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Author: Sara J. Czaja and Joseph Sharit
Human factors engineers can greatly increase the independence and improve the quality of life for older people.
Dramatic changes are taking place in the demographic structure of the United States and other countries (Figure 1). An estimated 22 percent of the population will be over the age of 65 by 2030, and the fastest growing cohort within this subgroup will be people over 75. Currently about 44.5 million people are over the age of 75; by 2050 they will number almost 50 million (Figure 1) (NCHS, 2005). Similar changes are occurring worldwide. By 2030 the percentage of people aged 65+ will be about 24 percent in Europe and about 12 percent in Asia and Latin America.
The aging of the population presents vast societal challenges to ensuring that our infrastructures can support the needs of older people enabling them to live healthy, independent, and productive lives. To meet these challenges, we must rethink our conceptualizations of aging and redefine what it means to be “older.” The cohort of older adults today is very different from previous cohorts of older people, and the next cohort of the elderly, who will be mostly “baby boomers,” is also likely to be different from today’s elderly.
FIGURE 1 Changes in the age distribution of people 65 and older in the U.S. population over the last century and projected through 2050. Source: U.S. Census Bureau, Decennial Census, Population Estimates and projections.
In general, older people today are healthier, more diverse, and better educated than previous generations, and many are pursuing active lives. For example, many older adults, either out of need or by choice, remain employed in a full- or part-time capacity; some are even pursuing new careers, and many are engaged in volunteer work. The increase in the number of older workers requires changes in government and organizational policies, work procedures, and educational and training systems. Many older people are also engaging in continuing education, recreational activities (e.g., competitive sports), and travel.
Overall, older people are living longer than ever before, and the number of older people reporting very good health and improvements in physical functioning (e.g., the ability to walk a mile or climb stairs) has increased in recent years. Never-theless, the likelihood of a person developing a disability or chronic illness increases with age. Many older adults are disabled in one or more aspects of self-care and, in general, the elderly require more health care services and incur higher health care costs than younger people. As the elderly population increases and people live longer, more people will require help with aspects of daily living and disease management.
Normative changes in function also occur with aging. For example, aging is accompanied by declines in visual and auditory acuity, a slowing of reaction and response times, declines in motor skills and agility, and changes in cognitive processes such as lapses in memory and attention. Thus there is a clear need for strategies to help healthy older people remain productive and independent and to ensure that those who are frail or disabled receive care and support so that they can live in their communities for as long as possible. Age-related changes in function have vast implications for the design of products, environments, and activities.
Diffusion of Technology
Simultaneously with the aging of the population, we are witnessing unprecedented development and the diffusion of technology into all aspects of everyday life. Currently, all forms of technology, including computers, communications, safety, and health monitoring devices, are being used to perform routine tasks and activities. The use of technology has become an integral component of work, education, communication, and entertainment.
Technology is also being increasingly used in the health care arena for the delivery of services, in-home monitoring, interactive communication (e.g., between patient and physician), the transfer of health information, and peer support. As communication protocols evolve, we can anticipate more sophisticated network applications that can provide faster and more powerful interactive services in the future. Intelligent technologies will also increasingly become embedded in our interactions with the environment, and robots performing daily tasks will be commonplace. People of all ages will interact with some form of technology to function independently and engage effectively in their surroundings.
Technology has great potential for improving the quality of life for older people. For example, telemedicine/e-health will improve the physical and emotional well-being of older people. Technology can also enable older people to remain connected to family and friends, especially with those who are distant. Technology can also help older people remain employed and maintain or upgrade their skills, or it can ease the transition to retirement.
To date, however, evidence shows that the potential benefits of technology for older adults have not been realized. In 2007, about 32 percent of people age 65+ were Internet users, as compared to 65 percent of people age 50 to 64 and 83 percent of people age 30 to 49. Older adults who use computers and the Internet tend to be well educated and white and have more social resources and fewer functional impairments than non-technology users. The number of older people who have adopted home broadband is also lower than in the general population. In 2007, only 15 percent of people aged 65+ had broadband access at home, which limits the scope and potential of their online experience (Pew Internet & American Life Project, 2006, 2007). The widespread use of technology in the larger society suggests that the lack of technology use among older adults will have increasingly negative implications. For example, older people, who are most likely to need medical care, may not have access to health care technologies.
To date, older adults have largely been ignored as a viable user group by designers of technology systems. Although older people will have more technology experience in the future, they may still have problems adopting or negotiating technologies with new features unless system designers perceive older adults as an important user group and take their needs into account. The age-related digital divide could be closed if efforts are focused on that goal.
