Home living older adults' subjective perceptions, evaluation, and interpretations of various welfare technology: A systematic review of qualitative studies

Objectives This paper aims to map home-living older adults' subjective perceptions, evaluations, and interpretations of various welfare technologies. Study design Systematic literature review. Methods The study was designed as a systematic literature review of qualitative studies. This systematic literature review was carried out according to the PRISMA statement and was prospectively registered in PROSPERO registration number CRD42020190206. The international electronic bibliographic databases included AMED, Academic, CINAHL, Cochrane Reviews, EMBASE, Google Scholar, MEDLINE via PubMed, Scopus, and Web of Science. The scientific evidence was synthesized using qualitative analysis. All aspects of the study method followed COREQ guidelines. Results Following a detailed systematic search and screening of 1405 studies, 10 were included in the systematic review. The study shows that implementing Welfare Technology seems to prolong older adults' independent living in their own homes and was perceived as a complement to face-to-face contact with health care providers. Conclusions This study indicated that older adults consider accepting Welfare Technology as it contributes to a sense of security and empowerment in their everyday lives.


Introduction
The growth in the old people population [1] puts pressure on health workers and welfare services [2].Among the solutions is Welfare Technology (WT) (e.g.information communication technology, ICT) used in aim to support independent Activities of Daily Living (ADL) for the home living older adults [3].In this review, we have chosen to use the overall concept of WT, which refers to digital technology used to maintain independence, maintain daily activities, security and participation in the event of a risk of impaired bodily functions [4][5][6].Hoffman defines WT as technical assistance that contributes to independent living [7].The introduction and use of WT [3] allows for the provision of more goal-oriented and practical care services, increases security, safety, independence, manageability of daily life, prolongs living at home, helps prevent fall accidents at home, and improves quality of life [8][9][10][11].
Hoffman groups WT based on purpose and function into the following categories: 1) communication technology, 2) compensation technology that complements lost and impaired functions, 3) technology that helps with practical work, 4) disease surveillance, 5) distance therapy technology [7].In addition, digital technology in health is classified into three levels, from A to C. Level A deals with services in the form of technology to the caregivers.Level B includes general health monitoring tools for users and caregivers.Level C deals with the technology used for preventive health work focusing on healthy behavioural changes [12,13].According to Hoffman [7], few studies shed light on how different types of ICT provide exchange and benefit old adults who are traditionally not used to using it.He also wonders whether ICT achieves the desired goals and what its side effects and costs are.In the Nordic context, the notion of WT refers to technologies and solutions that are used by users, including old people and others, in their everyday life to improve their daily living, promote independence, and reduces hospitalization or prolongs independent living in their own home [3,5,6,10].The concept of WT originally came from the healthcare sector and is strongly connected to adapting care and technology to specific users.Many studies provide an illustrative example of Universal Design (UD) and WT, who explained that restaurants and cinemas have long been designed to facilitate the entrance of individuals sitting in wheelchairs by making an accessible entrance through the back door [14][15][16].The Nordic countries pride themselves on fostering the diversity of their population's considerable variation in function [8,14,17].These individuals require independent living solutions that allow them to age in place but also active citizen participation in society [11,18].This paper aimed to map home-living older adults' subjective perceptions, evaluations, and interpretations of various welfare technologies.

Methods
This systematic review [19] was carried out according to the PRISMA checklist and statement [20] and prospectively registered in PROSPERO [21] registration number CRD42020190206.The critical aspects of the study method were followed by using COREQ guidelines [22].

Ethics statement
In this study, no new empirical material has been collected.Therefore, we have not applied for formal ethical approval.Included studies have undergone ethical review.

Eligibility criteria
We chose to include studies with a qualitative design to investigate subjective human experiences, and attitudes.

