DESIGN AND EVALUATION OF INTERGENERATIONAL HEALTH COLLABORATION SYSTEM WITHIN THE FAMILY

Abstract

Family members have the intrinsic desire to communicate and stay aware of one another’s lives and status (e.g., health) even when existing challenges may come across member’s communication practices (Judge, Neustaedter, Harrison, & Blose, 2011; Neustaedter, Elliot, & Greenberg, 2006; Romero et al., 2007). Family communication and awareness can be affected by different factors including geographical distance since it has become common for members to live apart due to lifestyle decisions or education opportunities, for example (Seiffe-Krenke, 2006). Moreover, as an older member ages, sustainable communication and awareness of one’s status is significant for care provision within the family, especially health care. An example of this phenomenon would be when a mother who lives apart from her daughter checks on her to see whether she is settling in at her new job in a remote place and eating healthy; the daughter worries if her aging parents are getting moderate exercise during winter time. Generally, those families use technology to overcome the challenge of maintaining regular communication (e.g., telephone, emails, text messages (Pew Research Center, 2013)). As a way to address this challenging situation in the family realm, many researchers in HCI have developed technological solutions to support families’ need for communication and awareness such as using video to share experiences among distributed family members (Inkpen, Taylor, Junuzovic, Tang, & Venolia, 2013) or _day-to-day activities (Mynatt, Rowan, Craighill, & Jacobs, 2001).

Besides assisting families to share general information, there has been a growing interest in the HCI field to develop innovative technology to promote family engagement in health interventions (Colineau, Paris, Marendy, Bhandari, & Shu, 2009; Escobedo et al., 2017; Ferdous et al., 2016). This line of work suggests that family engagement plays a significant role in promoting a healthy lifestyle and improving family’s wellness (Colineau et al., 2009; Escobedo et al., 2017). The family context has the means and the potential to help individuals to make choices that lead to a healthy life (Hubley & Copeman, 2018). For example, one member may engage others in building a culture of health within their family by supporting one another in behavioral changes for a healthier lifestyle (Escobedo et al., 2017; R. W. Johnson, 2017). Given the importance of encouraging family members to actively engage in healthy behaviors, it merits a study that provides a detailed understanding of how health communication is conducted in the family context, specifically considering the family dynamic between elderly parents and adult children.

While most studies on intergenerational family communication support activity or health awareness between grandparents/parents with underage children (Colineau et al., 2009; Grimes, Tan, & Morris, 2009; Pina et al., 2017), some researchers in HCI have turned their focus to examine family members – specifically considering elderly parents and adult children – unique challenges, such as providing care and support remotely. However, HCI related literature addresses intergenerational families’ burden on informal caregiving duties and discusses the inefficiency of communication and collaboration (Gutierrez & Ochoa, 2017; Gutierrez, Ochoa, & Vassileva, 2016) rather than looking closely at current practices, needs, and concerns regarding intergenerational family communication and collaboration in healthy living over distance.

In this research work, I turn my focus towards intergenerational interaction between elderly parents and adult children and complement previous HCI research by examining intergenerational family members communication practices and challenges around healthrelated topics when living apart. I seek to identify opportunities for developing familycentered health technologies to aid family collaboration in healthy living over distance.

In this dissertation, I conducted exploratory studies to understand individuals’ current practices, needs, concerns, and visions in the context of health communication within their family when living apart. Those studies findings helped me to identify and design interactive prototypes which were assessed and validated by potential participants. The proposed design system aimed to help distributed families to be more engaged in conversations about health and to be more aware of each other’s healthy practices that will ultimately benefit families in their efforts to collaboratively build a culture of health in their family context. Finally, working from my findings, I developed and deployed a web-based system called “PhamilyHealth” which provides a space for family members to share, communicate, and encourage one another in healthy behaviors. I fielded and evaluated this system by collecting a mix of self-report measures (e.g., preand post-survey measures; interview after usage) and a range of activity data gathered during the tool use (e.g., comments and photos exchanged). Combining across these multiple forms of data, I identified factors that contribute to make healthy living more present in conversations within the family. I also examined that the effects of increased awareness in one’s behaviors may move the other party’s motivation to intentionally engage in healthy practices. Finally, I discuss lessons learned about designing health interventions for families and how they are useful in raising members’ awareness and promoting family’s interaction.

