The Healthy e-Elderly People Assessment (HEPA) application An evaluation of health effects from smartphone and tablet usage among senior citizens in Thailand

Purpose – The purpose of this paper is to evaluate health effects and determine the factors associated with health effects from smartphone and tablet use among the elderly in Thailand. Design/methodology/approach – This study was a cross-sectional descriptive study. The participants comprised 490 elderly people. A self-administered questionnaire was used for data collection via the Healthy e-Elderly People Assessment mobile application in the Android operating system by Google which consists of five parts of a questionnaire. The variables were analyzed using SPSS such as frequency, percentage, mean and binary logistic regression. Findings – Altogether, the participants were 223 males and 267 females; mean age1⁄4 64.9± 5.4. The average time spent using a mobile device was 2.8± 1.9 h/day. Participants recorded that after use of either device, 59.0 percent experienced eye pain, 52.7 percent experienced dim eyes, 30.2 percent experienced tiredness, and 28.0 percent experienced moodiness. Socially, 26.8 percent recorded changes in social interaction. Periods of time using devices, time consumed in device usage (hours/day), the type of application, and the difference in times of use, place of usage and time spent in rest breaks from smartphone or tablet usage were significantly associated with health effects ( po0.05). Originality/value – The elderly users may be at risk of several health effects from smartphone and tablet use. The potential gap in knowledge conceals some of the risk factors for the current health effects. Practical intervention to reduce health effects from the use of smartphones and tablets should be considered.


Introduction
There are many mobile communication devices used in Thailand, such as smartphones, tablets, desktops and laptop computers, of which smartphones and tablets are the more popular choices [1].Smartphones are essentially cellular phones with built-in applications [2], and tablets are wireless portable personal computers with a touchscreen interface.
User behaviors of smartphones and tablets are increasingly demonstrating patterns related to internet addiction [3].Moreover, the increasing use and dependence of smartphones and tablets have become a prevalent issue in public health as reports of both positive and negative health effects from smartphone use increase.
Positive health effects that are evidenced in the use of voice communication in mobile devices have a positive correlation with well-being.Voice communication increases positive emotions in the individual [4].Moreover, sending photos to family members and friends is associated with stress reduction.When people take smiling selfie photos on their smartphone, it makes them happy [5].Additionally, there are some advantages of smartphone or tablet usages like mobile health that provide healthcare information, patient observation, and data collection for health [6].
More recently, however, there is increasing literature about the possible health effects of the internet and computer usages among elderly people [7].Nevertheless, there are some differences between computer usages and smartphone or tablet usages.Smartphone or tablet users are able to access their devices from various workstations and postures such as using a smartphone or tablet on a sofa or while using public transport [8].Additionally, the screen surface of smartphones or tablets do not allow the person's wrist and fingers to rest while using it [9].Therefore, smartphone and tables usages also have negative health effects such as musculoskeletal pain [10,11].Back pain and neck pain can occur when a screen is not positioned properly and poor body postures are practiced [12,13].Also, a previous study reported dizziness or headaches [14].Headaches can be caused by repeated eye strain [12,13] or effects from electromagnetic waves [14].Moreover, smartphone and tablet usages affect the eye system with reports of irritated eyes, dry eyes, eye strain, or double vision [15].Other symptoms reported were sleep disturbances, symptoms of depression [16], and lack of sleep quality.Depression and anxiety also affect the user's emotions and contributes to a much larger health issue [17].
The number of elderly people in Thailand is increasing annually, accounting for 15.1 percent (9,934,309) of the total population in 2016 [18].Of this number, there are 5,816,966 elderly people using mobile phones, including 639,911 or 6.4 percent that specifically use smartphones in Thailand [19].Currently, the target population of the mobile phone industry is young people who take advantage of multifunctioning small devices; there is limited concern for the requirements of the elder user [20].Elderly users may have problems with mobile phone usages such as limited size screens and text with small buttons because elderly users do not have the same finger dexterity, hearing sensitivity, and visual memory as younger people [21,22].Moreover, elderly people are amongst the vulnerable groups of the community who are unable to anticipate, cope with, resist, and recover from the impacts of disasters [23].Therefore, elderly user health effects from smartphone and tablet usages are of concern and should be addressed.Currently, there is a lack of research in Thailand, and worldwide, that addresses the health effects of using mobile communication devices, especially smartphones and tablets, within the elderly population.Also, there is a lack of approach in assessing the health risks of using smartphones and tablets within the elderly population.Thus, this study focuses on two factors.One, evaluating the health effects of smartphones and tablets among the Thai elderly; and two, identifying the factors associated with the health effects from smartphones and tablets among the Thai elderly.

