Quantitative Results
General characteristics of adult children’s willingness to use EMES
A total of 1936 participants finished the questionnaire. There were 955 (49.3%) males and 981 (50.7%) females, and the average age was 37.4 years old. Additionally, 645 participants were from Nanjing, 611 from Suzhou, and 680 from Changzhou. Then, participants were divided into two groups based on their willingness to use EMES: the willingness group (n=1321) and the unwillingness group (n=615). Table 1 shows that among all participants, 68.5% did not live with the elderly, and 73.1% had one or more siblings. When older people were sick, 38.6% went to tertiary hospitals and 39.8% adult children accompanied them to medical appointments. A total of 61.3% children were too busy to accompany the elderly to doctor's appointments, 72.2% had to take time off work, and 39.9% had difficulties asking for a leave. When they went to the hospital, 75.1% children believed that hospital guides and volunteers could help, and 63.3% were satisfied with the medical experience. Moreover, 54.1% children accepted to pay for EMES, and 1060 of 1321 (80.2%) accepted to be charged no more than 300 RMB for a half-day. Additionally, participants considered that the medical escorts should be trained (79.7%) and licensed (77.5%). Besides, 79.5% participants perceived that the EMES should be graded according to the severity of the seniors’ conditions. If the escort profession were to emerge, 76.2% participants would recommend it to their friends or colleagues. The above results presented significant differences between the two groups (p < 0.05).
Table 1
General characteristics of adult children’s willingness to use EMES
|
Overall
(N = 1936)
|
Group
|
p value
|
Unwillingness
(N = 615)
|
Willingness
(N = 1321)
|
Age, (mean, SD)
|
37.4 (11.2)
|
37.3 (11.2)
|
37.5 (11.1)
|
0.763
|
Monthly income, (mean, SD)
|
7186.5 (10610.2)
|
7349.3 (11388.9)
|
7110.7 (10231.1)
|
0.145
|
Gender, (%)
|
0.360
|
Male
|
955 (49.3)
|
294 (47.8)
|
661 (50.0)
|
|
Female
|
981 (50.7)
|
321(52.2)
|
660 (50.0)
|
|
Education, (%)
|
0.188
|
Senior/Polytechnic school or below
|
1012 (52.3)
|
308 (50.1)
|
704 (53.3)
|
|
Bachelor degree or above
|
924 (47.7)
|
307 (49.9)
|
617 (46.7)
|
|
Marital Status, (%)
|
0.630
|
Unmarried, widowed, divorced
|
569 (29.4)
|
176 (28.6)
|
393 (29.8)
|
|
Married
|
1367 (70.6)
|
439 (71.4)
|
928 (70.2)
|
|
Do you live with the elderly? (%)
|
0.002
|
No
|
1327 (68.5)
|
391 (63.6)
|
936 (70.9)
|
|
Yes
|
609 (31.5)
|
224 (36.4)
|
385 (29.1)
|
|
Do you have any siblings? (%)
|
0.047
|
No
|
521 (26.9)
|
184 (29.9)
|
337 (25.5)
|
|
Yes
|
1415 (73.1)
|
431 (70.1)
|
984 (74.5)
|
|
Where do older people usually go when they are sick? (%)
|
<0.001
|
Do not go to the doctor
|
88 (4.5)
|
44 (7.2)
|
44 (3.3)
|
|
Pharmacy
|
289 (14.9)
|
91 (14.8)
|
198 (15.0)
|
|
Private clinic
|
196 (10.1)
|
78 (12.7)
|
118 (8.9)
|
|
Community Health Service Center
|
615 (31.8)
|
181 (29.4)
|
434 (32.9)
|
|
Tertiary hospital
|
748 (38.6)
|
221 (35.9)
|
527 (39.9)
|
|
Who accompanies the elderly to their medical appointments when they are sick? (%)
|
<0.001
|
Seniors themselves/spouses
|
301 (15.5)
|
114 (18.5)
|
187 (14.2)
|
|
Volunteers, etc.