 

Chapter 1 |

Introduction

1.1 Background

According to U.S. Census Bureau, the nation’s elderly population will be more than double to 88 million by the year 2050 (Vincent & Velkoff, 2010). Due the aging of the population, researchers from different fields have debated on the changing age structure and implications for the society (Hagestad, 1986; Mancini & Blieszner, 1989). They have also discussed about some issues and wide-ranging implications that happen as a result of having a greater number of older adults than young adults, for example, socio and economical challenges, and provision of healthcare (Gillen, Mills, & Jump, 2003; Treas & Marcum, 2011). Finally, researchers have presented considerations at the roles of the family and intergenerational relationships in supporting the aging society (Stuifbergen, Van Delden, & Dykstra, 2008; Swartz, 2009), examined intergenerational relations and family members’ well-being (Sun, 2016), assessed intergenerational communication and relations (Strom & Strom, 2015), and proposed strategies to support families and family life (Kaplan, Sanchez, & Hoffman, 2017). Understanding the impact of the population’s change is important for families and society as those variations may reflect in adaptations at the contemporary socio-economical conditions.

In addition, most family members have the inherent desire to maintain constant communication and awareness of one another’s lives as well as to collaborate on their family’s common good (Sun, 2016). Many consider family as a source of support in which family members reciprocate and help one another at times of necessity, such as during the treatment of a chronic disease (Eschler et al., 2015; Pang, Neustaedter, Riecke, Oduor, & Hillman, 2013) and to engage in behavioral changes for healthy lifestyle (Colineau et al., 2009; Escobedo et al., 2017). However, these kind of support can be affected by different factors including demographic change, geographical distance, and aging. Thus, understanding how family structures and intergenerational relationships will develop in the future, and what consequences these changes will have for the arrangements of support giving, including health care, within the family are essential to increase interest in examining family communication and build support systems for these new family dynamics.

The current research is focused on the generations directly affected by the aging society – Elderly Parents and Adult Children – which is sometimes called “Stem Family” relationships (Swartz, 2009). The stem family provision of support is characterized when adult children give practical support to their parents, for example by helping with housekeeping. They may also offer social and emotional support such as making a phone call to check-in and visiting (Stuifbergen et al., 2008; Swartz, 2009). At the same time, elderly parents continue to present parental assistance if needed, for example, with child care (Sun, 2016). This reciprocal mechanism, by which family members help each other and contribute to the family’s common good, offers the opportunity to promote family engagement in different interventions. For instance, the family context may present a favorable space to engage members’ on behavioral changes, including promoting healthy lifestyle. Given that, this research focuses on intergenerational families and the implications of aging and geographical distance for families and health collaborationrelated issues that may arise. I frame family health as a form of _{collective practices}, which were consistent with supporting, improving, and maintaining the health of the individual and the entire family (Fertman & Allensworth, 2016; Hubley & Copeman, 2018). In this research, the health practices are defined as healthy eating, physical activities/exercises, and mental care as a way to maintain a healthy lifestyle. Therefore, I propose to examine distributed family members – specifically individuals filling the roles of “elderly parents” and “adult children” in their respective families – to identify opportunities that can be used to promote health collaboration within families when the family members are living apart.

1.1.1        Intergenerational Families

Researchers have used the term _generation to better understand the impact of aging on the family (Gillen et al., 2003). A generation is a group of people born and living around the same time. In a family, children, parents, and grand-parents are examples of different generations (Merriam-Webster, 2018). For example, “Parent Generation” is responsible to raise their children, while “Sandwich Generation” is responsible to care for their parents/grandparents, their own children, and their own personal responsibilities (e.g., jobs) (Gillen et al., 2003).

The family relationship between generations (e.g., minor children and parents, minor children and grandparents) is called Intergenerational Family Relationships.

