Exploring Barriers to and Enablers of the Adoption of Information and Communication Technology for the Care of Older Adults With Chronic Diseases: Scoping Review

Background Information and communication technology (ICT) offers considerable potential for supporting older adults in managing their health, including chronic diseases. However, there are mixed opinions about the benefits and effectiveness of ICT interventions for older adults with chronic diseases. Objective We aim to map the use of ICT interventions in health care and identified barriers to and enablers of its use among older adults with chronic disease. Methods A scoping review was conducted using 5 databases (Ovid MEDLINE, Embase, Scopus, PsycINFO, and ProQuest) to identify eligible articles from January 2000 to July 2020. Publications incorporating the use of ICT interventions, otherwise known as eHealth, such as mobile health, telehealth and telemedicine, decision support systems, electronic health records, and remote monitoring in people aged ≥55 years with chronic diseases were included. We conducted a strengths, weaknesses, opportunities, and threats framework analysis to explore the implied enablers of and barriers to the use of ICT interventions. Results Of the 1149 identified articles, 31 (2.7%; n=4185 participants) met the inclusion criteria. Of the 31 articles, 5 (16%) mentioned the use of various eHealth interventions. A range of technologies was reported, including mobile health (8/31, 26%), telehealth (7/31, 23%), electronic health record (2/31, 6%), and mixed ICT interventions (14/31, 45%). Various chronic diseases affecting older adults were identified, including congestive heart failure (9/31, 29%), diabetes (7/31, 23%), chronic respiratory disease (6/31, 19%), and mental health disorders (8/31, 26%). ICT interventions were all designed to help people self-manage chronic diseases and demonstrated positive effects. However, patient-related and health care provider–related challenges, in integrating ICT interventions in routine practice, were identified. Barriers to using ICT interventions in older adults included knowledge gaps, a lack of willingness to adopt new skills, and reluctance to use technologies. Implementation challenges related to ICT interventions such as slow internet connectivity and lack of an appropriate reimbursement policy were reported. Advantages of using ICT interventions include their nonpharmacological nature, provision of health education, encouragement for continued physical activity, and maintenance of a healthy diet. Participants reported that the use of ICT was a fun and effective way of increasing their motivation and supporting self-management tasks. It gave them reassurance and peace of mind by promoting a sense of security and reducing anxiety. Conclusions ICT interventions have the potential to support the care of older adults with chronic diseases. However, they have not been effectively integrated with routine health care. There is a need to improve awareness and education about ICT interventions among those who could benefit from them, including older adults, caregivers, and health care providers. More sustainable funding is required to promote the adoption of ICT interventions. We recommend involving clinicians and caregivers at the time of designing ICT interventions.


Introduction
Background Chronic diseases represent a significant public health challenge worldwide and are the predominant cause of death among older adults [1]. Older adults are also vulnerable to occupational injuries arising from the effects of chemical, physical, and biological exposure in the workplace. In 2016, approximately 70% of deaths and 40% of disability-adjusted life years because of occupational injuries occurred in persons aged ≥55 years [2]. The burden of chronic diseases such as cardiovascular diseases (CVDs), diabetes, neurological disorders, and musculoskeletal disorders falls heavily on older adults [3]. The population aged ≥60 years is expected to increase to 2 billion by 2050 worldwide [4]. Consequently, the global burden of chronic diseases among older adults is anticipated to rise [5,6]. Given the increasing prevalence of aging and chronic diseases, it is essential to focus on health care innovation to improve personal health services such as self-management. Self-management is based on the concept that people can learn to manage their health using their skills and resources and thus become less dependent on external agents [7].
Information and communication technology (ICT) has been used in several settings to help individuals diagnose, treat, and manage chronic diseases better [8]. ICT interventions in health care, which we define herein as eHealth, have been shown to be cost-effective for monitoring and controlling congestive heart failure, stroke, chronic obstructive pulmonary disorder (COPD), diabetes, hypertension, asthma, dementia, and depression [9][10][11][12][13]. ICT interventions have also been used to support caregivers [14]. For example, mobile health (mHealth) has the potential to reduce the caregiver's work burden by supporting the monitoring of medication use and providing significant interaction with older adults, thus minimizing the need for hospitalization [15]. Hence, ICT interventions may provide a solution to some of the challenges of aging and chronic diseases. However, there is conflicting evidence regarding the effectiveness of using ICT interventions among older adults with chronic diseases. Some positive outcomes have been identified for simple telephone interventions [16], which in some cases generated similar outcomes to more complex technologies [17][18][19]. As per suggestions made by other authors, there are opportunities to explore and compare perceptions among direct service providers, older adults living with chronic diseases, and caregivers about the challenges of various types of ICT interventions in both high-and low-income countries [20][21][22]. Therefore, there is a strong impetus for exploring the efficacy of ICT interventions and how this effectiveness differs in various settings.
The current high use of ICT among young people shows that ICT could be a future intervention model in health care, enhancing the number of people in need who are reached [23]. However, the approach of older adults to internet and health technology differs from that of younger people. Older adults may have lower rates of computer use and health-related internet use than younger adults [24]. Indeed, Heart et al [25] found that older adults require some skills to adopt the use of ICT interventions. Older adults with chronic diseases have also been reported to face numerous challenges such as altered cognition, visual and hearing difficulties, lack of trust, and privacy concerns as they encounter technology [26,27]. Without adopting these skills and addressing barriers, older adults might not receive the optimal benefits of ICT interventions in routine care. Hence, there is a critical need to better understand and map the barriers associated with the use of ICT interventions among older adults with chronic diseases to maximize the future uptake of ICT interventions and support personalized health care [28]. It is also essential to identify enablers of the use of ICT interventions so as to facilitate the design of mitigating strategies to overcome the barriers to use. Most ICT interventions described in the literature have targeted children, adolescents, or younger adults. We are not aware of any previous systematic or scoping review of the enablers of and barriers to the adoption of ICT interventions for supporting older adults with chronic diseases.