Inclusion criteria
The inclusion criteria were specified: • Primary studies with qualitative design published in English.
• Home-living old persons (≥60 years) who are users of WT • Use of WT in various ways (audio-visual monitoring (AL), WT, video communication, apps, computer software, telemedicine, ICT, sensors, wearable devices)

Exclusion criteria
The exclusion criteria were specified: • Not primary study with qualitative design

Information sources
Searches were performed in databases AMED, Academic, CINAHL, Cochrane Reviews, EMBASE, Google Scholar, and MEDLINE via PubMed, Scopus, and Web of Science (Fig. 1 PRISMA flowchart, and Tables 1-2).

Search strategy
The search strategy following MeSH keywords were used, singly and in combination: older adults, community-living, e-health, medical informatics, health informatics, mobile health, health, telemedicine, telehealth, telecare, telemonitoring, e-learning, active and assisted living, self-help devices, technologies, assistive technology, everyday technology, own home, qualitative research design, descriptive, grounded theory, content analysis.Examples of searching strategies are illustrated in Tables 1-2.

Selection process
Selected titles were imported first into the reference management software EndNote [23] and then into the web tool Rayyan [24].In total, 1673 titles were imported, and 268 duplicates were removed.After the first screening step, we excluded 1132 titles and found 273 titles that we deemed interesting for reading abstracts, full texts and discussion.This step resulted in an additional 255 records being excluded because they did not meet the inclusion criteria.Finally, we included ten eligible studies for quality assessment [25][26][27][28][29][30][31][32][33][34].

Critical appraisal
The CASP checklist [35] was used to assess the quality of the articles selected for this review (Table 3) by several co-authors (ZP, GK, BSS) first independently and then as a group as we discussed our review findings until a consensus was reached.

Procedure of data extraction and compilation of data
Data was extracted from the articles and compiled into Table 4. Based on the purpose of the study, we categorized the results (Tables 5  and 6) from selected studies into the following themes: "Welfare technology facilitates self-care and social contact", "Welfare technology is perceived as helpful" and "Incorporating welfare technology into everyday life".

Welfare technology facilitates self-care and social contact
Most participants in the studies expressed a strong need to live in their own homes as long as possible and avoid ending up in a nursing home [25][26][27][28][29][30][31][32][33][34].This theme illustrates various aspects of how older participants expressed the impact of technology on self-care and alternatives to social contact.The older participants in the study said that apps help them better understand their health situation and plan their everyday activities.Living with chronic disease requires self-monitoring of symptoms.Apps provide more information about the signs of problems and what action to take if there is a change.Old adults with chronic diseases experience that WT leads to better follow-up of health status and medication adjustment to a greater extent.The WT was a contributing factor to independence by being used to manage practical everyday tasks such as medication reminders.Some older participants expressed that independent living was important to them, even if they had to get used to being monitored around the clock and everywhere, including bathrooms.One of the older participants highlighted that this type of monitoring could create some space for a feel-good form of resistance or play games with the system, such as opening the refrigerator to eat something to activate the monitoring system or turning on the shower without showering.At the same time, sensor monitoring provides a strong sense of security because someone is watching what is happening in the home space.The surveillance itself was perceived as an artificial form of company, which reduced feelings of loneliness.Another aspect highlighted was that monitoring equipment is perceived as discreet and does not require active involvement on the participant's part.These sensors are connected directly to healthcare providers.Most participants do not have any privacy concerns with sharing data with people they trust, especially if the data is the basis for assistance.For many, it is, therefore, easy to accept and trust around-the-clock in-home monitoring.
The old people participants described that observing their symptoms meant they could contact the care provider directly at short notice to discuss and possibly adjust prescriptions.This way, the treatment is maintained optimally, minimizing the risk of complications.They experienced a significantly shortened time between when a change in their health information was observed and when their medication was adjusted.At the same time, older patients experienced a feeling of empowerment.Another difference is that the introduction of WT reduces the number of booked visits to the care provider.All information about health status is registered in a patient's record, and it is easy for care providers to follow it up at a distance.Medication adjustment is smooth without requiring an appointment and travel time for a physical visit.In addition, a video link may provide close contact with the care providers.

