This study demonstrated that a smartphone-based videoconferencing intervention reduced feelings of loneliness in older NH residents at 1, 3 and 6 months. These results are similar to other studies showing that increasing the personal interactions of NH residents through the use of computer-based applications can significantly reduce feelings of loneliness [12, 14, 28].
There were some significant differences in baseline scores between the intervention and control group, which must be considered. The intervention group was significantly older than the control group. We have no data to explain this difference and can only speculate. One explanation for the age difference may be a result of the requirement that the NH residents’ adult children participate in the videoconferencing. The adult children willing to participate in videoconferencing may have had time because they were older, resulting in older NH residents in the intervention group. In addition to the age differences, baseline scores for feelings of loneliness were significantly higher in the intervention than control group. However, a recent study reported that although advanced age is associated with increased loneliness [29], age is only one of many contributing factors. A study reported older adults born in the 1920s had higher levels of loneliness than those born in the 1940s [30]. However, after controlling for age and frequency of in-person visits, the decrease in scores for feelings of loneliness from baseline to 6 months was significantly greater than the control group. Therefore, we believe the reduction in scores for feelings of loneliness is due to the videoconferencing intervention.
Our findings showed the videoconferencing intervention did not improve depressive symptoms of the NH residents at any timepoint. This result differs from previous reports, which demonstrated use of the Internet for communication with friends and family was associated with decreases in depression among NH residents [12, 14, 31]. These differences may be due differences in characteristics of the NH residents who participated. While two of the previous studies were conducted with NH residents [12, 14] the third study examined a large general population whose median age was 44 years [31]. Functional decline is an important predictor of depression [32], therefore, further studies are suggested to understand the effects of videoconferencing on different age cohorts. Characteristics of social networks, social support, negative interactions with a partner or close friend, and feelings of loneliness are reported to be predictors of depressive symptoms [33]. Therefore, there might be differences in social and clinical characteristics of our participants and those of the previous three studies.
Differences in the format of communicating via the Internet also might explain the differences in our findings from previous studies. Two studies [12, 14] conducted videoconferencing via computers or tablets and the third study [31] examined on-line communication. The screen of the smartphone in our study was smaller (8 in.) than desk-based computers (15.6 in.), our intervention was free to use, and the previous studies examined 3 months of weekly technology use. This is the first study to examine the effects of smartphone-based videoconferencing, therefore further study is suggested to understand the relationship of smartphone videoconferencing and depressive symptoms for older NH residents.
A novel feature of this study was to better understand the effects of videoconferencing on QoL. With the exception of a lower mean score for physical function, baseline subscale scores of the SF-36 in both the intervention and control groups is comparable to findings elsewhere [34, 35]. The lower scores for physical function compared to other studies might be explained by cultural differences in the reasons family members are placed in residential NHs Taiwanese society, which is often poor health [36].
The study found that videoconferencing positive effects on QoL indictors for pain, vitality and physiological health dimensions at 6-months, but not on physical function. Pain among older adults in NHs is common [37]. Participants may benefit from more support through videoconferencing and contact with their families because it is known that social interaction enhances pain management and is associated with pain reduction [37]. It may, thus, be important to include the use of videoconferencing technology as possible options during patient education and the development of care plans for pain management. However, information and communication technologies can indeed be valuable tools enabling better self-management and self-empowerment of pain [38].
Our research also revealed videoconferencing had positive effects on vitality at the 6-month timepoint. It has been suggested that allowing older NH residents to use communication and information technology improves their overall outlook; they report that they “feel young” or “become one of the modern generation” [39]. Due to the limitation of the sample size of this study, it is only possible to speculate whether technology of this kind influences vitality because participants feel more youthful. Future qualitative studies may be needed to better understand this relationship between using videoconferencing technology and the vitality of our participants.
The study revealed that the frequency of videoconferencing per month ranged from 1.18 to 2.13 times, which was lower than anticipated. The frequency, however, is comparable to previous computer-based videoconferencing research, which ranged from 1.22 to 1.46 times per month after the intervention period [14]. Such infrequent use indicates that as useful and convenient as videoconferencing may be, it cannot replace in-person visiting; and videoconferencing visiting can only be regarded as a “second-best option” to an in-person visit [34].
The participants in the intervention group had more children, which could explain the greater frequency of in-person visits and telephone calls compared to the control group. Thus, it is possible that family members of participants in the intervention group may have communicated by videoconferencing as an alternative to in-person visits and phone calls. Future videoconferencing interventions should assess frequency of weekly in-person visits to determine if there is a shift in the communication modality. We did not determine if adequate staff were available to help NH residents needing assistance with the smartphone-based videoconferencing equipment, which may have limited videoconferencing to participants who were more independent.
Our total attrition rate at the 6-month timepoint of 37.5% in the intervention group and 33.3% in the control group was higher than the 6-month attrition reported by two previous studies of older NH residents in Taiwan [14, 40]. Although the attrition rate in our study was high, an attrition rate of less than 40% is considered weak, based on the Effective Public Health Practice Project (EPHPP) quality assessment tool [41]. Therefore, we consider the attrition rate of this study acceptable. The higher attrition in the intervention group was primarily due to patients being discharged prior to completing the study, rather than dropping out; 7 out of 12 in the intervention group compared with 4 out of 10 in the control group. Whether videoconferencing contributes to discharge is something worthy of further study.
This study had some limitations. First, parent-child relationships and interactions in Asian cultures differ from Western cultures. This relational difference may limit the generalizability of the study results to Western countries. Second, we did not recruit cognitively impaired NH residents in our study. Whether smartphone videoconferencing can effectively increase QoL among older cognitively impaired residents has not been explored. Future studies should examine the use of this communication technology among older NH residents with cognitive impairments. Third, we did not distinguish between social and emotional loneliness. The UCLA Loneliness Scale measures subjective feelings of loneliness as a single global score. Future studies should be conducted which measure both social and emotional loneliness. Finally, our high attrition rate might limit the generalizability of our findings. Additional studies with a larger population is recommended.
The findings of our study demonstrate the effectiveness of a smartphone-based videoconferencing intervention on reducing feelings of loneliness and improving QoL for older NH residents. We suggest future research be conducted to better understand how Internet technology can improve the emotional health and QoL for older NH residents. Studies should include examining the effect of videoconferencing using different combinations of media-based technologies and program designs; variables should include not only loneliness and depressive symptoms, but also stratification of age, number of children and/or family members, and cognitive status. Qualitative studies could add additional information regarding the response of NH residents to such interventions. Finally, cultural differences should be explored to determine if interventions should be tailored to match the cultural setting of the NH residents. Such explorative studies could provide important considerations for the development of interventions to enhance health of the older population within the NH setting.