Objective
In this review, we aim to identify (1) the available ICT interventions that have been used for managing older adults with chronic diseases and (2) the barriers to and enablers of using ICT interventions among older adults with chronic diseases.

Design
This scoping review was conducted using the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews) guidelines [29] and adopting the Arksey and O'Malley [30] framework. This framework outlines five stages for completing a scoping review: (1) identifying the research question; (2) identifying relevant published reports; (3) publication selection; (4) charting the data; and (5) collating, summarizing, and reporting the results [30], all of which have been followed in the conduct of this review.

Database Selection and Search Strategy
A literature search was performed using 4 databases: Ovid MEDLINE, Embase, Scopus, and PsycINFO. We also used the ProQuest database to include eligible papers and proceedings published in association with computer science and technology conferences. We included articles and conference papers published from January 2000 to July 2020, which had full text in English and were peer reviewed. We selected the time frame of the past 2 decades to identify recent work undertaken on ICT interventions among older adults with chronic diseases. The population of older adults with chronic diseases could benefit from targeted health education interventions. We defined older adults as those ≥aged 55 years [31], so only studies with this definition were included. The search strategies were drafted through team discussions and checked and revised by an experienced librarian. We used the following search terms: information and communication technology or mHealth or mobile health or telehealth or eHealth or remote monitoring or clinical decision support system or mobile phone technology or electronic health record and arthritis or asthma or back pain or carcinoma or cardiovascular disease or chronic obstructive pulmonary disease or diabetes or mental health or non-communicable diseases or chronic diseases and ageing or elderly or older adults or 55+ age group and barriers or enablers or challenges or opportunities or benefits or threats. We included eight major groups of chronic diseases in the review: arthritis, asthma, back pain, cancer, CVDs, COPD, diabetes, and mental health conditions. Multimedia Appendix 1 contains the search strategies and Boolean expressions for each database.
A total of 2 reviewers (SBZ and RKK) screened the titles and abstracts of the selected articles and identified duplicates. In cases of conflicting opinions regarding the eligibility of specific articles, the reviewers discussed their views with a third reviewer (SMSI) to reach a consensus. If inclusion was unclear from the title, the abstract was screened. Similarly, if inclusion was unclear from the abstract, the reviewer read the full text. We included original articles, all types of reviews, and conference papers (Table 1) for this scoping review. Once we identified suitable articles, we also looked for qualitative data included in the analysis. Here, we particularly looked for specific information related to barriers, enablers, and uses of ICT for supporting the care of older adults with chronic disease.