Materials and methods
A cross-sectional descriptive approach was used in this study.This study was conducted in every region of Thailand.All the users who installed the Healthy e-Elderly People Assessment (HEPA) mobile application between March and July 2017 were included as participants in this study survey.Males or females older than 60 years old who were confirmed by their answer on users' age in the HEPA application were recruited into this study.If the users' age was less than 60 years old, the users were not allowed to access the other pages of the HEPA application.Other inclusion criteria were people who have applied The HEPA application to it for more than six months and who were literate.The total number of participants was 490 elderly people in this study.The HEPA application is a free mobile application developed in the Thai language by the researcher team and runs on the Google Android operating system.Elderly users can download and install the app via their own mobile phone at: https://play.google.com/store/apps.The HEPA consists of a five-part questionnaire including: demographic characteristics, usage of mobile communication devices and applications, frequency and magnitude of health effects lasting three months during and after using smartphones or tablets based on participant's perception and judgment, knowledge, attitudes and practices regarding health effects of smartphone or tablet usage, and quality of life.A self-administered questionnaire was used for data collection throughout the HEPA application.The validity of the questionnaire in the HEPA application was evaluated by three experts in public health; the validity and reliability were deemed acceptable (IOC ¼ 0.85, Cronbach's α ¼ 0.75) [24].The study protocol was approved by the Ethics Review Committee for Research Involving Human Research Subjects, Health Sciences Group I, Chulalongkorn University (RECCU No. 146.2/59).
Data were entered and analyzed with licensed SPSS.Descriptive statistics were used for describing information.Evaluation of the relationship between smartphone or tablet usage and health effects was analyzed by binary logistic regression adjusted by age, status in-house, gender, number of members in-house which were variables relating to the possible health outcomes [12,24,25].

Results
Based on responses to the questionnaire, the number of participants in this study was 490 including 267 (54.5 percent) females and 223 (45.5 percent) males.The average age was 64.9 ± 5.4 years old.Most (67.1 percent), participants were married and living together as a couple.In total, 223 (45.5 percent) of them graduated with a bachelor's degree or higher.Most of them (63.3 percent) had a current income.Almost (75.3 percent) had no chronic disease.

The behavior of smartphone and tablet use
In total, 253 (49.6 percent) participants had used smartphones or tablets for more than a year but less than five years.The average period of using devices was 3.1 ± 2.1 years.The majority of 453 participants used smartphones (92.5 percent) and 45 (9.2 percent) of them used tablets.The average use of the devices was 2.8 ± 1.9 h per day.Almost the same number of participants used smartphones or tablets for making a phone call and application.The top three applications used were reported to be for social networking 260 people (53.1 percent), photo and video recording 177 people (36.1 percent), and games 102 people (20.8 percent).The elderly commonly used their device before sleep 418 people (85.3 percent), in the evening 255 people (52.0 percent), and in the morning 233 people (47.6 percent).Locations for use of their mobile device included the living room 377 people (76.9 percent), in their bedroom 330 people (67.3 percent), and in a restaurant 149 people (30.4 percent).About half of them (53.1 percent) sometimes rested their eyes before continuing to use smartphones and tablets (Table I).