Human Factors Engineering
Human factors engineering, the study of human beings and their interactions with products, equipment, and environments in the performance of tasks and activities, could have great benefits for improving the independence and quality of life of older people. The overall objective of human factors engineers is to improve the “fit” between people and the designed environment to maximize performance, safety, comfort, and user satisfaction and minimize the likelihood of errors, inefficiencies, injuries, fatigue, and user dissatisfaction. To achieve this objective, human factors engineers espouse a user-centered, systems approach to design in which age-related changes in capabilities, tendencies, and preferences are incorporated into guidelines for design of products, tasks, and environments (Rogers and Fisk, 2000).
User-centered design can address the problems of older adults and help them retain and enjoy independence in their later years. In the following sections, some examples are presented of how older people could benefit tremendously, especially in the areas of information technologies, health care, and employment, from the application of human factors principles and concepts. These examples illustrate opportunities for human factors engineers.
The likelihood of developing a disability or chronic illness increases with age, and many older adults are unable to perform one or more self-care tasks. In general, the elderly require more health care services and incur higher health care costs than younger people. The application of human factors and ergonomics principles and methods to the design of assistive and information technologies can improve the lives of elders in the areas of e-health, medication adherence, health care delivery, warnings and instructions, home safety, and the design of assistive devices.
Improving Medication Adherence
Failure to take medications as prescribed is a common problem among older adults and a significant predictor of hospital admissions. Generally, the person fails to take a prescribed medication, takes the incorrect dosage, takes medications at improper times or in the wrong combinations, or fails to comply with special instructions such as dietary restrictions. Noncompliance is particularly problematic for older people who take multiple drugs and are susceptible to side effects and drug interactions.
The problem of medication non-adherence is complex and may be attributed to numerous factors, such as an individual’s perceptions or beliefs (e.g., the person does not believe that he or she is ill or that the medication is effective), cognitive problems (difficulty comprehending or remembering medication instructions), or ineffective strategies to encourage compliance. Many of these factors can be addressed by engineering solutions to help offset memory problems associated with comprehending and integrating medication schedules.
Products and devices could be designed to improve the organization of medications, such as calendars, electronic pill dispensers, and compartmentalized containers that are congruent with a medication schedule. Voice mail or beepers might be used to remind individuals to take medications. Automated telephone messaging is effective not only for medication adherence, but also for reminding people of appointment times and for monitoring chronically ill patients and older adults who live in the community and are not being monitored in health care, assistive, or other facilities. Other engineering solutions include improvements in the packaging and labeling of medications and educating individuals about the nature of their illnesses and the importance of medication in illness management. The appropriate intervention depends on an understanding of the reason for non-adherence (Park and Jones, 1997).
Improving Health Care Delivery
Engineering and technology applications can improve health care delivery for people who are frail or have limited mobility, facilitate access to health care information and services, and make it easier for health care professionals to deliver care. For example, computers and information technologies, such as e-mail and the Internet, can give older people access to information about a particular illness, medication, diet, or exercise program. Technology can be used by health care providers to communicate with older patients; remind them of appointments and home health care regimens, such as dietary schedules; and check on a patient’s general health status.
Interactive health communication, or “e-health,” generally refers to the interaction between an individual and an electronic device or communication technology (such as the Internet) that provides access to information, transmits health information, or provides health-related guidance and support (Robinson et al., 1998). The scope of e-health applications is fairly broad, but most applications involve searching for health information, participating in support groups, and consulting with health care professionals. Millions of websites currently provide health information, and in 2006 about 113 million Americans searched for health information online on a typical day (Pew Internet and American Life Report, 2006).
The fact that consumers have access to e-health applications has significant implications for both patients and providers. On the positive side, access to health information can empower patients to take an active role in their health care. Patient empowerment can result in more informed decision making, better and more individualized treatment decisions, stronger patient-provider relationships, increased patient compliance, and better medical outcomes. On the negative side, access to such a wide array of health information can overload both patient and physician, disrupt existing relationships, and lead to poor decision making on the part of consumers.
The Internet can help older people communicate with health care providers or other people with similar problems. Several studies have shown that online support groups are beneficial for this population (Fogel et al., 2002). The Internet may be particularly beneficial for hearing impaired or aphasic individuals. However, for these technology-based applications to be successful, the technology must be relatively simple to use, readily available, and affordable, and adequate training must be provided. In addition, designers should take into account the credibility of information, privacy issues, and trust.
The term “telemedicine” refers to a wide range of technologies, from simple telephone connections to live two-way video and audio transmissions (interactive television). With telemedicine, physicians can directly assess patients and measure blood pressure, gait, and cognitive status. Physicians can also measure vital signs and ask hypertensive patients about disease manifestations and drug side effects. The cost of the technology varies with the sophistication of the system.