ICT Types and End Users
Our definition of ICT interventions in health care, otherwise known as eHealth, includes the following: mHealth, electronic health records (EHRs), clinical decision support systems (CDSSs), telehealth and telemedicine, virtual reality in health care, and information technology systems used in health care settings. mHealth includes the use of mobile phones, mobile apps, PDAs, and PDA phones (eg, smartphones and handheld and ultraportable computers such as tablet devices) [11]. Telemedicine and telehealth are considered subdomains of eHealth and comprise communication networks to deliver health care interventions from one geographical location to another [32]. A remote monitoring system is defined as a subset of mHealth and telemedicine, which uses sensors to generate patient data.
We use the following ICT terminology in this paper: • ICT device: refers to hardware only • ICT intervention: refers to a specific program of research or implementation of ICT (eg, computer, mobile phone or tablet apps, and telehealth) We considered older adults living with chronic diseases, their caregivers or family members, and health care providers as end users of ICT interventions.

Data Extraction and Synthesis
SBZ, RK, and SMSI developed a data extraction form based on the aims of this review. SBZ and RK extracted data on the article title, names of first authors, publication year, study types or methods, setting, sample size, findings or recommendations, and expected or experienced barriers for all selected articles. Outcomes related to the use of ICT interventions were presented as positive, no difference or negative based on the conclusion reported in the included articles. No negative or neutral (no difference) outcomes were identified. In the case of qualitative data, factors related to barriers and enablers were coded in the data extraction form according to themes that emerged from the studies.
Second, we described and identified various ICT interventions-mHealth, EHR and CDSS, telemedicine, and remote monitoring-that were used for older adults with chronic diseases. Third, we reviewed articles to identify challenges in using ICT interventions among older adults with chronic diseases. For example, factors such as lack of motivation, comorbidities, poor adherence to treatment following ICT interventions, and absence of prior experience in the operation of ICT devices for older adults were considered as challenges. Issues related to costs of implementation, infrastructure, data security, and delays in making a decision were considered in the implementation category. Finally, we conducted a strengths, weaknesses, opportunities, and threats (SWOT) [33] analysis to explore the enablers of and barriers to the use of ICT interventions among older adults with chronic diseases. We used a codebook for the domains of strength, weakness, opportunity, and threat to report a descriptive analysis. Before this qualitative analysis, strategies for data coding were identified. SBZ and RK independently read and coded the articles. Each of the domains of SWOT was grouped into two categories: patient-related factors (operational) or health care provider-related factors. The patient-related category included factors associated with ICT interventions, which we define as operational here. We then applied this conceptual framework to identify emerging themes in each of these categories from the selected articles. Codes were then grouped into categories and eventually aggregated into 4 domains. After the initial round of coding, the 2 coders met with a senior researcher (SMSI) to cross-check the coding; thus, a final set of codes was agreed upon. The reviewers used Microsoft Excel 2014 to sort the articles.

Overview
A total of 1149 articles, including conference papers (863/1149, 75.12%), were identified. Of the 1149 articles, 44 (3.83%) were duplicates ( Figure 1). We excluded 86.51% (994/1149) of articles that were either not related to ICT interventions for older adults with chronic diseases or studies already reported in the systematic reviews that we included. Of the 1149 articles, after screening the titles and abstracts, 46 (4%) additional articles were excluded, leaving 63 (5.48%) articles for full-text screening. Of the 63 articles, there were 4 (6%) conference papers that were mostly based on formative research (design and development). As these papers lacked both quantitative and qualitative data (patient recruitment and barriers to and enablers of using ICT), we did not include them in the final selection. Finally, of the 63 articles, 26 (41%) were excluded following a full-text review, with 31 (49%) articles remaining ( Figure 1).

ICT Interventions Used in Health Care
All articles provided evidence that ICT interventions are beneficial for health care among older adults with chronic diseases (Table 1). We identified various ICT platforms used for supporting health care providers as they manage chronic diseases in older adults. A total of 3 studies and 2 reviews mentioned the use of ≥1 mixed eHealth intervention such as electronic technologies, internet counseling, video consultation, EHR, and telehealth [39,45,46,48,55]. A total of 3 studies and 5 reviews, including 2 scoping reviews, focused particularly on mHealth [43,46,47,50,52,54,58], including mobile apps [37,42].
A total of 4 studies and 2 reviews focused on telehealth [34,38,40,44,51,56]. One study specifically focused on the use of a patient portal or EHR [36]. One study was on a web-based health management tool [40] for chronic care. Finally, 7 further reviews incorporated the use of a combination of ICT interventions [49,53,57], including EHR, mHealth, and video consultation, in providing care for older adults with chronic diseases. Figure 2 shows the distribution of ICT interventions that have been primarily used or described in the included original articles or reviews.