The frequency of health effects from smartphone and tablet use
The participants reported the top five physical health effects from smartphone and tablet usage over a period of three months.These included the following symptoms: retinal disease or eye pain 289 participants (59.0 percent), conjunctivitis or dim eyes 258 participants (52.7 percent), shoulder or neck pain or sore muscle 238 participants (48.6 percent), wrist pain 188 participants (38.4 percent), and headache 183 participants (37.3 percent).The report on the top five mental health effects from smartphone and tablet usage included tiredness for 148 participants (30.2 percent), moodiness for 137 participants (28.0 percent), lack of  The HEPA application concentration for 136 participants (27.8 percent), anxiety, strain, tension, worry amongst 118 participants (24.1 percent), and feeling lonely for 115 participants (23.7 percent).The top five social health effects included a change in social interactions, e.g., less talk, fewer activities for 131 participants (26.8 percent), strangers trying to make contact via social networks for 124 participants (25.4 percent).A total of 109 people (22.2 percent) reported that using devices resulted in lost or stolen smartphones or tablets.A total of 104 sometimes had communication problems with others (21.2 percent) such as mistyping resulting in misunderstanding.In total, 101 people (20.7 percent) of them had a loss of concentration when working with others or alone (Figure 1).

Association between smartphone and tablet usages and health effects
Participants who used a smartphone or tablet for longer periods of time had an increase in physical health effects (OR ¼ 1.18; 95% CI ¼ 1.03-1.35)and social health effects (OR ¼ 1.03; 95% CI ¼ 1.00-1.60).Those who used the devices for more than an hour per day experienced an increase in physical health effects (OR ¼ 1.23; 95% CI ¼ 1.05-1.45)and social health effects (OR ¼ 1.13; 95% CI ¼ 1.02-1.25).Participants who used social networking applications had an increase in physical health effects (OR ¼ 2.07; 95% CI ¼ 1.22-3.53)and social health effects (OR ¼ 1.82; 95% CI ¼ 1.25-2.65).Those who used travel applications had an increase in physical health effects (OR ¼ 2.50; 95% CI ¼ 1.37-4.58)and social health effects (OR ¼ 1.73; 95% CI ¼ 1.18-2.55).However, participants who used photo and video applications had statistically decreased mental health effects compared to those who did not use them (OR ¼ 0.57; 95% CI ¼ 0.39-0.83).Those who used music applications had decreased social health effects (OR ¼ 0.54; 95% CI ¼ 0.31-0.95).Furthermore, differences in the place of device use were associated with health effects; participants who used their device in the living room experienced a statistical increase in social health effects compared  II).

Discussion
The results of this study reported physical health effects such as eye symptoms, musculoskeletal symptoms, and nervous system symptoms similar to a previous study in Thailand that conducted a study among elderly users of mobile communication devices [24].Moreover, these study results are consistent with the previous study in a 2012 survey among American people, which reported neck and shoulder pain, eye strain, dry eyes, blurred vision, and headache [12].The previous studies among other age groups in India show that participants had redness in the eyes, fatigue, irritated eyes, dry eyes, eye strain, or double vision [15].Screen glare can cause blurred vision.Bright backlight in the device's screen can cause eye redness or irritation when users used devices for long periods of time.Reduced blinking of eyes can cause dry eyes [13].A suggestion to prevent eye symptoms is to adjust the brightness of devices and increase the text size on the screen [12].The users' reported nervous system symptoms and musculoskeletal symptoms in this study were similar to another study in Korea [11].When people use a smartphone, they usually flexed their neck downwards to stare at the lowered screen and maintained the head in a forward position for long periods of time which may cause musculoskeletal disorders [26][27][28].In addition, these study results were similar to previous studies where adults had reported chronic headaches or dizziness [3,14].Due to periods of focusing on the screen, stresses to the eye muscle can occur.The resulting eye strain can cause headaches [13].
Reports of mental health effects in this study can be supported by several studies.Using the internet for e-mails or texting among elderly people increased anxiety symptoms [29].Uncomfortable workplace strain may be a result of looking down at the device and touching the touchscreen display for texting on smartphones [30,31].Likewise, sleep disturbance, lack of concentration, and impairment of short-term memory were related to mobile phone use [32].The decrease of sleepiness may be another effect from the blue light in smartphone [33].
Moreover, our findings also raised questions about the overuse of devices resulting in social health effects.These results are similar to other studies.They had shown the reasons that overuse of smartphones resulted in a decrease in the amount of time spent in The HEPA application developing face-to-face social relationships and in engaging in social activity [34].Using a mobile phone could increase reports of carelessness, forgetfulness, and poorer reflexes [35].Excessive use of mobile phones interferes with romantic relationships and can indirectly affect depression through relationship happiness and life satisfaction [36].
The present study found statistically significant associations between physical health effects and the use of mobile applications.Previous studies described how most mobile communication devices required users to hold their arms out in front of them to read.Thumb postures while text messaging could lead to pain in the neck and shoulders as well as fatigue [27] and showed that thumb disorders have been associated with the use of handheld devices [37].Resting of eyes before continuing is associated with health effects in this study.Previous studies had shown an association between time spent using a mobile device during the day and neck or shoulder pain [38].Resulting from the continuous use of smartphones, users may experience problems with their eyes caused by faster evaporation of the tear film [39].
The results from this study regarding mental health effects and factors associated with mobile device use are supported by other studies.A previous study found that taking photos and sharing them with other people decreased stress in people [5].Besides, participants who have always rested their eyes before continuing to use their mobile devices experienced statistically reduced mental health effects.It is reasonable to state that reduced device usage results in more rest for the eyes.
Participants who used smartphones or tablets for a longer period of time or used devices for more than an hour per day or practiced reduced time resting eyes before continuing to use smartphones or tablets had an increase in social health effects.The previous study found that overuse of smartphones resulted in a decrease in the amount of time spent in developing face-to-face social relationships and in engaging in social activity [40].The previous study showed a negative association between using social networking application with people who follow strangers on social media and social health effects [41].
There are some limitations to this study.First, due to a lack of a comparison group, it is possible that the result overestimated the health effects attributed to mobile communication device use.Second, there was a low population representativeness due to the online survey.Finally, there may be an element of subjectivity of the health effect attribution based on participant's perception and judgment.