Welfare technology is perceived as helpful
WT was perceived as an efficient aid to keep a good overview of disease symptoms.Such an overview makes it possible to plan medication and everyday activities [25][26][27][28][29][30][31][32][33][34].Some older users thought that they should be involved in WT design.In this way, they would have the opportunity to point out their needs as users that the software producers have not considered, for example, problems with vision, hearing, fine motor skills, or pain.This kind of involvement seems to be a way to empower older users.The use of telecare provides the opportunity to prevent accidents in the home, especially for people with a tendency to fall or cognitive impairment.Motion sensors and reminders are activated automatically.Further observation occurs at a distance, which is appreciated by the users, who do not want frequent visits by countless health personnel.Indoor and outdoor motion sensors, door alarms and personal alarms were perceived as providing a complete feeling of security.WTs are perceived as essential, and users should be offered training in all WT functions before they become an integral part of their lives.Older people's positive attitude towards WTs seems to be driven by fear of having an accident at home and not being able to contact anyone for help.WT solutions enable the older adults to continue living as they have before while knowing that someone will see it and can help if something happens.Regarding communication using WT, some people find it easier than others.The local context in which WT is used is also essential, including the care provider or institution to which it is linked.Users need to know where to turn when needed.User instructions must be accessible, understandable, and searchable, even for those with poor eyesight.Knowledge and skills related to WT have also been equated with citizens' rights.People who cannot manage these tools lose the opportunity to participate in planned activities, political processes, or private banking.While monitoring via distance undoubtedly gives a feeling of security, there is still ignorance about how this technology can reduce feelings of loneliness.Video meetings positively affect daily routines because people are motivated to look good in these meetings.Another aspect of WT is that it can capture things that users cannot note, such as changes in daily routines.Sensors that remind users about changes to their health can positively impact them and lead them The app was judged to be valuable but must be adapted to the user's needs, the local context must be user-friendly, and the data collected in the app must be linked to the care providers so that they can adjust care, guidance, and support.
Not all older people find the app exciting or relevant, the app must be a link between the user and the caregiver to achieve the desired result; the app must be developed so that it can be used easily, and users must be involved in the design and development of the app Ambient assisted living (AAL) contributes to the feeling of security in their own home but using AAL could be demoralizing and seen as a severe problem.Being watched by others was seen both as security and even as a loss of independence.
There is a need to understand better how AAL will affect the lives of residents being monitored.This is critical, so strategies can be implemented to prevent AAL from becoming an instrument of oppression rather than a technology of empowerment.The automatic and manual alerting functions of the bendable device and the sensor were made of waterproof material.They had optimal weight, and were wearable for 24 h in a row.They were welcomed.There were requirements regarding the reliability of the sensor that should determine its size.to continue with prescribed exercises to maintain health and regain lost functions.Saving travel time to care institutions and providers is one of the much-appreciated positive benefits of using WT, which is why home rehabilitation using video conferencing is appreciated.Real-time monitoring of vital body parameters allows the user to feel calm.In such cases, the user can do his or her activity and rest.

Incorporating welfare technology into everyday life
The participants appreciated the opportunity to have contact with others in the same situation and be able to support each other [25][26][27][28][29][30][31][32][33][34].WT makes it possible to cope with everyday life, increases self-confidence, and makes life more meaningful by allowing people to follow what is happening in society.WT is essential for participating in modern life and maintaining social contact at a distance.It is easier to accept video surveillance if it allows one to continue living in one's own home and remain independent.For most older people, acceptance means integrating video surveillance as a natural part of life.WT, which consists of reminder sensors, primarily serves as a stimulus to perform exercises or move indoors and strengthens personal responsibility.Several people emphasized that they were interested in WT, which represents an excellent opportunity for them to remain in their homes because they cannot imagine moving.Many older adults had changed their views on WT and were willing to invest in it if necessary for their safety.WT provided a sense of security, allowing participants to live at home independently thanks to built-in sensors and the knowledge that if something happened, it would be discovered because there is someone on the other side of the technology who will note the need for help and respond to it.

