Abstract

Introduction

Internet- and mobile-based health interventions, or eHealth/mHealth interventions, are promising modalities for electronically providing health education and tools for patients, healthcare providers, and caregivers.^{1, 2} They offer particular opportunities for use with individuals with disabilities and/or chronic illness who are more likely to employ electronic methods to access health information, as compared to individuals in excellent and good health.³ However, electronic devices are not universally accessible for individuals with disabilities. The accessibility of devices to individuals with physical impairments such as traumatic spinal cord injury (SCI) can be problematic because of financial constraints that limit the ability to purchase the devices and/or Internet service, as well as functional impairments that make controlling the device difficult. Previous research on computer and cell phone use has found lower rates of use among individuals who have sustained SCI as compared to the general population.^3–5 In addition, significant age-related differences in the use of electronic devices have been noted in the general population as well as among people with disabilities.⁶

In order to inform the development and use of eHealth/mHealth interventions for individuals with SCI, it is necessary to first understand patterns of use and ownership as well as the limitations of these modalities. With regard to individuals with SCI, information about the characteristics of those who use various electronic devices, including computers, tablets, and smartphones or other handheld devices, can be beneficial to inform how interventions and assessments are tailored, given both the diversity of physical functioning as well as trends in device use by characteristics such as age.

Although previous research has found electronic methods to be a promising treatment modality for communicating health information to individuals with SCI,^7,8 no study has looked at a population of individuals who have sustained SCI to understand the specific electronic devices they own and use while also considering differences in age groups. Indeed, doing so may inform effective and appropriate electronic interventions to improve health outcomes for individuals with SCI. The purpose of this study is to describe the use and ownership of various mobile and electronic devices by individuals with SCI and to examine patterns of use/ownership by age and functional impairment.

Materials and methods

This study was reviewed by and received the approval of the Institutional Review Board at a Midwestern university. It employed a cross-sectional mail survey design and used the electronic medical records of a large academic medical center to identify potential participants. Those individuals deemed eligible were contacted via a four-stage mail survey between May and July of 2013: a postcard notifying them about the study, a survey packet with introduction letter, a reminder postcard, and (to those who had not yet responded) a second survey packet. For the first group of mailed surveys, a small incentive (US$3) was included with the survey packet. For those between the ages of 7 and 13, cover letters for both the parents and the child with SCI were included. Responses to the survey could also be entered via a web-based platform if preferred; this option was used by 76 of the 451 respondents.

Results

Table 1 shows the demographic data on participants. A total of 451 individuals completed and returned the survey. Participants ranged in age from 7 to 96 years old; the mean age was 47.73 years (SD=16.92). Most participants were male (71.2%), in the 50–64 age range (36.5%), and self-identified as White (85.4%). There was diversity in injury-related characteristics, with the most common duration of a SCI being five years or less (28.6%) and the most frequent injury type being paraplegia (47.5%). Of note, most participants were not currently in school (88.5%), and of those who indicated completion of less than a high school education, 50% were currently enrolled in school at grade 12 and below.

The percentage of participants who indicated owning and/or using each of the three types of electronic devices (computer, tablet computer, handheld device) is displayed in Table 2 according to age group. Within the computer category, a majority of participants across all age groups indicated owning/using a desktop and/or laptop. Within the tablet computer category, with the exception of participants aged 65 and older, respondents were more likely to indicate owning/using an iPad than any other tablet computer device. Across all age groups most participants were not likely to own/use more than one device per category (P<0.001 for all analyses).

Table 2

Percentages of participants who owned/used each type of electronic device according to age group (N=451)

Device		7–17 (n=17)	18–29 (n=62)	30–49 (n=143)	50–64 (n=165)	65+ (n=64)	χ2*
Computer	88.2	80.6	93.0	87.9	89.1	Ns
	Desktop	58.8	54.8	71.3	58.8	54.7	Ns
	Laptop	70.6	62.9	69.9	66.7	64.1	Ns
	Both	41.2	37.1	48.2	37.6	29.7	Ns
Tablet computer	88.2**	71.0**	52.4	36.4**	29.7**	42.768
	iPad	58.8	54.8**	33.6	22.4	20.3	31.835
	Android	23.5	17.7**	15.4	6.7**	3.1**	40.600
	Kindle Fire	23.5	8.1	14.0	7.3	9.4	Ns
	e-Book reader	5.9	12.9	10.5	6.1	7.8	Ns
	Other	5.9	6.4	2.8	1.8	1.6	Ns
	2+ devices	35.3**	21.0	16.1	5.4**	11.0	23.18
Handheld device	82.4**	79.0**	58.7**	33.3**	17.2**	77.139
	iPod touch	35.3**	27.4**	16.8	3.0**	3.1	43.22
	iPhone	41.2	45.2**	30.8	18.2**	14.1	25.429
	Android	41.2	41.9**	29.4	14.5**	3.1**	40.600
	Apple and Android	23.5	17.7**	10.5	0.6**	1.6	33.638

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* df=4; P<0.001

** More likely to use device than at least one other age group at the 0.05 significance level with Bonferroni adjustment.