In this research, I focus only on the intergenerational family relationship between elderly parents and adult children. I decided to target this audience because as elderly parents age, they may need help from family members to perform daily routines, such as housekeeping. Generally, adult children become informal caregivers, and provide most of the care and support to their aging parents (Center, 2013). Meanwhile, elderly parents also keep providing parental assistance to their children. However, these kinds of support can be affected by different factors, such as geographical distance. It is common to see the health care supporters living apart, e.g., the young adults who leave their parents’ house or the siblings who have their own family. The “leaving home” family members may provide or receive health support remotely (Seiffe-Krenke, 2006), which may cause the everyday encouragement and support to change compared to when members lived together.

Therefore, my research goal is to examine how this type of intergenerational dynamic may balance between provision of help and respecting one another’s independence when living apart as a way to identify a design opportunity to develop a health collaboration system that support individuals’ efforts to engage in building a culture of health within the family from a distance (R. W. Johnson, 2017).

1.1.2         Promotion of Health within Families

Previous researchers have reinforced the importance of family collaboration on health because, for many people, a family can be a source of encouragement at times of necessity, such as during a chronic disease treatment (Pina et al., 2017; Sun, 2016).

Studies have examined the needs and challenges of family members living together to manage and support individuals with their health conditions (A. Barbarin, Veinot, & Klasnja, 2015; Eschler et al., 2015; Kaziunas, Ackerman, Lindtner, & Lee, 2017; Toscos, Connelly, & Rogers, 2012; Yamashita, Kuzuoka, Hirata, & Kudo, 2013). Others have investigated the challenges faced by individuals with a chronic condition on sharing health information with distributed family members (Pang et al., 2013; Wu, Birnholtz, Richards, Baecker, & Massimi, 2008). The results of these prior works show that engaging the entire family on managing a health condition may have great benefits such as reducing feelings of anxiety (Toscos et al., 2012) and providing family’s peace of mind (Kaziunas et al., 2017).

Researchers have further explored the issues of family support in promoting healthy practices, i.e., to engage family members in behavioral changes for a healthy lifestyle. For example, Colineau et al., (2009) investigated the requirements for a collaborative family weight management site to promote lifestyle changes by engaging family members to support one another in weight management. And Saksono & Parker (2017) examined families’ reflections on physical activity to help members gain insights and improve their behaviors.

In this research, I adopt family collaboration on health by considering family members’ practices of health promotion, or put simply, members’ practicing and encouraging others in healthy ways. I frame family health through the perspective of salutogenesis. In contrast to the dominant impression of care as something that needs to be done to remedy a health issue, a salutogenetic point of view leverages people’s capacity to care for each other and support their own well-being as a part of daily life (Antonovsky, 1991; Yuan, Kropczynski, Wirth, Rosson, & Carroll, 2017). Thus, I consider family health as a form of collective practices, which are consistent with supporting, improving, and maintaining health of the individual and the entire family fits within the salutogenetic framework (Antonovsky, 1991; Fertman & Allensworth, 2016; Hubley & Copeman, 2018). Specifically, this research focuses on individuals’ health practices related to healthy eating, physical activities/exercises, and mental care as a way to maintain a healthy lifestyle.

1.1.3           Family Collaboration on Health over Distance

Many people seeking to improve self-understanding have adopted pervasive tools to foster self-insight and promote positive healthy behaviors. Personal informatics (Epstein, Ping, Fogarty, & Munson, 2015) and quantified-self (Choe, Lee, Lee, Pratt, & Kientz, 2014; Rapp et al., 2017) literature, for example, have explored a diverse range of situations including how individuals collect and make sense of their health data (Choe, Lee, Zhu, Riche, & Baur, 2017; Epstein, Caraway, et al., 2016; Tang et al., 2018). The collection of health data is important because it allows individuals to create a holistic view of their health, and it also may improve the communication between patients and doctors (Bussone, Stumpf, & Buchanan, 2016; Schroeder et al., 2018). As an individual ages, collecting such data can make a significant difference on health care, particularly if one decides to age in place. Prior work has shown that 90% of seniors has the intention to age in place (Place, 2019). This fact has motivated researchers to further investigate seniors’ needs and experiences of aging in place (Birnholtz & Jones-Rounds, 2010; White, Singh, Caine, & Connelly, 2015) as well as their motivations to seek and engage in daily activities for health such as leisure activities (Lazar & Nguyen, 2017).