|
270 (13.9)
|
108 (17.6)
|
162 (12.3)
|
|
Relatives
|
594 (30.7)
|
198 (32.2)
|
396 (30.0)
|
|
Adult children
|
771 (39.8)
|
195 (31.7)
|
576 (43.6)
|
|
Do you have situations where you are too busy to accompany an elderly person to a doctor's appointment when they are sick? (%)
|
<0.001
|
No
|
750 (38.7)
|
294 (47.8)
|
456 (34.5)
|
|
Yes
|
1186 (61.3)
|
321 (52.2)
|
865 (65.5)
|
|
Do you have situations where you have to take time off work to accompany them to see a doctor? (%)
|
<0.001
|
No
|
539 (27.8)
|
223 (36.3)
|
316 (23.9)
|
|
Yes
|
1397 (72.2)
|
392 (63.7)
|
1005 (76.1)
|
|
Is there any difficulty in taking time off work to take the elderly to see a doctor? (%)
|
<0.001
|
No
|
1164 (60.1)
|
410 (66.7)
|
754 (57.1)
|
|
Yes
|
772 (39.9)
|
205 (33.3)
|
567 (42.9)
|
|
Can hospital guides and volunteers help you and the elderly when you go to the hospital? (%)
|
<0.001
|
Can not help at all
|
483 (24.9)
|
195 (31.7)
|
288 (21.8)
|
|
Partially helpful
|
739 (38.2)
|
215 (35.0)
|
524 (39.7)
|
|
Totally helpful
|
714 (36.9)
|
205 (33.3)
|
509 (38.5)
|
|
How was your recent experience accompanying an older adult to a doctor's appointment? (%)
|
<0.001
|
Very dissatisfied
|
101 (5.2)
|
62 (10.1)
|
39 (3.0)
|
|
Not satisfied
|
120 (6.2)
|
82 (38.1)
|
38 (2.9)
|
|
Average
|
488 (25.2)
|
130 (21.1)
|
358 (27.1)
|
|
Satisfied
|
619 (32.0)
|
168 (27.3)
|
451 (34.1)
|
|
Highly satisfied
|
608 (31.3)
|
173 (28.1)
|
435 (32.9)
|
|
Would you agree paying for the use of EMES? (%)
|
<0.001
|
No
|
889 (45.9)
|
400 (65.0)
|
489 (37.0)
|
|
Yes
|
1047 (54.1)
|
215 (35.0)
|
832 (63.0)
|
|
Who do you think is an appropriate medical escort? (%)
|
0.003
|
Those who are familiar with the consultation process
|
470 (24.3)
|
142 (23.1)
|
328 (24.8)
|
|
Volunteers
|
250 (12.9)
|
79 (12.8)
|
171 (12.9)
|
|
Housekeeping staff
|
126 (6.5)
|
58 (9.4)
|
68 (5.1)
|
|
Interns/Nursing students
|
554 (28.6)
|
185 (30.1)
|
369 (27.9)
|
|
Nurse practitioners
|
536 (27.7)
|
151 (24.6)
|
385 (29.1)
|
|
How much should be charged for a half-day EMES? (%)
|
<0.001
|
Free
|
389 (20.1)
|
128 (20.8)
|
261 (19.8)
|
|
1~150 RMB
|
1116 (57.6)
|
318 (51.7)
|
798 (60.4)
|
|
151~300 RMB
|
431 (22.3)
|
169 (27.5)
|
262 (19.8)
|
|
Do you think medical escorts need regular training and assessment? (%)
|
<0.001
|
No
|
393 (20.3)
|
220 (35.8)
|
173 (13.1)
|
|
Yes
|
1543 (79.7)
|
395 (64.2)
|
1148 (86.9)
|
|
Do medical escorts need to be licensed? (%)
|
<0.001
|
No
|
436 (22.5)
|
209 (34.0)
|
227 (17.2)
|
|
Yes
|
1500 (77.5)
|
406 (66.0)
|
1094 (82.8)
|
|
Should EMES be graded according to the severity of the elderly’s conditions? (%)
|
<0.001
|
No
|
396 (20.5)
|
213 (34.6)
|
183 (13.9)
|
|
Yes
|
1540 (79.5)
|
402 (65.4)
|
1138 (86.1)
|
|
If the escort profession were to emerge, would you recommend it to your friends or colleagues? (%)
|
<0.001
|
No
|
460 (23.8)
|
215 (35.0)
|
245 (18.5)
|
|
Yes
|
1476 (76.2)
|
400 (65.0)
|
1076 (81.5)
|
|
Factors associated with the children’s willingness to use EMES among all participants
Among all participants, the children's willingness to use EMES was considered a dependent variable (0 = no, 1 = yes). The dummy variables were assigned to the multicategorical variables in the independent variables: monthly income, whether you have siblings (0 = no, 1 = yes), do you live with the elderly (0 = no, 1 = yes), where do older people usually go when they are sick (0 = other, 1 = tertiary hospital), who accompanies the elderly when they are sick (0 = other, 1 = children), whether you are too busy to accompany the elderly when they are sick (0 = no, 1 = yes), do the children have leave of absence to accompany the elderly to see a doctor (0 = no, 1 = yes), is there any difficulty in taking time off (0 = no, 1 = yes), can hospital guides and volunteers help you and the elderly (0 = no, 1 = yes), outpatient satisfaction (0 = no, 1 = yes), whether the escort is regular trained (0 = no, 1 = yes), whether the escort is licensed (0 = no, 1 = yes), whether the EMES is paid for use (0 = no, 1 = yes), and whether the EMES is graded according to the elderly’s conditions (0 = no, 1 = yes). Confounding factors, such as age and gender, were controlled and binary logistic analyses were performed. Table 2 indicates that long-distance separation from seniors [OR=0.79, 95% CI (0.63-0.98), p=0.033], difficulties in taking leaves to accompany the elderly to medical appointments [OR=1.39, 95% CI (1.11-1.73), p=0.003], outpatient satisfaction [OR=1.24, 95% CI (1.13-1.36), p<0.001], payment for EMES [OR=2.56, 95% CI (2.07-3.18), p<0.001], escorts being trained [OR=2.35, 95% CI (1.80-3.07), p<0.001] and licensed [OR=1.31, 95%CI (1.01-1.72), p=0.044], and EMES being graded [OR=1.93, 95% CI (1.48-2.51), p<0.001] were independent influential factors for the children’s willingness to use EMES.