Ns=Non-significant

Table 3 displays the percentage of participants who owned and/or used computers, tablets, and handheld devices according to different injury classifications of SCI. Individuals with high-level tetraplegia, motor complete, were significantly less likely to own/use iPads than all other groups (P<0.001 –<0.05 for all analyses). These individuals were also significantly less likely to own/use handheld iPhone devices than individuals with low-level tetraplegia, incomplete, and with paraplegia (P<0.001 –<0.05 for all analyses).

Table 3

Percentages of participants who owned/used each type of electronic device by injury classification (N=451)

Device		C1–C4 Motor complete (n=42)	C1-C4 Motor incomplete (n=49)	C5-C8 Motor complete (n=75)	C5-C8 Motor incomplete (n=65)	Paraplegia (n=220)
Computer	92.9	93.9	85.3	89.2	87.7
	Desktop	71.4	63.3	62.7	58.5	60.0
	Laptop	64.3	77.6	73.3	64.6	63.2
	Both	42.9	56.9	50.7	33.8	35.5
Tablet computer	33.3	51.0	53.3	49.2	46.8
	iPad	19.0	38.8	41.3	27.7	30.5
	Android	7.1	8.2	9.3	13.8	12.3
	Kindle Fire	9.5	14.3	8.0	10.8	10.9
	e-Book reader	2.4	4.1	10.7	7.7	10.5
	Other	4.8	6.1	1.3	1.5	2.7
	2+ devices	4.8	16.3	14.7	6.2	7.7
Handheld device	33.3	36.7	50.7	47.7	51.4
	iPod touch	7.1	8.2	14.7	10.8	13.6
	iPhone	14.3	26.5	36.0	23.1	26.4
	Android	14.3	8.2	14.7	29.2	27.7
	Apple and Android	2.4	2.0	4.0	4.6	10.9*

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*More likely to use device than at least one other age group at the 0.05 significance level with Bonferroni adjustment. χ² (df=4)=9.950; P=0.041.

Fig. 1 shows the percentage of participants who reported being unable to use each type of device because of their spinal cord injury. Individuals with high-level tetraplegia, motor complete, were significantly more likely to report that they were unable to use tablets than individuals with low-level tetraplegia, motor incomplete, and paraplegia (P<0.001 for all analyses). Individuals with high-level tetraplegia, motor complete, were also more likely to report being unable to use handheld devices because of their SCI than individuals in all other injury classifications (P<0.001 –<0.05 for all analyses).

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Figure 1.

Inability to use electronic device due to SCI in study participants according to injury level (N=451). Computer includes desktop and/or laptop computer. Tablet computer includes iPad, Android, Kindle Fire, e-Book reader, and/or other tablet computer device. Handheld device includes iPod touch, iPhone, and/or Android handheld device.

Fig. 2 compares the use of computers, tablets, and handheld electronic devices among the subset of study participants age 18 and older (n=434) to national surveys of American adults in the general population in the United States.^11–13 The use of all types of devices is lower among our sample of adults with SCI as compared to the national sample of American adults.

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Figure 2.

Percentage of electronic device use in American adults from Pew reports versus study participants 18+ years of age. Note: For American adults, the data consist of averages of electronic device use in 2013, as reported by the Pew Research Center.^11–13 For adults with SCI in the study population, n=434.

Discussion

While health information and resources (e.g. patient portals, recruitment marketing, medical electronic newsletters, etc.) are increasingly being communicated electronically,¹⁴ our findings suggest SCI does impact ability to access electronic devices. Specifically, our study found that individuals with different functional abilities had different patterns of device use and ownership. As noted in the results, individuals with high-level tetraplegia are less likely to own and/or use certain tablet and handheld devices than those with lower levels of injury but are more likely to use desktop or laptop computers (particularly those with motor-complete high tetraplegia). This pattern may reflect the number of accessories and input/interaction methods to facilitate accessibility that are available on computer systems, including screen readers, voice-recognition software, and other peripheral devices. More important, though, device use may depend heavily on reason for use—a facet that was not reflected in the survey—with certain modalities being specifically designed for different types of use (e.g., simple data entry and accessing electronic health records or more media-rich interactive experiences).

