Attitudes Toward and Predictors of Videoconferencing Use Among Frequent Family Visitors to Nursing Home Residents in Taiwan

Abstract

Background: Videoconferencing with family members benefits nursing home residents by decreasing their depression and loneliness. Nevertheless, the rate of participation in videoconferencing by family members is low. The purpose of this study was to explore attitudes toward and factors related to videoconferencing by family visitors to nursing home residents in Taiwan. Materials and Methods: For this cross-sectional study, data were collected from 231 family members of residents at 16 medium to large (>70 beds) nursing homes in Taiwan. Data were collected on participants' and residents' demographic and clinical characteristics, acceptance of and attitudes toward using videoconferencing as a form of nursing home visit, and reasons for/roles during visits to nursing home residents. Factors related to the use of videoconferencing were analyzed by logistic regression. Results: Family members' acceptance rate of videoconferencing use was low (7.8%). The findings also showed that videoconference use was predicted by hiring a private caregiver (odds ratio=6.90), the role during/reason for family visits being to maintain residents' emotional status (odds ratio=5.46), and the frequency of in-person visits to the nursing home. Conclusions: We recommend encouraging family use of videoconferencing by available equipment such as smartphones or tablet programs that can address residents' emotional issues in a timely fashion. We also suggest developing more interactive content for videoconferencing, such as a family-oriented picture program to help broaden topics of conversation.

Introduction

Social support for nursing home residents is crucial because it may provide emotional comfort. An important aspect of social support for older nursing home residents is continuous involvement of family members. However, one-third of nursing home residents seldom have visitors,¹ and 6 months after relocation to a nursing home, they have fewer visitors.²

The rapid expansion of technology, particularly videoconferencing, has provided an alternative means for family members to stay involved with each other. In particular, Internet videoconferencing programs have been demonstrated to be a feasible way to promote social interactions among people who have difficulty communicating.³ These programs enable people with communication challenges to use pictures and other media to share information about themselves.^4,5 Providing real-time audiovisual telecommunication systems to nursing home residents has been shown to have a positive effect on residents with difficulty adapting to the nursing home environment.^6,7 Furthermore, videoconferencing has been shown to effectively reduce depression and loneliness among Taiwanese nursing home residents, in both the short term⁶ and long term.⁷

Nevertheless, in those studies, nursing home residents believed that videoconferencing was the second-best option for communicating with family and friends.⁸ Furthermore, family members' acceptance rate of videoconferencing with residents was low (13.5–28.6%).^6,7 The top two reasons that family members did not participate in the videoconference program were an inability to use the videoconference technology and a lack of equipment such as a computer or Internet connection.^6,7 These barriers may no longer apply to relatives of nursing home residents' use of videoconferencing due to the greater availability of relatively inexpensive devices such as mobile phones and tablets.^8,9 For example, the percentage of mobile phone holders in Taiwan in 2013 was 81.9%, with the rate of smartphone holders among the elderly increasing 16.9% from 2012 to 2013.¹⁰ In addition, family members' use of videoconference programs may be related to their reasons or motivation for visiting nursing homes and their visitation patterns. However, the relationship between family members' motivation for visiting nursing homes and their characteristics, which were shown to be important predictors of visiting patterns,^11
–13 have not been explored.

Despite the documented benefits of using Internet communication technologies for nursing home residents,^6,7,14 few empirical data are available to date on family members' acceptance of and factors related to the use of videoconferencing to communicate with nursing home residents in Taiwan. Such information would improve understanding the acceptance and predictors of videoconferencing use by family members of Taiwanese nursing home residents and could lead to developing ways to increase the acceptance and use of high-tech communication devices in long-term care facilities. Such an understanding would also provide useful information to policymakers concerned with the quality of care for nursing home residents. Because inexpensive videoconferencing technology is now widely available in Taiwan,¹⁰ equipment would not affect family members' decision to use videoconferencing to contact residents. Our hypothesis was that, given widely available videoconferencing technology, family members' use of videoconferencing to interact with nursing home residents would primarily be influenced by their reason for visiting residents. Therefore, the purpose of this study was to explore attitudes toward and factors related to videoconferencing use by family visitors to nursing home residents in Taiwan.