Table 2
Combination of quantitative and qualitative findings by associated factors
Related factors
|
Quantitative findings, OR (95% CI)
|
Qualitative findings
|
Meta-inferences
|
Long-distance separation
|
0.79 (0.63-0.98)
|
Children do not live with the elderly and when they are sick, children can not accompany them to the hospital, who can pay for someone to accompany seniors to medical appointments.
|
Accordance: the two studies identified that long-distance separation, having a leave of absence to accompany seniors to see a doctor by themselves, and difficulty in taking time off work are influential factors in children's willingness to use EMES.
|
Children accompany seniors to see the doctor by themselves
|
1.14 (1.03-1.26)
|
Smart hospitals are only friendly to young people. The elderly do not know how to use hospitals’ smart terminals and have communication barriers with the medical staff. Children are concerned about the elderly going to see a doctor alone and I always take time off to accompany them to medical appointments.
|
The children have a leave of absence
|
1.34 (1.08-1.66)
|
Children are busy with work and it is difficult to take time off, so they are willing to use EMES.
|
Difficulty in taking time off work
|
1.39
(1.11-1.73)
|
Would you agree to pay for EMES?
|
2.56 (2.07-3.18)
|
Escorts are professionals who are familiar with the consultation process and are highly efficient, so they get their money's worth for their work. However, the price can not be higher than the salary deducted for the leave.
|
Outpatient satisfaction
|
1.24 (1.13-1.36)
|
Children were not familiar with the consultation process, so they had to keep asking the guide, waiting in line and taking care of the elderly, and worrying if they would fall, which was particularly testing.
|
Discordance: The rate of dissatisfaction with medical experience in the quantitative survey data was much lower than the qualitative data, showing that terrible medical experience was common.
|
Regular training and assessment of escorts
|
2.35
(1.80-3.07)
|
There have been previous reports of babysitters abusing the elderly. Hence, whoever accompanies an older person to a doctor's appointment must be trained and qualified for the job, especially in professional ethics, to ensure the safety of the elderly.
|
Expansion: Both surveys demonstrated that escorts should be trained and licensed. However, adult children paid more attention to the ethics of the escorts and their ability to love and care for the elderly.
|
Escorts need to be licensed
|
1.31
(1.01-1.72)
|
EMES is graded according to the elderly’s conditions
|
1.93 (1.48-2.51)
|
There is a necessity for graded companionship based on the condition of the elderly, but the elderly still want to have their children with them when they are seriously ill, which is also a traditional Chinese virtue.
|
Expansion: Both data showed that it is necessary to have level-to-level escorting, but it is also important for family members to accompany the patient, especially if the older person is seriously ill because of the Chinese filial piety culture.
|
Qualitative Results
Basic information of the interviewees
21 individuals participated in the qualitative interviews, including 7 from Nanjing, 7 from Suzhou, and 7 from Changzhou. There were 11 men (52.4%); and the average age was 38.9 years old. 10 (47.6%) interviewees had a bachelor's degree or above (Table 3). The demographic characteristics of the participants in the qualitative interviews were similar to those in the quantitative study.