Of course, ownership and access of computers and electronic devices may be in part due to other factors such as cost of the device and associated Internet service.^6,11 The purchase of a mobile device capable of what individuals may need for their health is an added cost and a personal purchase since people rarely share mobile devices. However, computers are frequently already present in most homes and are shared, thus mitigating the cost and making the technology more accessible.

As might be expected, participants with motor-complete high-level tetraplegia were less likely to report being able to use tablet and handheld devices due to their SCI, as compared to individuals with other levels of injury. Significantly fewer individuals with lower-level injuries reported a similar inability to use devices due to their injury. This is consistent with aforementioned findings that individuals with higher levels of injury are most likely to use computer devices. One finding in this area which remains unexplained is the report by several individuals with paraplegia that they were unable to use computers (and to a much lesser extent tablets and handheld devices) because of their SCI; given that paraplegia alone should not reduce the hand and arm functioning needed to access either computers or the electronic devices in the same way that those without SCI access them, these types of responses may require additional exploration and highlight the limitations of the survey.

Another observation worth noting is the variation in the use of electronic devices according to age group. While ownership/use of desktop computers is comparable across all age groups in our study, there are important age differences relative to more recent innovations, such as tablet computers and handheld devices. Those devices are owned or used significantly more by the younger age groups in our study (7–17, 18–29, and 30–49), a pattern that resembles that of national samples,^12,15 although we consistently found lower ownership/use rates across all age groups with SCI. These findings point to the value of considering age diversity in addition to injury-related characteristics among individuals with SCI.

Taken together these findings highlight the importance of tailoring how information is provided to the audience one hopes to attract. If providing information or interventions for adults with SCI age 50 or older, it appears critical to format it to be viewed and/or accessed on computers or laptops. In contrast, information aimed at adolescents and young adults is likely to benefit from formatting that fits and can be viewed on mobile devices. Similarly, the injury classification of the audience may suggest the type of device that programs, information, and/or interventions need to be formatted for in order to enhance access by that group. Specifically, using a tablet or smartphone app to deliver information or interventions may be limiting, and creating browser-based versions may be important to maximize reach to people with all levels of SCI.

Given trends in device use in the general population over the past 5 years, it may be expected that there has been a similarly sharp rise in the use of electronic devices among individuals with SCI, with likely similarities in relative use based on severity of injury as well as age differences. However, these data suggest that handheld devices may not be an appropriate method to electronically communicate health information to individuals with SCI, given the considerably lower percentage of use among our sample as compared to national statistics. Given clear differences between the two groups it would be important for future studies to further compare use of electronic devices among individuals with SCI and national samples.

Accordingly, for medical professionals using electronic methods to communicate health information to patients, it is thus necessary to consider the perceived inability to operate tablet computers and handheld devices among patients with higher levels of injury. With consideration of differences in ability to use electronic devices due to SCI level, medical professionals can improve electronic communication of health resources among individuals with SCI.

The area of electronic device use and ownership by individuals with SCI and other disabilities is one that deserves additional attention by researchers, healthcare providers, and developers of mobile technology. Information collected from quantitative surveys would be enhanced by including additional demographic characteristics such as income and access to Internet services and impairment characteristics beyond those imposed by SCI (e.g. cognitive limitations, sensory impairments). In addition, allowing respondents to provide details about how frequently and why they use their devices (e.g. work, information collection, social networking), the reasons that they do not or no longer use all or some electronic devices, and the perceived impact of impairment on use of each type of device would provide significant data for the development of both education and technology. Clinical research examining differences in perceived versus actual ability to use various electronic devices could also inform the need for education regarding accessibility features. Finally, developers are encouraged to continue to explore features of hardware as well as mobile apps, websites, and other software components which may impact use by individuals with limited functioning in their hands and arms.

Conclusion

This study provides important information about the use and ownership of electronic devices by individuals with SCI that can inform the design and use of eHealth/mHealth studies, programs, and dissemination strategies. When this study was conducted, individuals with SCI were most likely to own or use a computer as opposed to a tablet or handheld mobile device. Device use was influenced by both age and severity of injury. Since that time it seems likely that the percentages of individuals using specific types of devices have changed, given increasing availability and accessibility of tablets and mobile devices.

Acknowledgments

References