Materials and Methods

Study Settings and Sample

For this cross-sectional study, family caregivers of nursing home residents were recruited by stratified random sampling from 16 nursing homes in Taiwan. Nursing homes were purposively selected based on two criteria: capacity (>70 beds) and accessibility to the researchers. Accessibility was determined by the nursing home's geographical accessibility to the researchers. Because the researchers lived in northern Taiwan, the ratio of the number of nursing homes selected in northern, central, and southern Taiwan was 4:2:1. Furthermore, nursing homes were recruited only if they had available videoconferencing systems.

Nursing homes that met our sampling criteria (n=137) were assigned a number, and 21 were chosen by simple random sampling. Administrators of these 21 nursing homes were approached for their willingness to participate in the research. Five nursing homes refused to participate in the study, which resulted in 16 nursing homes. Family members who visited residents at these nursing homes were recruited by purposive sampling. They were enrolled if they met these criteria: (a) could communicate in Mandarin or Taiwanese, (b) visited the nursing homes during times when the researchers were present, (c) were members of a resident's family, and (d) agreed to fill out a set of questionnaires.

Study Variables

Data were collected on the family member participants' and residents' demographic and clinical characteristics, acceptance of using videoconferencing as a form of a nursing home visit if this equipment were available to them, and family members' reasons for/roles when visiting nursing home residents.

Nursing home residents' demographic data included their age and duration of residency, and their clinical data included their physical and cognitive status. Physical status was measured by the Barthel Index,¹⁵ which assesses performance of activities of daily living. Cognitive status was measured by the Mini-Mental State Examination (MMSE).¹⁶ The MMSE cutoff score for no severe cognitive deficit was ≥16 for participants without a formal education and ≥20 for those with at least a primary school education.¹⁷ Family members' demographic characteristics included age, gender, marital status, educational level, employed (yes/no), self-perceived health status, perceived health status of the resident after admission, hired a private caregiver to assist in the nursing home (yes/no), had problems making conversation with residents (yes/no), and visiting patterns. Visiting patterns included frequency, travel time to the nursing home, and time spent visiting in the nursing home (duration of visit). Visiting frequency was coded as daily (five to seven times/week), weekly (one to four times/week), and monthly or less.

Family caregivers' reasons for and roles when visiting visiting nursing home residents were measured with the Family Meaning of Nursing-Home Visits (FMNHV) scale.¹⁸ The 32-item FMNHV, which uses a 5-point Likert response scale, was developed based on in-depth qualitative interviews with family members about their roles during/reasons for visiting nursing home residents.¹⁸ The FMNHV includes six subscales: emotional maintenance (eight items), family education model (four items), responsibility for care quality (nine items), making up for guilt (three items), maintaining family relationships (five items), and supporting health-promotion activities (three items).¹⁸ Cronbach's alpha for the entire FMNHV scale was 0.87 and for the subscales ranged from 0.51 to 0.97 in this study.

Procedure

The study was approved by the Institutional Review Board of the authors' institution. Because nursing homes in Taiwan do not have institutional review boards, the authors obtained permission to conduct this study from the directors at each study setting prior to data collection. After the permissions were granted, an announcement about the study, which contained detailed research procedures, was posted at the nursing homes' entrances. A trained research assistant collected data for 3–4 weeks at participating nursing homes, as suggested by the nursing home managers. Before collecting the data, the research assistant explained the study purpose and procedures, confidentiality, and privacy to potential participants. Participants faced no potential risks from involvement in this study. Family members were informed of their rights to withdraw from the study at any time or to refuse to answer any questions. Informed consent was signed after the participants agreed to participate.

Data Analysis

All data analyses were performed using the Statistical Package for the Social Science (SPSS) version 15.0 software (SPSS Inc., Chicago, IL). Participants' characteristics and scores on the FMNHV were analyzed by descriptive statistics (i.e., means, standard deviations [SDs], and percentages). Participants were categorized into videoconference acceptance and nonacceptance groups. Differences between the acceptance and nonacceptance groups were analyzed by t test, chi-squared test, and Fisher's exact test. Factors related to utilization of videoconferencing were analyzed by multiple logistic regression.

