Background

Aging is one of the greatest social and economic challenges of the 21st century and will affect all European countries.1 The aging population will lead to a rise in the number of people with age-related diseases, thus increasing the demand for home care services.2 This trend in the general population is also expected to cause a major shortage of health professionals, and there is a need for new ways of organizing services in the healthcare sector in the years ahead.3 Telecare is seen as a potential way to address the future care needs of the aging population through empowering older people and helping them to maintain their independence as long as possible so that less care is required.4

Telecare is defined as the use of communication technology to provide health and social care directly to the user5 and is an umbrella concept of several technological solutions that provide safety and security to people living in their own homes. Telecare products can be classified into three categories.6 First-generation devices are the simplest form of telecare and includes a user-triggered alarm button. Second-generation telecare systems utilize a range of sensors that detect specific hazards, and they do not require the users to trigger them. Third-generation telecare systems have more complex capabilities and can include measurement, and collection and analysis of data in the user's home.6

These changes in the way health care is provided, via the use of technology, come at a time when older people's expectations of home care services are also changing.7 Home care services represent a large field of care activities and encompass care provided by professionals to a person in his or her own home. The goal is to contribute to the person's life quality and functional health status and also to replace hospital care with care in the home.8

The elderly are pressing for improved standards of care, support and greater independence.9 However, the desire to live independently varies and is influenced by several factors such as health status, age and gender.10 In this review, elderly is defined as 60 years and older.11 Results from a study based on qualitative data collected from people aged 80-89 years in England illustrate the benefits, problems and challenges that exist in relation to aging in place.4 According to the researchers, the home provides the person with a sense of independence, security, privacy and comfort and is an important place socially. However, as part of the aging process, functionality and health status decrease, and the physical aspects of the home can create barriers and make it more difficult for the person to remain living at home. Technology is seen as a solution to some of these challenges, and much effort has been invested in the development of technology to support aging in place.12 Nevertheless, there is still a poor understanding of the elderly's experiences with the actual use of telecare.5,12

A recent study conducted in 2015 by Bjorkquist et al.13 showed that two general themes stood out as important for the elderly: safety and the importance of social relations as a platform for coping and wellbeing. The elderly participants in the study took a positive approach to technology, which allowed them to be more mobile and get in touch with somebody if something happened. Further, they focused on their own fundamental need for safety but had limited knowledge about the possible functions of telecare. The authors reported a broad desire for more information about telecare from both home care professionals and the elderly. According to the care professionals in the study, considerable effort is required to inform and motivate the elderly to use telecare devices.13 A scoping review conducted in 2015 by Blackman et al.14 identified ambient assisted living technologies that could potentially be used by older people with some degree of cognitive impairment. The study included technology still under development and recent developments.

The current qualitative review will consider studies that include experiences with implemented technology for the home-dwelling elderly in the context of home care services. Getting an overview of the elderly's experiences with the actual use of telecare will facilitate a better understanding of the needs of the elderly, and how telecare may help in meeting these needs.

Previous research on the elderly's use of technology mainly focused on the intention to use the technology, and factors that influenced acceptance of technology in the pre-implementation stage.12 According to Peek et al.,12 older people express various concerns when they consider technology that they have not yet used. A systematic review conducted in 2014 summarized 27 factors that influenced acceptance in the pre-implementation stage, divided into six themes: concerns regarding technology (e.g. high cost, privacy implications and usability factors); expected benefits of technology (e.g. increased safety and perceived usefulness); need for technology (e.g. perceived need and subjective health status); alternatives to technology (e.g. help by family or spouse), social influence (e.g. influence of family, friends and professional caregivers); and characteristics of older adults (e.g. desire to age in place). A comparison of these results with a small number of studies on post implementation stage indicates that some factors are consistent across the studies, but that some new factors have emerged, such as satisfaction with technology and attitude toward technology.12

According to Reeder et al.,15 research on the use of technology in health care has been conducted in both the healthcare services and the technology field, and scientific findings have been published in different literature repositories that do not always overlap in their indexing. The fragmentation of reported evidence leads to a knowledge gap concerning what research has been done, and this leads to a barrier for knowledge translation to relevant stakeholders.15 Qualitative evidence will provide a better understanding by exploring and explaining why telecare in home care services is or is not effective in providing aging in place from a person centered perspective. By conducting this review, we wish to contribute knowledge to this field. Such knowledge is relevant for professionals in home care services and can be applied in their clinical work when using telecare to the home-dwelling elderly. It can also inform planners and policy makers about the need for a user perspective when implementing telecare.

A preliminary search of the JBI Database of Systematic Reviews and Implementation Reports, Cochrane Library, MEDLINE, PROSPERO and DARE databases revealed that there is no available systematic review or protocol on this topic.

Inclusion criteria

Types of participants

The current review will consider studies that include persons older than 60 years living in their own home. They may live home alone, or they can be living with partners, children or other significant persons. There will be no limits of the type of diseases or chronic conditions.

Phenomena of interest

The current review will consider studies that investigate the home-dwelling elderly's experiences with the use of telecare as part of home care services, and what beliefs home-dwelling elderly hold regarding the impact of telecare on the ability to age in place.

Context

The current review will consider the home-dwelling elderly using telecare in the context of home care services, from studies across the world.

Types of studies

The current review will consider studies that focus on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, and action research and feminist research. Mixed method studies with a qualitative component will also be included where appropriate.

Search strategy

The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the articles. A second search using all identified keywords and index terms will then be undertaken across all included databases. Third, the reference list of all included articles will be examined to search for additional studies.

Studies in English, Norwegian, Swedish and Danish published from 2005 and later will be considered for inclusion. Findings published in these languages will be translated. Given the rapid development in this field, studies older than 10 years will not be included. Gray literature such as theses and dissertations will be considered for inclusion if they report findings relevant for this review.

The databases to be searched include: Scopus (MEDLINE, Embase), CINAHL, PsycINFO, SveMed+.

The search for unpublished research studies will include: Google and Primo Central Index.

Initial keywords to be used will be: elderly, aged, old, older adults, older people, senior citizens, technology, telecare, sensor, alarm, eHealth, smart home, telehealth, gerontechnology, smart devices, digital health, home care, healthcare services, primary health care, community care, community health, community dwelling, homebound, aging in place, independent living, experience, perception, adapt, attitude, satisfaction and adopt.

Systematic searches will be developed for each database and conducted in cooperation with a research librarian.

Assessment of methodological quality

Qualitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.

Data extraction

Qualitative data will be extracted from individual studies independently using the standardized data extraction tool from JBI-QARI (Appendix II). The data extracted will include specific details about methodology, method, phenomena of interest, technology, duration of use, service context, setting, geographical, cultural, participants, data analysis and authors conclusion. The congruency between the findings and illustrations from the included studies will assign a level of credibility by the researchers according to Joanna Briggs Institute methodology.16

The lead author will carry out the data extraction, and this will be crosschecked by the co-authors. The authors of the primary studies will be contacted for missing information or to clarify unclear data.

Data synthesis

Qualitative research findings will, where possible, be pooled using JBI-QARI. This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings rated according to their quality and categorizing these findings on the basis of similarity meaning. These categories will then be subjected to a meta-synthesis to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. The ConQual approach for qualitative systematic reviews will be used.17 Where textual pooling is not possible, the findings will be presented in narrative form.

Acknowledgements

We acknowledge the support of the Norwegian Science Foundation and Kvinesdal Municipality.

Appendix I: Appraisal instrument

QARI appraisal instrument

Appendix II: Data extraction instruments

QARI data extraction instrument

References