Discussion of results
Results in this study illustrate that WT seems to be recognized and normalized among old adults because it enables them to stay in their homes.Furthermore, the technology allows them to have an overview of their health status and plan daily activities.They save time travelling to caregivers, it was easier for them to communicate online, and they dared to ask questions they would not have asked in person.Problems with loneliness and the need for human contact are not solved using WT.Chen's study [36] confirms that WT solutions often focus only on replacing or supplementing reduced physical needs to minimize risks.Users' emotional and psychological skills have been considered to a greater extent during the product development, design and implementation processes [36].The implementation and use of WT became a must for many.Many had to discover some of the benefits, resulting in increased self-esteem [37].Moreover, issues of inclusion, accessibility, digital literacy, and language were evident with old people users of WT.Saplacan and Herstad (2019) [38] discuss a case where robots were integrated into the homes of older people.Still, these people did not always understand the language used in the interaction design with the robots.In line with our results, Saplacan et al. (2021) [39] highlight the ethical challenges and opportunities resulting from integrating robots in-home care of older people.Challenges include the lack of legal frameworks and harmonized standards regulating artificial intelligence (AI) care systems and robots, decreased human contact, the feeling of objectivization and perceived loss of control over autonomy among older adults, aspects of privacy, deception, and infantilization as well as the problem of not knowing who is responsible for essential failures of the software or hardware used as part of the care process, the so-called many hands problem [39].Similarly, Saplacan et al. [40] talk about the need for a sense of coherence.The WT needs to be understandable, manageable, and meaningful for older users: they should clearly understand how to use WT and for what purpose [41].Other studies emphasize the need to carefully assess the utility value of the WT in the home care sector in opposition to privacy [42,43].

Strengths and limitations
There are several strengths of this research.The study protocol has been registered in advance in PROSPERO.The method was performed according to PRISMA guidelines.Published articles were identified in relevant databases using MeSH terms in close collaboration with the research librarian.Detailed information on selected studies' screening steps and quality control has been described in detail.However, the results can be seen in the light of limitations.The searches were limited to the period between 2015 and 2023.Therefore, it is possible that some relevant article was missed or that errors in the data collection were made.Inclusion criteria included studies published in English, which could result in missing research results in other languages.

Conclusion
The results of this study show the use of WT provides easier access to caregivers; it helps users develop a more profound knowledge of their disease and related symptoms, and being monitored at home offers a sense of security.In addition, it is necessary to increase WT literacy, especially among those who have not used the WT before.More studies on users and WT manufacturers and their interaction are needed.

What this study adds
• This systematic literature review breaks new ground by focusing on old people as end users' subjective perceptions, evaluations, and interpretations of WT. • This study shows that older people seem to accept WT if they feel that it provides an experience of security and independence in everyday life.

CRediT author statement
The idea, conceptualization, methodology, supervision, analysis, results, writing-original draft preparation, co-writing of the original

Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Table 1
Example searching in databases.

Table 2
Example searches in AMED.

Table 3
CASP assessment of included studies*.

Table 4
Study characteristics data extraction, authors, country, CASP sore, technology type, length of use, results, the implication for practice.

•
This study points to the end user's understanding, insight, and reasoning about what works well and what challenges remain regarding using WT.Developers of WT can use this information to address challenges by involving end users as co-creators.• This study raises awareness of the potential of WT to support independent and autonomous ageing.Disseminating the results of this study can help create incentives for further research focusing on Z.Pajalic et al.

Table 5
Example of meaning units, condensed meaning units and codes.

Table 6
Overview Themes and codes.