Results

Participant Characteristics

The 231 family participants had a mean age of 57.68 years (SD=11.93 years; range, 30–93 years) (Table 1). Most were married, female, and employed, had less than a college education, and perceived themselves as in good health. The residents' mean age was 76.60 years (SD=13.50 years; range, 26–95 years), and they had been living in a nursing home for a mean of 25.17 months (SD=23.54 months; range, 0–93 years). About half the participants (48.9%) visited the nursing home longer than 2 h, and most (63.2%) traveled from home to the nursing home in less than 30 min. The majority of participants did not hire private caregivers to take care of their family members in the nursing home. Most participants visited their family residents at least once a week (91.3%), but approximately half perceived having difficulty finding topics of conversation when visiting residents.

Table 1.

Demographic and Clinical Data of Family Members and Nursing Home Residents

		VIDEOCONFERENCING
CHARACTERISTIC	ALL PARTICIPANTS	ACCEPTANCE (N=18)	NONACCEPTANCE (N=213)	T/χ² (P)
Residents
Age (years) (mean±SD)	76.60±13.50	80.28±11.15	76.15±13.81	1.23 (0.02)^a
Residency (months) (mean±SD)	25.17±23.54	16.76±16.61	23.38±21.65	−1.23 (0.22)^a
CBI score (mean±SD)	32.81±21.55	46.07±18.52	32.10±21.23	2.70 (0.02)^a
Cognitive status
MMSE (mean±SD)	12.79±8.75	19.86±7.28	11.30±8.62	4.19 (<0.001)^a
Cognitive deficit (MMSE<16) [n (%)]	146 (63.2)	5 (27.8)	141 (66.2)	10.14 (0.001)^b
Cognitively intact (MMSE>16) [n (%)]	85 (36.8)	13 (72.2)	72 (33.8)
Family members
Age (years) (mean±SD)	57.68±11.93	49.89±11.69	56.91±12.55	−2.29 (0.02)^a
Gender [n (%)]				10.50 (0.62)^b
Male	95 (41.1)	6 (33.3)	89 (41.8)
Female	136 (58.9)	12 (66.7)	124 (58.2)
Employed [n (%)]				0.01^c
Yes	114 (50.6)	14 (77.8)	100 (46.9)
No	117 (49.4)	4 (22.2)	113 (53.1)
Perception of resident's health [n (%)]				3.27 (0.07)^b
Poor	148 (64.1)	8 (44.4)	140 (65.7)
Better	83 (35.9)	10 (55.6)	73 (34.3)
Visiting patterns (frequency of visits [n (%)])				4.87 (0.03)^b
Daily (5–7/week)	92 (39.8)	5 (27.8)	87 (40.8)
Weekly (1–4/week)	119 (51.5)	8 (44.4)	111 (52.2)
Monthly or less	20 (8.7)	5 (27.8)	15 (7.0)
Travel time (min) to nursing home [n (%)]				0.48 (0.49)^b
<30	146 (63.2)	10 (55.6)	136 (63.8)
30–180	85 (26.8)	8 (44.4)	77 (36.2)
Hired private caregiver [n (%)]				0.02^c
Yes	15 (6.5)	4 (22.2)	11 (5.2)
No	216 (93.5)	14 (77.8)	202 (94.8)
Difficulty conversing with resident [n (%)]				0.01^c
Yes	124 (53.6)	4 (22.2)	124 (56.3)
No	107 (46.4)	14 (77.8)	93 (43.7)

By independent t test.

By chi-squared test.

By Fisher's test.

CBI, Chinese Barthel Index; MMSE, Mini-Mental State Examination; SD, standard deviation.

The major caregiving roles played by participants when visiting the nursing home were emotional maintenance (mean±SD, 3.46±0.75) and responsibility for care quality (3.18±0.45), whereas the two least important roles were supporting health-promotion activities (0.71±1.99) and making up for guilt (0.90±0.74).

Participant Acceptance of Videoconferencing

The acceptance rate of family participants' use of videoconferencing as a way to connect with the residents was 7.8%. Family members who accepted and did not accept videoconferencing differed significantly in terms of the residents' MMSE and Chinese Barthel Index scores, but not in terms of residents' age or duration of residency (Table 1). The acceptance and nonacceptance groups also differed significantly in family members' age, visiting frequency, employment status, whether private caregivers were hired, and whether they had problems making conversation with residents (Table 1). Furthermore, participants in the videoconferencing acceptance group tended to have higher FMNHV scores (indicating stronger roles during [reasons for] nursing home visits) for emotional maintenance, making up for guilt, and supporting health-promotion activities than participants in the nonacceptance group. However, only the role during/reason for visits of emotional maintenance was significantly different between groups.

