 8.0%
858 28 110
86.1% 2.8% 11.0%
913 28 54
91.8% 2.8% 5.4%
P < 0.01), respondents who disagreed that the storage of personal information on the computers of health professionals was a threat to personal privacy (OR 1.92; 95% CI 1.65–4.93; P < 0.01), disagreed that health professionals asked for too much personal information (OR 2.85; 95% CI 1.65–4.93; P < 0.01) and who agreed that patients should be allowed more control over medical records (OR 2.01; 95% CI 1.07–3.76; P = 0.03). In comparison, people aged over 60 years (OR 0.51; 95% CI 0.29–0.90; P = 0.02) and those who agreed that IT in health care was a threat to personal privacy (OR 0.50; 95% CI 0.30–0.85; P = 0.01) were less willing to support the CH approach.
Discussion The majority of the public had never heard of CH, similar to survey findings in North America [11,12]. However, most respondents provided positive views of CH following an explanation of the approach. The actual proportion supporting the concept of CH was much larger in NI, that is, almost 90% indicated that they would be prepared to use CH, when compared with approximately 50% of those surveyed regarding telemedicine in Quebec, Canada [12]. Lack of awareness has been identified as a barrier to implementation of telemedicine [14]. The higher levels of acceptance of CH in NI may be a temporal effect, as the survey in Quebec was conducted almost a decade ago. IT is much more integrated in today’s society, for instance, the proportion of people in the UK with access to the Internet has steadily increased from 61% in 2007 to 77% in 2011, similar to the levels reported in the current project, 79.4% [21]. Respondents felt that GPs were in the best position to provide CH. Given the GP’s role as the main gatekeeper to hospital services in the UK, this is not surprising. The primary reason behind the choice was the GP’s familiarity with the patient and their condition, lending support to the belief that trust and a good rapport with a health professional can facilitate the uptake of CH [22]. The greatest perceived benefit of CH was its potential to make patients feel more secure at home, a finding common across other studies, particularly when the monitoring is conducted by a trusted health care professional [22,23]. It had been suggested that patient concern regarding reduced face-to-face contact with a health care
© 2014 John Wiley & Sons, Ltd.
provider could be a major barrier to the implementation of remote monitoring technologies [24]. However, this was not a major cause of concern among the current respondents. Respondents were less certain about the potential of CH to reduce the workload on health professionals. In a recent systematic review of barriers and facilitators to telemedicine implementation, 11 studies identified telemedicine as time saving compared to 30 studies where it was perceived as time consuming or as increasing the workload for the health professional [25]. Particular concerns have been raised about the loss of treatment time due to the initial implementation and learning phases of new IT and telemedicine programmes in health care [25–28]. The review also highlighted ease of use as a major barrier to the introduction of telemedicine and IT technologies in health, that is, similar to the current study [25]. Privacy and confidentiality of information were also common concerns. However, they have been viewed as both facilitators and barriers to CH implementation [25]. Some consider remote patient monitoring as a protector of privacy by allowing people to be monitored from home, therefore offering patients more independence, while others argue that it impinges upon individual privacy and are opposed to providing personal information over the Internet [11,22].
CH and the pharmacist Community pharmacists are the most frequently contacted health professionals in the UK and the results of the current survey indicated public support for their involvement in CH provision [29]. Some contend that the community pharmacist could act as the ‘hub’ for a CH service [15]. Such integration of services provided by different health professionals could help with the successful implementation of CH [23]. Interestingly, females (compared to males) and respondents with primary or secondary education (compared to tertiary) were happier for the pharmacist to be involved in the provision of CH, and upon further analysis, it was shown that both groups visited the pharmacist more often than their comparators. This reinforces the importance of patient familiarity with the health professional providing CH services [22].
Willingness to use CH In comparison to younger age groups, those aged over 60 years expressed less willingness to use CH in the future. Respondents over 60 years were also less likely to have Internet access (49.8%); however, access among respondents was higher than official figures of those aged 65 or older in the UK (40%) and the United States (41.5%) [30,31]. Previous studies have suggested that older people may find the use of IT-related technology both complicated and confusing, leading to low self-efficacy in terms of utilizing a new technology [32,33]. However, Irizarry et al. believed that this is simply a ‘transitional issue’ as IT has become integrated in the home, work place and educational settings in recent years [34]. Lack of training of older adults in the use of IT has been identified as a key barrier to the implementation of IT devices and it is therefore important that CH devices are user-friendly, particularly for older patients who may have less experience with IT [35,36]. Knowing someone with a chronic disease was associated with an increased willingness to use CH in the future. This observation 251
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Table 4 Factors influencing the willingness to use connected health in the future* Variable
Unadjusted odds ratio (95% CI)
P-value
Adjusted odds ratio (95% CI)
P-value
Demographic Male (%) Female
Gender (Reference: Male) 0.91 (0.64–1.29)
0.58
0.86 (0.60–1.24)
0.43
Age (Reference: 60 years
1.06 (0.66–1.72) 1.03 (0.68–1.56)
0.81 0.88
0.89 (0.43–1.84) 0.51 (0.29–0.90)
0.76 0.02
Education (Reference: Primary/secondary) Tertiary
0.85 (0.55–1.30)
0.44
0.81 (0.47–1.41)
0.46
Socio-economic classification (Reference: Intermediate) Professional/managerial 0.80 (0.44–1.44) Routine/manual 0.67 (0.46–0.95) Student 1.68 (0.77–3.67) Unemployed (not including retired) 3.77 (0.54–26.3) Retired 1.40 (0.80–2.44)
0.45 0.03 0.19 0.18 0.24
0.70 0.83 1.35 3.40 2.33
(0.34–1.44) (0.59–1.17) (0.49–3.70) (0.41–28.0) (0.86–6.31)
0.34 0.28 0.56 0.25 0.10
Live alone (Reference: No) Yes
0.73 (0.52–1.03)
0.08
0.73 (0.52–1.02)
0.06
Live in NI entire life (Reference: No) Yes
2.25 (1.4–3.38)