Table 3
Basic information of the 21 interviewees
Coding
|
Gender
|
Age
|
Education
|
Accompanying patients
|
Occupation
|
Willingness to use EMES
|
A1
|
Male
|
27
|
Bachelor degree
|
Grandmother
|
Engineer
|
No
|
A2
|
Male
|
30
|
Bachelor degree
|
Grandfather
|
Civil engineer
|
Yes
|
A3
|
Male
|
43
|
Junior high school
|
Mother
|
Welder
|
Yes
|
A4
|
Male
|
51
|
Senior high school
|
Mother
|
Cook
|
No
|
A5
|
Female
|
24
|
Bachelor degree
|
Grandfather
|
Clerk
|
Yes
|
A6
|
Female
|
48
|
Junior high school
|
Father-in-low
|
Saleswoman
|
Yes
|
A7
|
Female
|
50
|
Primary school
|
Mother
|
Worker
|
No
|
A8
|
Female
|
43
|
Primary school
|
Father
|
Construction worker
|
No
|
A9
|
Female
|
47
|
Senior high school
|
Father
|
Construction worker
|
Yes
|
A10
|
Male
|
50
|
Junior high school
|
Mother
|
Welder
|
Yes
|
A11
|
Male
|
42
|
Senior high school
|
Parents
|
Construction worker
|
No
|
A12
|
Male
|
26
|
Bachelor degree
|
Grandmother
|
Engineer
|
Yes
|
A13
|
Female
|
42
|
Bachelor degree
|
Mother-in-law
|
Company employee
|
Yes
|
A14
|
Male
|
49
|
Master degree
|
Father
|
Civil servant
|
Yes
|
A15
|
Female
|
32
|
Bachelor degree
|
Grandfather
|
Company employee
|
Yes
|
A16
|
Male
|
45
|
Bachelor degree
|
Mother
|
Company employee
|
Yes
|
A17
|
Female
|
46
|
Senior high school
|
Mother-in-law
|
Company employee
|
Yes
|
A18
|
Female
|
35
|
Bachelor degree
|
Mother
|
Civil servant
|
Yes
|
A19
|
Male
|
40
|
Senior high school
|
Father
|
Driver
|
Yes
|
A20
|
Male
|
25
|
Bachelor degree
|
Grandfather
|
medical representative
|
Yes
|
A21
|
Female
|
50
|
Primary school
|
Mother-in-law
|
worker
|
No
|
Qualitative Findings
Five themes were summarized from the qualitative study: the feelings of children accompanying the elderly to see a doctor, difficulties encountered by children accompanying the elderly to medical appointments, children’s willingness to pay for EMES, and children's suggestions on EMES (Table 4).
Table 4
Qualitative Findings
Theme
|
Qualitative findings
|
Feelings of children accompanying the elderly to see a doctor
|
Satisfaction with medical experience
|
A1: The hospital provided wheelchairs, and it was convenient to push my grandmother to see the doctor.
A2: The hospital self-help machine was equipped with staff to guide how to use it.
|
Dissatisfaction with medical experience
|
A4: The consultation process was complicated and cumbersome, I was not familiar with the hospital, running back and forth to find the department, the efficiency of seeing a doctor was low, and taking my mom with me made both of us very tired.
|
Difficulties encountered by children accompanying the elderly to medical appointments
|
Smart hospitals are not friendly to the elderly
|
A15: Smart hospitals are only friendly to young people, and I am concerned about my grandfather going to see a doctor alone.
A5: My grandfather did not know how to use hospital smart terminals and had communication barriers with medical staff, and need us to accompany him to medical appointments
|
Difficulty in taking time off work to accompany seniors to medical appointments
|
A12: I am a developmental engineer and very busy, so it is very difficult to take time off. If I take time off, the whole project will be affected.
A13, A17: I have to take time off by transferring, and I have to work overtime to make up the work I should do, otherwise it will affect the progress of the team.
A15, A19: Taking time off will affect attendance and will deduct salary, so I accompany the elderly to his appointments on weekends and feel tired on weekdays because I didn't rest properly on our days off.
|
Hospital guides and volunteers can not help
|
A6: Accompanying the elderly, the registration was fast, but the waiting time to see the doctor was long, especially the tests. Some tests could not even be done on the same day, and I only took one day off, so it was a hassle.
A5: We made an appointment to register online in advance, but, when we arrived at the hospital, we were told that we had registered for the wrong department and had to wait in line to register again, which made us very annoyed.
|
Adult children's attitudes toward EMES
|
Willingness to use EMES
|
A2: I am busy with work and it is difficult to take time off, so I am willing to use EMES.
A14: We do not live with the elderly and when they are sick, we can not accompany them to the hospital. We can pay for someone to accompany them to medical appointments.