Finally, personal health records, especially patient-oriented electronic medical records (EMRs), can bring together fragmented information from multiple sources. A study committee of the Institute of Medicine concluded that EMRs are necessary to improve the quality and decrease the costs of medical care and recommended that patients have unfettered access to their own medical information (IOM, 2001). Patient-oriented EMRs are being designed to provide tailored information that can be accessed through on-line patient portals. Patient portals to EMRs also have the potential to personalize health education according to an individual’s demographic characteristics and medical conditions. In addition, they can supply decision-support tools that can synthesize a great deal of medical information into linguistically appropriate messages for that individual.
Despite the growing popularity of EMRs, little research has been done on the usability of these tools for patient self-management, especially for at-risk populations such as older adults who are already experiencing a much larger variety of health problems than other segments of the population. Although the number of patient-accessible EMRs is increasing, many of them have not been evaluated to establish their usefulness and usability. Widespread public acceptance of EMRs and other e-health tools will require that designers pay more attention to the needs and circumstances of intended users, including their experience with health information and digital technologies and their capacities for health self-management (DHHS, 2006).
Employment and Work Settings
Current demographic projections indicate that by 2010 there will be about 26 million workers in the United States age 55+, a 46 percent increase since 2000. By 2025, the number will increase to approximately 33 million (GAO, 2003). The number of workers age 65+ will also increase substantially. Parallel trends have been identified in other developed countries throughout the world.
In addition to changes in demographics, we are also witnessing changes in the structure of work organizations. For example, vertically integrated business organizations are becoming less-vertically integrated, specialized firms. Decentralized management, collaborative work arrangements, and team work, and a new paradigm of knowledge-based organizations in which intellectual capital is an important organizational asset are also becoming commonplace. These changes in work structures and processes will have a pronounced effect on the nature of work and on the required capabilities of workers.
Ongoing developments in technology are also reshaping work processes, jobs, workplaces, and the delivery of job education and training. The introduction of automation and computer technologies into the workplace has dramatically changed the nature of many jobs and work situations.
To ensure that older adults can adapt to new workplace technologies, employers must provide them with access to retraining programs and incentives to invest in learning new skills and abilities. In addition, training and instructional materials should be designed for older learners, and technologies themselves should be designed (or modified) to be usable and useful for older adults, especially people with some type of impairment.
The benefits of new work arrangements (e.g., teleworking) should also be explored for older workers. Telework may be particularly appealing to older adults, who are more likely than younger people to be “mobility impaired” or engaged in some form of care giving (Schulz and Martire, in press). Telework also allows for flexible work schedules and autonomy and is amenable to part-time work.
There are also challenges, however, associated with telework for both workers and managers. The challenges for workers include isolation, managing home and work responsibilities, and the lack of technical support and feedback from managers and co-workers. For managers, the challenges relate to supervision and management of workers and decisions about which workers are best suited to telework. A more fundamental concern is that most teleworkers must interact with computers and the Internet or some other form of technology to perform their jobs. Although some data suggest that older workers are receptive to telework opportunities (Sharit et al., 2004), in general limited systematic evaluations of telework, especially with older workers, have been done.
Areas for Future Research
Human factors engineering focuses on improving interactions among people, tasks, environments, and products. The application of human-factors and ergonomics principles can improve the health, safety, and quality of life of older people. The basic premise of human factors and ergonomics is that user-centered design, based on a fundamental understanding of user capabilities, needs, and preferences, will lead to improvements in performance. Thus, according to this principle, improving the health and quality of life of older people requires that the knowledge of aging be applied to the design of products and environments.
For example, in today’s health care and work environments the ability to use technology is a critical skill. Technology can greatly improve the well-being and quality of life of older adults, and studies indicate that older people are receptive to using new technologies. However, they often encounter difficulties because they receive inappropriate training or because designers of the technology have not taken into consideration the needs of older people. User testing and user-centered design are critical to the success of technical systems. Guidelines for human-computer interaction suggest how computers and other forms of technology can be useful to, and usable by older adults (Czaja and Lee, 2002, 2006; Fisk et al., 2004).
We currently know very little about the efficacy of design aids and support tools for older adults. We also need more information on the best way to train older adults to use new technologies, and there are many unanswered questions about the best designs of online training programs and multimedia formats.
Issues of privacy and trust in technology are critical areas for research. There are also many questions about the Internet, such as how access to Internet information impacts health care behavior and how we can teach seniors to identify and integrate relevant information from the enormous amount of information available on the Internet.
In the workplace, research on how technology impacts employment opportunities and the work performance of older people would be extremely helpful. Not much research has been done on telework as it relates to older people or the factors that influence technology adoption, especially for minority elderly people and people who are not highly educated or well off economically.
Finally, many questions related to quality of life and socialization have not been fully explored. Many of the needs of older people could be addressed, or partly addressed through technological solutions. However, we will first need a systematic effort to understand their needs and incorporate them into the design of products for the marketplace.
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