Inductive content analysis revealed the emergence of three main themes and twelve sub-themes. The three main themes revolved around the following thematic areas: general views and perceptions on technology-assisted living, usability evaluations and ethical considerations. Figure 1 provides an overview of overall themes and subthemes.
The analysis showed that most participants were fairly familiar with existing digital health technologies for healthy ageing. Many of them reported to be frequent personal computer and smartphone users. However, even among our small study sample, we observed a generational gap in technology penetration and use between older adults aged between 65-79 and people aged 80 or older. In the latter subgroup, both device use and general digital awareness were lower or absent altogether. Most participants familiar with the use of smartphones and personal computers reported using these technologies already before retirement, especially in the workplace.
Most interviewees had a generally positive attitude towards digital health technologies and believed that digital tools could positively contribute to improving their overall wellbeing. No interviewee displayed an explicitly anti-technological stance. In particular, interviewees expected that technology use could improve their safety and empower them by promoting their autonomy. When further articulating the reasons of such technological optimism, interviewees shared hope that digital health technologies for healthy ageing could help them fulfil their wish to age in place and prolong their permanence at home [Participant 19: “I think being at home is the most important thing”].
Interviewees who considered themselves as physically and cognitively healthy perceived a less urgent need to use digital health technologies but argued that they would be willing to increase their technology use if this could help them ensure their safety [Participant 1: “I don't think it is necessary now. But if that was the case (feeling no longer safe), then I would try everything possible to avoid that. So I would try to be in my apartment as long as possible”; Participant 8: “And if you can keep your independence with such digital things for a while, I would think that's great, yes, absolutely”].
Safety emerged as a key concern, and a major motivational factor for digital technology use among the participating seniors. Interviewees feared that, as aging progresses, they may become more vulnerable to everyday risks as a consequence of loneliness, memory lapses or simple distraction [Participant 10: “If the radio or the TV is on and I forget to turn it off it's no big drama. But if I forget to turn off the stove… well… so if some technology helps me live a year longer, either independently or on my own responsibility, then I would probably choose something like that, yes. As a help, yes”]. However, while all interviewees highly valued safety, most of them appeared unwilling to increase their safety at any cost, but only compatibly with broader wellbeing considerations. For example, one interviewee criticized the safety-oriented paradigm of digital health technology and argued that such paradigm is rooted in a widespread unwillingness to accept our mortality and the vulnerability of the human condition [Participant 18: “I believe that getting old is connected to becoming frail and lapsed. At some point you might fall for the last time and break your femur. And this is often the end. I believe that behind too much surveillance there is ultimately a non-acceptance of the mortality that is part of our lives”.]
Prompted by the interviewer, interviewees also discussed issues related to access to digital health technology and cost reimbursement. All interviewees argued that digital health technologies whose clinical effectiveness is scientifically proven should be reimbursed by compulsory health insurance according to the Swiss Federal Law on Health Insurance. Some interviewees observed that if the basic health insurance does not cover the cost of digital health technology for health aging, then such technologies could amplify pre-existing socio-economic inequalities and result in poor technology adoption.
Usability evaluations of digital health technologies
Usability assessment revealed generally positive attitudes towards the care coordination app and the wearable devices and a negative stance towards the conversational robot. Some of the participants found the toy-shaped robot cute or charming and appreciated the device’s ability to speak in Swiss-German dialect. However, most interviewees found that the stuffed toy aspect of the device (in the form of a teddy bear, hence the name Teddy) was infantilizing them [Participant 1: “I find that a bit primitive and ridiculous! (…) Well, that seems to me a very primitive way to occupy myself. I hope I never need that. It looks cute but that's all”]. Some older participants even reported to be offended by the alleged “puerile” and “childish” aspect and voice of the robot. Indicative of this, is one interviewee’s decision to withdraw from the study due to the perceived infantilization induced by the device. The interviewee confirmed his desire to withdraw from the study even after the research team clarified that the study was aimed at collecting user feedback (including negative feedback) on the technologies, not to promote or market them. One participant argued that the conversational robot could raise the risk of deception, especially among older people with cognitive disabilities [Participant 18: “Yes, this is deception, yes, it’s deception! Some deception factor is natural, natural, it’s is always inherent in all these things. That people take something for real because they can no longer assess correctly that it is actually not real at all. So that seems to me to be something very difficult”]. Another interviewee had a more charitable perspective and argued that the Teddy may be helpful to people who are lonely and/or ‘have dementia’.
All interviewees had a favorable view on the care coordination app as they highlighted the importance of improving and facilitating communication between patients, family caregivers, physicians and ambulant formal caregivers. Interviewees observed that such care coordination could be particularly useful to facilitate the coordination of ambulant care through the so-called Spitex organizations (which some of them had already being confronted after a hospital stay and most of them having positive experiences), that are organizations in Switzerland providing home care to community-dwelling seniors by trained nursing and housekeeping personnel. From a usability perspective, they found the app interface intuitive and easy-to-use. They also observed that visual similarity with mainstream messaging platforms such as WhatsApp could facilitate ease of use, in virtue of their pre-existing familiarity with such platforms. At the same time, its similarity with conventional messaging platforms such as WhatsApp made interviewees question the “added-value” of an additional application. A few participants noted that they would not use the app because they either lacked technological competence or preferred communicating via phone call instead of messaging.