Predictors of Videoconference Use

Multiple logistic regression was used to test the predictive relationship between acceptance of videoconferencing and participants' characteristics. The 10 variables that differed significantly between the acceptance and nonacceptance groups were entered in the regression model. To avoid overparameterization in the logistic regression, a backward stepping procedure (Wald test) was used. The results demonstrated that videoconference use was predicted by hiring a private caregiver (odds ratio=6.90), having the role when/reason for visiting of maintaining residents' emotional status (odds ratio=5.46), and the frequency of in-person visits (Table 2).

Table 2.

Results of Multiple Logistic Regression Model of Predictors of Videoconference Use Among Family Members of Nursing Home Residents

	B	WALD χ²	P	EXP(B)	95% CI
Frequency of visits		5.88	0.05
Daily versus monthly	−1.69	4.39	0.04	0.18	0.038, 0.89
Weekly versus monthly	−1.59	4.98	0.03	0.20	0.050, 0.82
Hire private caregivers	1.93	6.33	0.01	6.90	1.53, 31.08
Emotional maintenance	1.69	5.17	0.02	5.46	1.26, 23.59
Constant	0.32	0.01	0.92	1.37

CI, confidence interval.

Discussion

Our study is the first to consider the correlation between reasons for (purpose of visiting) nursing home residents and videoconference use. The study results demonstrated that videoconference use for nursing home visits was predicted by hiring a private caregiver, having the role when visiting to maintain residents' emotional status, and the frequency of in-person visits.

The acceptance rate of using videoconferencing as a way to connect with nursing home residents (7.8%) was lower than that seen in previous studies (13.5–28.6%) conducted in Taiwan.^6,7 This difference may be related to the personnel who recruited potential participants to the study. The participants in previous studies^6,7 were recruited by the nursing home staff. In the current study, however, participants were recruited by a research assistant. Another likely reason for our participants' low acceptance rate for using videoconferencing was that most of them (91.3%) visited the nursing home at least once a week. This visiting frequency is higher than that reported from research conducted in Japan,¹⁹ which indicated that 61.7% of family members visit the nursing home at least one to two times per week. This may be due to cultural differences in the relationships between parents and their adult children. In the Taiwan culture, which is influenced by Confucianism, filial piety is still the root of all morals and social values and has greatly influenced caring relationships between parents and children.^20,21 Therefore, participants who believe visiting their elderly parents in the nursing home is their filial responsibility and demonstrates to their own children the importance of filial piety¹¹ would not accept videoconferencing as a replacement for in-person visits. Frequent in-person visits make the videoconference visit unnecessary and lower the acceptance of using videoconferencing.

Among the family caregivers' roles when (reasons given for) visiting nursing home residents, emotional maintenance was the only predictor of acceptance of videoconference use as a way to connect with residents. This result is consistent with previous reports that videoconferencing reduced residents' depression and loneliness,^6,7 suggesting that videoconferencing can provide emotional maintenance to residents. This aspect of videoconferencing may increase family members' incentive to use it. However, we recommend using more available equipment than a desktop computer to also provide videoconferencing in real time such as tablets and smartphone that can address residents' emotional issues to provide an incentive for families' use of videoconferencing. Further research is suggested to compare the acceptance rate between smartphone-based and computer-based use of videoconference and its effect on maintaining residents' emotional health.

Another predictor of family acceptance of videoconference use was having a hired private caregiver for the nursing home resident. This result has seldom been reported, possibly because personal assistants are hired only in Asian or Taiwanese nursing homes and not in Western nursing homes. Hiring a private caregiver may be one way for adult children to achieve intergenerational well-being and to practice filial piety toward their parents in a nursing home.²² Adult children of nursing home residents may feel comforted if they have hired a private caregiver to care for their loved one in the nursing home when they had no time to visit. The fact that they can afford to hire an attendant also indicates that they are in a good economic social position and had more confidence in using this equipment. They may also use this technology to communication with both hired private caregiver and residents. Thus, they may accept the use of videoconferencing as an alternative way to visit residents.

