What factors have impacted on older people’s (75+) access/experience of public services during COVID-19?
Research team: Alex Hall, Alison Littlewood, Annemarie Money, Charlotte Eost-Telling, Chris Todd, Danielle Harris, Jane McDermott
Chief investigators: Jane McDermott and Annemarie Money, University of Manchester
Funder: This project was funded by NHS England through the Greater Manchester Health and Social Care Partnership and supported by the National Institute for Health Research (NIHR) Applied Research Collaboration Greater Manchester (ARC-GM).
Access to digital services for older people
We know the digital divide and health inequalities often intersect, with groups such as older adults tending to be the most likely to have a need to access healthcare whilst being the group most likely to experience digital exclusion. Although use of the internet is increasing across all age groups, nearly half of people aged 75 and over have not used the internet within the last three months and over a third have never used it. The COVID-19 pandemic does not seem to have led to substantially higher numbers of older people getting online. Older adults who are at further risk of digital exclusion include those on low incomes, those living in social housing, living with disabilities, living in rural areas and those for whom English is not their first language.
What we did
In this project we aimed to gather insight around factors that may contribute to older adults’ (75+) digital participation in Greater Manchester (GM). This directly aligned to the ambitions of the GM Digital Inclusion Task Force. The project involved two phases:
- A rapid review, which integrated the latest evidence from a broad range of sources and summarised key issues regarding older adults’ digital skills, internet use, non-use and disengagement.
- A series of interviews undertaken with a range of older adults aged 75+ years with digital community support officers based in GM, to explore issues around digital participation.
Initial Public Patient Involvement and Engagement (PPIE) was through the ARC-GM PPIE panel, who advised on the research idea and offered insight on the issue of digital inclusion and exclusion for older people in GM. The panel also commented on documentation that would be sent to older adults to ensure it was easy to understand and conveyed the correct information. We also engaged with the GM Ageing Hub and GM Older People’s Network throughout the project, to share initial findings, gather and integrate feedback on the work and present the results of the project on completion. This helped to ensure that our work was relevant and representative of our target group.
What we found
Phase I: Rapid review of evidence
The academic evidence about the extent to which digital technologies can support older people to access health and care services is currently very limited and therefore does not match up very well with NHS ‘Empower the Person’ roadmap, which focuses on use of digital technologies (such as the NHS app) to enable people to better manage their health and wellbeing. There is often a lack of awareness among older adults about the support that may be available to them to get online.
Phase II: Qualitative interviews with older people
We explored a variety of issues around digital participation for adults over the age of 75 years in GM; six key themes emerged from analysis of the interviews (see below).
Initial motivation to participate digitally
- Connecting socially with friends and family was a motivational factor that led to older adults’ willingness to participate digitally.
- Being given hardware by family and friends was a further influencing factor – tablets were preferred by participants.Accessing services online was convenient, in particular when ordering prescriptions and for online shopping
- Accessing services online was convenient, in particular when ordering prescriptions and for online shopping
“And with ordering the prescription, if I didn’t do it over the internet, I would have to go to the doctor’s surgery which is a bus ride away” (Female, 88 years, Manchester)
Narrow use and restriction of activity online
- The majority of participants’ online activity can be described as ‘narrow’ – users undertaking between 1-4 activities online.
- Online activity and skills were often limited to this ‘narrow’ use with little interest in further skills development to enable broader use.
- Within the defined narrow online activity, older adult’s only carried out tasks they were comfortable doing. These were often very specific and potentially limited – e.g. only using online banking to check balance.
- Limited use was linked to confidence in skills but also lack of knowledge of data protection and fear of scams.
Public services and freedom of choice
- There was very little use of online public services by participants other than for ordering repeat prescriptions.
- There was consensus that alternatives to digital access must be provided by public service organisations and these needed to be inclusive and accessible
“Personally I don’t think you can beat seeing the doctor face to face, they can pick up on your body language, colour of your skin. I think there’s lots of things that you can pick up on face to face. So, I do think seeing the doctor face to face is essential for the majority, I really do. I think going online for some things is good, but I do think if you’re not very sure about what you’re doing, I think…I would imagine it could cause a lot of stress,” (Female, 76 years, Stockport)
Impact of digital participation on well-being
- Too much digital participation was seen as potentially leading to loss of social interaction, in particular the widespread use of smart phones and impact on everyday interactions that occur spontaneously (e.g. on a bus or train).
- Not being online was also described as being good for physical and mental health. Going out to make and attend appointments, the physical exercise involved in shopping, as well as making oneself use their brain to recall information (rather than an internet search engine) were listed as non-digital benefits.
“I’ve gone back to going out because you get a little bit of exercise, you know. So yeah, I don’t shop for groceries online anymore, no, I always go to the shop” (Male, 76 years, Trafford)
The 'last generation’
- The pandemic has done little to close the digital divide but rather may have amplified it, in particular levels of hard (never used or no access) and soft exclusion (engagement, skills, confidence).
- Inaccurate perceptions of younger generation’s ability and fluency in digital technology use resulted in older adults feeling less confident and deskilled.
Making digital accessible
- One-to-one sessions and on-going support were identified as important enablers for encouraging older adults to engage with and to develop digital literacy and skills.
- Learning about and using accessibility features that were embedded in digital software programmes (font size adjuster, text reader, microphone, etc.) were valuable for older adults who experienced changes in senses or dexterity due to health conditions.
What we recommend for improving older people’s access to digital services
Based on our findings, we have the following recommendations for those who are working to improve older people’s access to digital services:
For technology developers
- As people aged 75 and over are not digitally homogenised, a range of options with future digital healthcare services should be offered that will enable them to engage in ways that work best for them and digital inequalities are not further exacerbated
- Provide support to older people to gain digital skills, investment in services that enable people to maintain their skills would likely be beneficial.
- Accessible offline alternatives must always be offered and then maintained.
For researchers
- Further learning across the realm of digital technology provision is needed to understand what work could inform future development of accessible digitalised services, in particular further understanding of acceptance and use of online prescription ordering in over-75s.
For policy makers and practitioners
- Distinguish between unproblematic non-use of the internet, where people choose not to use the internet, and genuine digital exclusion, where people want to use the internet but are unable to for a variety of reasons.
- Support should concentrate on helping people do the things they want to do via technology, rather than on the technology itself. Relationships, particularly via peer mentoring, are important for helping people engage with support.
- Consideration of the impact of digital technology on other policy ambitions is vital. For example, strategic objectives to enable older people to be more active or approaches to reduce violence in the home may be compounded by a shift to digital only appointments.