Conclusion
The elderly people in Thailand have increased the length of time they spend on mobile communication devices resulting in this growing group of the nation's population being at risk of several serious health effects.The potential gap in knowledge conceals some of the risk factors for the current health effects of using mobile communication devices.The HEPA application offers the potential to assess the effects of excessive use of mobile communication devices.Further communication interventions may be required to reduce health effects on elderly people.
The HEPA application

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those who did not (OR ¼ 1.99; 95% CI ¼ 1.29-3.09),participants who used their device while riding the bus, train, or in car as a passenger had a statistical increase in social health effects (OR ¼ 1.93; 95% CI ¼ 1.11-3.33),while those who used their device in restaurants had an increase in physical health effects (OR ¼ 2.21; 95% CI ¼ 1.14-4.27),also participants who used their device in the toilet had an increase in physical health effects (OR ¼ 2.36; 95% CI ¼ 1.09-5.13).Differences in the time of device use were associated with health effects; participants who used their device late in the morning experienced a statistical increase in physical health effects compared to those who did not (OR ¼ 2.29; 95% CI ¼ 1.28-4.09),participants who used their device in the afternoon showed a statistical increase in mental health effects (OR ¼ 1.97; 95% CI ¼ 1.34-2.90)and increase in social health effects compared to those who did not use them (OR ¼ 2.25; 95% CI ¼ 1.51-3.35).Those who used their device during bed times showed a statistical increase in mental health effects (OR ¼ 1.48; 95% CI ¼ 1.01-2.16)and increase in social health effects compared to those who did not use them (OR ¼ 1.53; 95% CI ¼ 1.03-2.26).Participants who always rested their eyes before continuing to use their device experienced a statistical reduction in physical health effects compared to those who did not rest their eyes (OR ¼ 0.24; 95% CI ¼ 0.13-0.42),a reduction in mental health effects (OR ¼ 0.53; 95% CI ¼ 0.33-0.86),and a reduction in social health effects (OR ¼ 0.20; 95% CI ¼ 0.12-0.34).But those who never rested their eyes before continuing statistically increased in physical health effects compared to those who did rest them (OR ¼ 6.23; 95% Lack of concentration while working with others or in the act of doing Communication problem with others Forgetting carelessness, stealing of smartphones or tablets Strangers will try to know in social network The change of surrounding people, e.g., less talk, fewer activities Note: n = 490to CI ¼ 2.44-15.93),increases in mental health effects (OR ¼ 1.68; 95% CI ¼ 1.12-2.54),and an increase in social health effects (OR ¼ 2.54; 95% CI ¼ 1.64-3.94)(Table Binary logistic regression adjusted by age, status in-house, gender, number of members in the house.*Significant at 0.05 probability level