Health Care Provider-Related Factors
Only a few weaknesses were reported for health care provider-related factors. Health care providers reported that some older adults with chronic diseases were dependent on family members or friends for using their ICT devices [38,47,50,52,61]. Hence, these participants, who were dependent on others, were sometimes not interested in learning how to operate the technology independently. In such cases, health care providers sometimes found it difficult to directly interact with patients using ICT interventions. An additional list of barriers to and challenges for the use of ICT interventions synthesized from current evidence is provided in Multimedia Appendix 3.

Principal Findings
Overall, findings from this scoping review highlight the potential benefit of ICT interventions or eHealth (eg, mHealth and mobile apps, EHR, remote monitoring, CDSS, and telemedicine) for supporting older adults in self-managing chronic diseases. The review highlighted a range of operational and technical barriers to using these ICT interventions for older adults. Our review highlighted age-related barriers to using ICT interventions, including cognition, motivation, physical limitations (eyesight and fine motor skills), and perception, which limited the use of ICT interventions among older adults with chronic diseases. In this case, personalized learning may meet the unique needs, interests, and capacities of individual users to mitigate these limitations [65]. Some of these limitations could be resolved via design optimization of ICT interventions, such as increasing the screen contrast to mitigate the loss of visual acuity or simplifying task movements to facilitate ICT use in patients with arthritis or physical disability [41]. A number of challenges and enablers in integrating ICT interventions into routine practice were also identified. Most of the included studies were pilot or short-term interventions conducted in a controlled environment. Hence, longitudinal studies aimed at assessing the long-term effectiveness of ICT interventions should be a priority.
Our results indicate that some older adults with chronic diseases might have reservations when it comes to engaging with ICT interventions. We found operational and technical challenges, including a lack of willingness to adopt new skills, poor confidence, and the lack of necessary skills to operate ICT devices. These findings are consistent with the results of other studies where older people expressed no interest in using novel technology and struggled to think of the need for such an application in their own lives [66,67]. Acceptance of these electronic or digital technologies may be more difficult for the current generation of older adults who did not grow up with these technologies [68,69]. Mitigating strategies to increase ICT literacy using short e-learning courses (eg, 2 weeks with 10-minute sessions each day) have been shown to be suitable for older adults [70,71].
We found strong motivation and desire to use ICT interventions among older adults with chronic diseases because of the nonpharmacological nature of the intervention. Self-management of chronic diseases includes the maintenance of a healthy lifestyle and adherence to medication. However, older adults seem to require specific motivation to make practical changes, such as eating a healthy diet and being physically active, even if they are already aware of their value [36]. Nilsen et al [72] reported that the traditional approach of episodic care provided in the clinic or through hospital support systems might not be sufficient to prevent chronic diseases without incorporating ICT interventions in health care. Therefore, health care providers are motivated to use ICT interventions to communicate with their patients to know whether they follow their advice.
It is imperative to understand the duration that people require to achieve a cost-effective outcome from ICT interventions. Findings from this scoping review suggest that older adults living with chronic diseases and caregivers were unwilling to pay for the use of ICT interventions, although they were happy with the service. Most participants only offered to pay partially. An explanation for this result is that all participants in the studies we reviewed were from high-income countries and frequently reported the lack of an appropriate insurance scheme and reimbursement for procuring devices required for ICT interventions. Without addressing the payment model, it will be challenging to ensure the proper use of ICT interventions in health care, even if older adults desire to use them. Chen and Chan [73] also reported that implementation costs were not adequately highlighted in designing specific ICT interventions in many countries. Therefore, the high cost seems to be a critical factor in determining the ability of an older adult to accept these interventions. Similarly, we also reported a home telehealth program's failure after more than a decade of use because of financial challenges [44]. Hence, more sustainable funding and reimbursement are essential for promoting the adoption of ICT interventions.
In addition to the financial factors discussed above, this review highlights workload as an additional determinant of the adoption of ICT interventions. Managing life-threatening events, such as arrhythmia or heart attack, requires an immediate response from health care providers, and such a rapid response can be challenging to execute in many places, particularly in hard-to-reach areas. Failure to react to patients immediately may exacerbate the health risks of older adults with chronic diseases and render health care providers susceptible to accusations of negligence [74]. There is also the risk of generating false-positive alarms from these ICT interventions, which may require physical verification. Thus, such alarms could increase the workload of clinicians if they are required to personally evaluate every call. This may partly explain why not all clinicians were receptive to their patients using ICT interventions. Training can be a significant factor that influences health professionals' eagerness to use or refer their patients for using ICT interventions at home [75][76][77].
Future app developers should consider involving end users in the design and development process for ICT interventions. We reported that clinicians' involvement in the recruitment process appeared to influence the decision of participants to take part in the trials or studies. Hence, their involvement will be crucial for motivating patients to use ICT interventions. The authors also point out the necessity of ensuring that health care providers are encouraged and committed to recommending ICT interventions for their patients [13,78]. Otherwise, the willingness to use ICT interventions will never develop among patients, despite their ability to operate these devices. The general assumption that education is a relevant factor in adopting the use of ICT may not always be accurate, with the authors of an article reporting that level of education was not positively associated with the uptake of ICT interventions in the sample of patients they studied [79]. Health care providers can be an additional barrier to the adoption of ICT interventions by older patients. For example, Smelcer et al [80] reported that 30% of EHR system implementations worldwide failed because of their underutilization or inappropriate use by the clinician. They identify the concept of medical authority, where clinicians or health care providers affect medical practices such as diagnosis and management of chronic diseases for their patients, as critical for the implementation of EHR [81]. It seems likely that medical authority is also an essential factor in the implementation of other forms of ICT interventions.
Management of chronic diseases may require the engagement of multiple health care service providers [82]. This arrangement could be too complex for older adults with chronic diseases who are disabled or living in rural areas, particularly in hard-to-reach areas. Here, ICT interventions can play a significant role by offering interconnectedness among multiple providers. For example, some ICT interventions (CDSS and EHR) provide valuable features such as sharing data with other providers (interoperability) and providing patient-specific information such as drug adherence [83]. In doing so, we also report that some participants raised ethical and legal concerns related to sharing data (eg, privacy and security) with several providers. These barriers can be overcome if clinicians, health care workers, and service providers are obliged to maintain confidentiality and report all harmful events associated with the use of ICT interventions [10,13,78,84].
There are opportunities for implementing ICT interventions in LMICs to support the care of older adults with chronic diseases. Approximately 6.5 billion people reside in LMICs, and the proportion of older adults within this population will increase in the near future in these countries [85]. Most intervention studies that we included were from high-income countries. However, very few were from LMICs. Most developing countries lack the necessary financial strength to fund and implement ICT interventions properly. The good news is that the governments of many LMICs are also interested in investing in deploying eHealth to enhance health services, particularly in remote areas [86]. Finally, ICT interventions should help patients self-manage chronic diseases with minimal support from health care providers or clinics. Hence, clinicians and health care providers are required to convince patients to use ICT interventions in addition to routine clinic visits. None of the included reviews on ICT interventions reported harm. However, there are challenges to the implementation of these ICT interventions, particularly for older adults with chronic diseases. The provision of ICT literacy by health care providers and user-centered design by app developers may help older adults widen their engagement with ICT interventions [54]. Hence, longitudinal studies aimed at assessing the long-term effectiveness of ICT interventions should be a priority. Another priority should be to determine whether ICT interventions are clinically effective and cost-effective when used by rural health care providers. Hence, we recommend conducting a systematic review of existing studies on ICT interventions to evaluate their efficacy.