A5, A20: The escorts are more familiar with the hospital and the consultation process than I am, and are more professional and will not register in the wrong department. It is more efficient, the elderly suffer less, and I get a good rest, too. It is a win-win situation for everyone.
|
Unwillingness to use EMES
|
A1, A8: There have been previous reports of babysitters abusing the elderly. Thus, I am concerned about the character of the escorts, and will not leave the elderly with them alone.
A7: If it's free, I'm willing to use.
|
Children’s willingness to pay for EMES
|
Willingness to pay for EMES
|
A12, A20: Escorts are professionals who are familiar with the consultation process and are highly efficient, so they get their money's worth for their work.
A10: The price can not be higher than the salary deducted for the leave.
A18: I am too busy at work to take care of the elderly, so we are willing to pay for a professional to accompany them to the doctor.
|
Unwillingness to pay for EMES
|
A1: EMES does not meet my requirements, especially the professional ethics, I do not feel comfortable leaving the elderly to them.
A21: EMES is part of the hospital's work and cannot be charged for.
A7, A11: I can not afford the high cost of EMES.
|
Children's suggestions on EMES
|
The escorts should be trained and licensed
|
A9, A12: Whoever accompanies an older person to a doctor's appointment must be trained and qualified for the job, especially in professional ethics, to ensure the safety of the elderly.
|
EMES should be graded according to the elderly’s conditions
|
A14: I think there is a necessity for graded companionship based on the condition of the elderly.
A3: The medical escort can accompany the patient in minor cases alone. But my parents should be accompanied by me if they are seriously ill. It is a traditional virtue for my parents to want to be accompanied by their loved ones at medical appointments.
|
Hospitals strengthen the supervision and training of escorts
|
A1, A16: The hospital should be responsible for training and supervising the escorts so that we can use EMES with confidence.
|
Combination of quantitative and qualitative findings by associated factors
In the quantitative study, long-distance separation, children accompanying seniors to see a doctor by themselves and having a leave of absence to accompany the elderly to see a doctor, difficulty in taking time off, outpatient satisfaction, payment for EMES, the escort being trained and licensed, EMES being graded according to the elderly’s conditions were independent influential factors for children’s willingness to use EMES (Table 2). The results of the interview offered a deeper understanding of the factors influencing the children’s willingness to use EMES. All interviewees accompanied the elderly to see a doctor in the past three months. Most respondents considered that the consultation process was complicated and cumbersome, and smart hospitals were not friendly to the elderly, who had communication barriers with the medical staff. Hence, children were concerned about the elderly going to see a doctor alone and had to take time off to accompany them. However, there were some difficulties in taking time off: “I had to take time off by transferring and had to work overtime to make up the work I should do, otherwise it will affect the progress of the team.” “Taking time off would affect attendance and deduct salary, so I accompanied the elderly to his appointments on weekends.” Additionally, some children felt physically and mentally exhausted when accompanying older adults to medical appointments: “Yesterday I was at work, today I accompanied my mom to a doctor's appointment. I was not familiar with the consultation process, so I had to keep asking the guide, waiting in line and taking care of the elderly, and worrying if she would fall, which was particularly testing.” Therefore, most participants were willing to use EMES: “The escorts are more familiar with the hospital and the consultation process than I am, and are more professional and will not register in the wrong department. It is more efficient, the elderly suffer less, and I get a good rest, too. It is a win-win situation for everyone.” Moreover, some respondents noted that they were willing to pay for EMES because the escorts got their money's worth for their work, but the price should not be higher than the salary deducted for the leave.
The quantitative survey showed that outpatient satisfaction [1227 of 1936 (63.3%)] was positively associated with the children’s willingness to use EMES. However, the findings from the interviews revealed that only 23.8% of the interviewees (5 of 21) were satisfied with the medical experience: “We made an appointment to register online in advance, but, when we arrived at the hospital, we were told that we had registered for the wrong department and had to wait in line to register again, which made us very annoyed.”
Both surveys demonstrated that the escorts should be trained and licensed. However, the adult children paid more attention to the professional ethics of the escorts and their ability to love and care for the elderly: “There have been previous reports of babysitters abusing the elderly. Hence, whoever accompanies my parents to a doctor's appointment must be trained and qualified for the job, especially in professional ethics, to ensure the safety of the elderly.”
The data from both studies showed that level-to-level escorting is required according to the elderly’s condition. However, several interviewees assumed it was also important for family members to accompany the old patient because of Chinese filial piety culture, especially if they were seriously ill: “I think there is a necessity for graded companionship based on the condition of the elderly, but my parents still want to have me when they are seriously ill, which is also a traditional Chinese virtue.”