However, promotion of health has gone beyond the personal level to involve families. Research in HCI has studied how to support the complexity of family dynamics and has tried to address many of the existing challenges of connecting families (Neustaedter, Harrison, & Sellen, 2013). One important challenge is: how to support families when members live apart. While family members may be distributed by temporal or spatial distances due to different reasons such as work/educational opportunities or lifestyle preferences (Bouchard, 2014; Seiffe-Krenke, 2006), they still have the desire to stay in touch and maintain awareness of each other’s status across distance and time zones

(Forghani & Neustaedter, 2014; H. Kim & Monk, 2010; Mayasari, Pedell, & Barnes, 2016; Santana, Rodríguez, González, Castro, & Andrade, 2005; Tee, Brush, & Inkpen, 2009; Vutborg, Kjeldskov, Paay, Pedell, & Vetere, 2011). Given that, some researchers have developed systems that aimed to provide better communication channels for individuals who are apart from their loved ones (H. Chung, Lee, & Selker, 2006; H. Kim et al., 2013; Muñoz et al., 2015). Others proposed platforms for family members to share their lives and experiences (Inkpen et al., 2013; Pan, Forghani, Neustaedter, Strauss, & Guindon, 2015; Procyk & Neustaedter, 2013), to increase feelings of connectedness and awareness

(Cornejo, Tentori, & Favela, 2013; Judge et al., 2011; Judge, Neustaedter, & Kurtz, 2010; Romero et al., 2007), and to foster a sense of closeness across generations (Vutborg, Kjeldskov, Pedell, & Vetere, 2010; Yarosh, Tang, Mokashi, & Abowd, 2013).

When designing for distributed family members, specifically considering elderly parents and adult children, researchers have considered the unique challenges that this family dynamic poses, including providing care and support remotely (Seiffe-Krenke, 2006). In many families, elderly parents want to stay in their homes as they age. Aging in place allows older adults to remain in a comfortable home environment safely and longer (Wiles, Leibing, Guberman, Reeve, & Allen, 2011). As for the adult children, many assume responsibility for the care of their aging parents such as by assisting with emotional support (Center, 2013, 2015). However, at the same time, elderly parents continue to provide parental assistance as needed, for example, with child care (Center, 2013).

Under such circumstances, researchers have examined how to support family members who take the role as caregivers. Prior works have explored opportunities to support those individuals on negotiation and coordination of their actions of care (Gutierrez et al., 2016) and to balance their caring duties (Gutierrez & Ochoa, 2017). Also, researchers have proposed systems to support family ties through sharing information and stories

(Santana et al., 2005) and strengthen family communication when members are away (Cornejo, Weibel, Tentori, & Favela, 2015). While these efforts are important since they seek to better support this family dynamic in terms of communication and coordination in informal caregiving, more work is needed to look closely at other aspects of support in this context such as health promotion within non-collocated families. This research aims to complement prior works and investigates current practices and challenges for both elderly parents and adult children in their individual pursuit of a healthy lifestyle as well as their desire to collaboratively promote healthy living within their family over distance.

1.2 Area of Focus and Term Definition

For clarity, I present more details about each research area in which this dissertation project will focus on.

The theory of Family Communication Patterns (FCPT) explores family communication behaviors and family beliefs according to two dimensions: conversation orientation and conformity orientation. Through the combination of these dimensions, it is possible to understand family communication patterns. Understanding different family types is important to better assist family’s practices of social support and to clearly identify the reasons behind family’s obstacles on sharing information. In light of these family types, I take into consideration different family contexts and background to propose the development of a unique intergenerational system that promotes mutual sharing of information related to healthy living within the family.

The salutogenetic framework explores the idea that health is a dynamic and multidimensional state that comprises physical, mental, social, and collective well-being, which requires constant adjustments (Antonovsky, 1996). In other words, it is an approach that supports health and well-being, rather than factors that cause disease (pathogenesis). I decided to use this concept broadly as a way to understand the spectrum of health and to get some guidance on how to frame family health in a positive manner.

The field of Human-Computer Interaction (HCI) holds great promise for supporting effective sharing of health information among family members. This field seeks to develop technologies to support individual’s needs. Many researchers in this field have investigated different approaches to support family communication and awareness. However, intergenerational family communication about health has not yet been further explored in HCI. Thus, this study proposes to complement previous HCI research by examining intergenerational family communication about health and designing systems to promote health collaboration within the family.