Acceptance versus nonacceptance of videoconference use did not differ by duration of nursing home residency. However, videoconferencing tended to be more acceptable with a shorter duration of residency (16.76 months) than with a longer duration (23.38 months). Length of residency has been found to reduce the motivation for in-person visits,¹² which may also be true for videoconference visits. This result reflects the old Chinese saying, “The longer the disease persists, the less the children are filial.” Thus, we recommend promoting a videoconference program to newer residents, who have a higher prevalence of symptoms such as depression, related to adapting to living in the nursing home than other residents.^23,24

We also found a difference between the acceptance and nonacceptance groups in the cognitive status of residents. Families of residents without cognitive deficits tended to accept the use of videoconferencing, suggesting that acceptance of videoconferencing use was influenced by the possibility of using it to maintain residents' emotional status, which was a predictor of accepting videoconference use. This result suggests the benefit of promoting videoconferencing use to families of residents without cognitive deficits, which in turn may increase its acceptance rate. A higher acceptance rate would enhance the cost-effectiveness of videoconferencing because the equipment and Internet access fee could be shared among more families.

We also found that acceptance of videoconferencing use was not predicted by family member gender, as previously reported.²⁵ Age, however, was a factor in the current study; those who accepted videoconferencing tended to be younger (49.89 years) than those who did not (56.91 years). This result is in keeping with the finding that age was a predictor of videoconference use,²⁵ even though our study participants were older (57.68) than those (46 years) in the previous study. In addition, 37.7% of our participants were over 60 years old, which might have influenced their acceptance of videoconferencing.

Travel time to the nursing home was not a predictor of videoconference use, similar to a report that travel times up to 4 h did not influence the willingness to use videoconferencing.²⁵ Our result may also be due to the geography of Taiwan, where the majority of nursing home residents (68.6%) are close to their family home.²⁶ On the other hand, our finding differs from a previous report that frequency of visits was affected by distance to the nursing home.¹² Another factor that may explain why the acceptance and nonacceptance groups did not differ in terms of travel time to the nursing home is that we did not include family members who lived overseas. We thus recommend further research that includes family members for whom travel to nursing homes is a significant barrier (e.g., those with a disability or who live overseas).

We also found that far fewer participants in the acceptance group (22.2%) had problems communicating with residents than participants in the nonacceptance group (56.3%). Moreover, over half of all participants perceived themselves as having problems carrying on a conversation with residents. We thus recommend developing a program to teach family members skills to improve communicating with residents or to broaden the topics of conversation. This result also suggests that the quality of family visits needs to be improved (e.g., through meaningful interactions during nursing home administration-sponsored activities). These kinds of activities may include supporting health promotion via videoconference. This possibility is supported by evidence suggesting that text messaging by cell phone is helpful in chronic disease management.²⁷ Finally, this result calls for developing more interactive content for videoconferencing, such as a family-oriented picture program that can help to broaden topics of conversation.

Although univariate analysis revealed differences between the acceptance and nonacceptance groups for 10 variables, multivariate analysis found only three significant predictors. The inconsistency between the results of multivariate and univariate analyses may have been due to the low percentage of acceptance of videoconference use.

Limitations

Despite its contributions to understanding the use of and factors related to acceptance of videoconferencing by nursing home resident's families in Taiwan, this study had some limitations. First, we had problems contacting family members who infrequently visited residents and might have been more likely to accept videoconference to communicate with residents during our research period. Second, we only examined whether family members would have an incentive to use videoconferencing if they had videoconference equipment; their acceptance may have been higher if they had been able to try the equipment.

Conclusions

The acceptance rate of videoconference use was low (7.8%). The study demonstrated that videoconference use was predicted by hiring a private caregiver, visiting the nursing home to maintain residents' emotional status, and the frequency of in-person visits. Participants who perceived that visiting their relative in the nursing home was a responsibility and a way to teach their adult children the value of filial piety may not accept videoconferencing as a replacement for in-person visits. We recommend encouraging family use of videoconferencing by more available equipment such as a smartphone or tablet program that can in time address residents' emotional issues. We also suggest developing more interactive content for videoconferencing, such as a family-oriented picture program that can help broaden topics of conversation.

Footnotes

Acknowledgments

This research was supported by grant National Science Council (NSC) 98-2314-B-182-055-MY2.

Disclosure Statement

No competing financial interests exist.

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