Limitations
To the best of our knowledge, this is the first review of its type to use the SWOT framework to identify strengths, weaknesses, opportunities, and threats for the use of ICT interventions to support the care of older adults with chronic diseases. A potential limitation of our approach is that we did not consult external experts during the review process. Nevertheless, by conducting a scoping review on this topic, we have defined the nature, extent, and range of research activities on ICT interventions for older adults with chronic diseases. Although we searched the literature exhaustively using 4 academic databases, in addition to ProQuest, there is a possibility that we missed some important studies. In this scoping review, we focused on providing an overview of the available research evidence on the use of ICT interventions in older adults with chronic diseases. Therefore, we included a good range of original studies, systematic reviews, and conference papers to help answer our research question. Importantly, none of the studies included in these reviews overlapped. We did not perform a critical appraisal of the literature, which was beyond the scope of our objectives (PRISMA-ScR checklist is given in Multimedia Appendix 4 [29]).

Conclusions
ICT interventions might help support the care of older adults with chronic diseases by increasing adherence to treatment and healthy lifestyles. However, the incorporation of ICT interventions into medical practice is still challenging. The involvement of clinicians is crucial for motivating people with chronic diseases to adopt ICT interventions to support self-management. There is a need to improve awareness and training in the available and effective ICT interventions among older adults and health care providers. Widespread implementation of ICT interventions will also require more sustainable approaches to funding and reimbursement. We recommend involving clinicians and caregivers when designing ICT interventions and integrating them into routine medical care.