In this study, I define the term intergenerational health communication as _mutual collaboration: each member is helping one another to become more active and engaged in building a culture of health within the family, placing well-being at the center of family life (R. W. Johnson, 2017). It is not just adult children care for their elderly parents under healthy or critical situations but also elderly parents’ consideration for their adult children. Thus, to foster a culture of health in the family, members’ communication and collaboration become essential.

Finally, I apply the User-Centered Design (UCD) approach as a design practice that states users should be the center of the design of any system (Ritter, Baxter, & Churchill, 2014). In this research, I follow the six steps proposed by Nielsen Norman Group (Norman & Nielsen, 2018) to envision and develop an intergenerational health collaboration system within the family. During this research project, I have applied the following six steps: (1) identify a design problem and define a target audience of whom you are designing for, (2) understand the audience, (3) come up with several creative solutions, and choose one to refine, (4) prototype the design, (5) evaluate the design with users and get feedback, and (6) develop and build the finalized idea.

1.3 Research Objectives

In this research, I propose to apply user-centered design method to design and evaluate an intergenerational health collaborative system for distributed families. In light of the rationale that family plays an important role in engaging members to achieve healthrelated goal, I find potential in this design space to develop a system that builds the family up in health collaboration. This study focuses on the interaction between elderly parents and adult children generations. My goal is to promote the culture of health within the family and engage members from different generations in mutual collaboration by helping one another to become more active and encouraging each other on healthy behaviors change.

Throughout the project, I have conducted exploratory studies to better understand family communication about healthy behaviors, and to identify opportunities for family collaboration in health over distance. I have defined and recruited elderly parents and adult children as my target participants. Then, I used qualitative approaches to understand participant’s current practices, needs, concerns, and visions in the context of health communication and cooperation within the family.

Based on the studies findings, I developed and deployed for a field study a creative design product to aid intergenerational sharing of healthy living information among family members when living apart.

There are three main contributions of this dissertation:

1. Although there have been a good amount of research studies about family communication in different disciplines, including HCI, yet how to leverage intergenerational communication for health between elderly parents and adult children and how technology can support this process have been under-explored. In this dissertation, I propose to examine how intergenerational family relationships and technology use influence health communication and collaboration among family members, from which I aim to identify a design opportunity to promote a culture of health within the family.
2. While most HCI studies on intergenerational family communication support awareness, connectedness, and coordination between grandparents/parents with underage children, this dissertation directs its attention to examine intergenerational family communication between elderly parents and adult children. By targeting and exploring this intergenerational family interaction, this dissertation aims to bring more understanding to this family dynamic and contributes with more knowledge about the experiences and challenges faced by this family relationship to the realm of the HCI field.
3. This dissertation follows the _{design research} approach (Laurel, 2003) which aims to create solutions that corresponds to the users needs. Based on this research findings, I offer a design solution to address the challenge of intergenerational family communication about health when apart. I implemented the proposed solution into a working prototype, and assessed the effectiveness of the it by conducting lab and field experiments for a period of time as a way to gain knowledge and insights of how such system would work in natural settings.

In the following chapters, I first review related literature on family communication patterns theory and present previous research on disclosure and channels of disclosure. Also, I present an overview of the salutogenesis framework and further examine family communication and technology use according to the HCI field by presenting a concise literature review on previous studies in both of these topics (Chapter 2). In Chapter 3, I present detailed information about the research methods, each empirical studies, correspondent findings of each study, and summary of findings. Building on my findings, Chapter 4 presents the design concept, series of interactive prototypes and evaluation study to iteratively refine the proposed design product. In Chapter 5, I introduce detailed information on “PhamilyHealth” architecture, interface, and functions. As for the Chapter 6, I describe the evaluation of the “PhamilyHealth” application which I carried out as part of its deployment to distributed families in natural settings. Finally, Chapter 7, I discuss the implications for the multiple research areas I used as a foundation for my work and opportunities for future work.

DESIGN AND EVALUATION OF INTERGENERATIONAL HEALTH COLLABORATION SYSTEM WITHIN THE FAMILY

Sharing is caring!