The two wrist wearable devices under assessment were all positively evaluated by the participants. There was, however, a strong preference for those wearables with larger screen size (and Apple Watch over the Fitbit). Further, visually impaired study participants reported difficulties with the interface and attributed them to the fact that those interfaces were probably designed for the younger generation, not with a senior population in mind. Managing messaging and other services from the smartwatch appeared difficult to most study participants. However, they positively valued simple safety-enhancing features such as the Emergency SOS function on Apple Watch. This feature allows users to make a call with local emergency services, automatically share the user’s GPS position and alert selected emergency contacts with a predefined text message. Most interviewees observed that such easy-to-use feature would increase their sense of safety when they are alone at home or on a hike.
The ethics assessment revealed four main themes: privacy, striking the right balance between safety and surveillance, empowerment and (lack of) human contact. With regard to privacy, even the most techno-friendly interviewers shared concern about preserving their private sphere from invasive uses of digital health technologies. Much of this concern regarded the risk that one technology used for some assistive purpose could be either repurposed or used to collect redundant information. They also shared concerns about the proportionality between the overall benefit of a certain assistive task and the volume and variety of data collected from them by the application [Participant 15: “I mean, if I fall out of bed and that (app) sends a message, then that's not something that greatly disturbs my privacy. But if it records everything, how you move, where you move, what you eat, what you drink, and whatever else can be recorded with these apps today… pulse, blood pressure, behavior etc. then it becomes much more problematic”]. The risk of misuse was also a chief concern [Participant 19: “As soon that you simply give out your personal data, there is a big danger that this data will be misused”]. Some interviewee argued that, from their perspective, camera-based surveillance systems for home use (e.g. ambient assisted living technologies) raise greater risks of privacy invasion compared to wearable devices [Participant 8: “I think in the bathroom, in the toilet, if you go there naked and anyway to the toilet and so on, I would not like to have that.... But if you fall then, well, then at least you have the watch, which you can still put into operation. But video equipment, especially in the bedroom and bathroom, no… I’ll pass on that… otherwise I would have no problems”]. Many privacy concerns revolved around data and informational privacy. Interviewees showed a general willingness to share health-related data for health-related purposes, especially with health professionals [Participant 2: “With the doctors I know that (my data) won’t be re-shared, that's clear”; Participant 8: “When it comes to health and (the app) only documents that, I find it perfectly okay”]. Interviewees also attributed great importance to the trust relationship between them and their healthcare professionals and/or medical institutions [Participant 6: “To professor [name of the doctor] I would tell him everything, how things go etc. He probably knows most of it (laughs) and if he wants to know something, I tell him... An official institution can have my data. But not the general public”]. Overall, interviewees rated privacy as a very important asset [Participant 14 : “Privacy is, you could say, a sacred good to me”]. One interviewee linked the privacy risks of digital health technologies with data acquisition by health insurers [Participant 15: “Privacy I find something very important. I've always worked for it and I think that's something essential for me. It's that there's not just a camera here… then somehow that goes to a health insurance company, to an insurer and they see what's going on here. That's why I also have trouble with these apps, because there I give so much price of my life and my attitude and about how I move, feed, how I react, that's none of the insurers business”].
When discussing issues of privacy, many interviewees reflected on the importance of striking the right balance between enhancing safety and minimizing privacy-violating surveillance. For example, one interviewee observed that although digital technologies could erode information privacy, they could also thereby increase their physical privacy by obviating the need for institutionalized care. This reflects a broad notion of privacy which envelops both physical and informational privacy. [Participant 18: “I give up my privacy also when I am in a nursing home, don't I? You can come and look at me at any time and come in and so on. (Sighs) I think if you become in need of care, become invalid, you automatically give up a part of your privacy”].
Empowerment through independent living was another key ethical concern. Most interviewees stated frequently the wish to remain independent and age in place [Participant 6: “Yes, especially the possibility to be at home longer and to be independent, I think that is something important, yes”].
Many interviewees attributed great importance to the preservation of human contact in the old age, especially as part of the care relationship. They feared that the expanding use of digital health technologies could reduce human contact and eliminate care tasks which require human empathy and emotions [Participant 2: “Yes, but then you don't talk to the staff anymore, don’t you? I think communication with the caregivers is very important. I don't think I would ever use the [robot]. I think I would just use it sometime. But you need people”]. Several participants seemed to concur that not all care needs and aging-related phenomena can be addressed using digital technologies. [Participant 10: “You can not only talk about the digital world, (…) but about the practical, about the social, about the human and so on, where you can do something, where you can see each other, where you can play or walk or do something and not only digital”].