This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on https://www.jmir.org/, as well as this copyright and license information must be included.
Care policies emphasize deinstitutionalization and
The purpose of this systematic literature review is to appraise, synthesize, and summarize the literature on older adults’ (aged ≥60 years) eHealth learning and use in real home settings, particularly in rural and remote areas, with a focus on the social and cultural context.
A systematic search was conducted in January 2020 using 4 academic databases. The studies by means of qualitative thematic analysis to identify the barriers, enablers, and support practices involved in the domestication process were examined. In addition, we identified the various meanings attached to eHealth technologies for older adults living in rural and remote areas.
In total, 31 empirical studies published between 2010 and 2020 were included in this review. A total of 17 articles included participants from rural and remote areas. The most regularly reported barriers related to older adults’ learning to use and use of eHealth were health-related difficulties, such as cognitive impairment or impaired hearing. The most reported enabler was the support provided for older adults in learning and use of eHealth. Support mainly comprised older adults’ own digital competences, which were distributed with their social network. It was found that eHealth technology is needed for rural and remote areas to facilitate access and reduce logistical barriers to health care services.
The literature review provided information and practical implications for designers, health care providers, and policy makers. On the basis of these findings, eHealth technologies should be easy to use, and adequate support should be provided to older adults for use.
The aim of this systematic literature review is to advance the understanding of older adults’ (aged ≥60 years) eHealth learning and use during its domestication. The main target is older adults living in rural and remote environments, as they are far removed from traditional health care services [
On the basis of future demographic changes, the world will face two challenges: a growing care burden per capita and organizational changes to health care systems [
This study’s theoretical framework is built on the concept of
The concept of domestication focuses on how technology users and nonusers adopt technologies culturally and socially in their everyday lives [
Research into health-related barriers has found that the key reasons older adults avoid ICT adoption are the accessibility of support, their health status, lack of need or interest, functionality, added value, cost, and concerns regarding privacy and trust [
Recent international literature reviews on eHealth and older adults focus on a variety of topics: eHealth access and use from a health equity perspective [
What barriers and enablers are related to the learning and use of eHealth technologies in domestication processes among older adults living at home?
How are older adults living at home supported in their domestication of eHealth technologies?
What are the meanings attached to eHealth technologies for older adults living in rural and remote areas?
The methodology follows the standard PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for studies that evaluate health care research [
Flow of information through the different phases of the systematic review.
To begin the search process, the author consulted an information specialist at her university library regarding search phrases and relevant databases. A literature search was conducted in January 2020 and included the following international web-based databases: ProQuest (ERIC—Education Collection, Social Science Database, Applied Social Sciences Index and Abstracts, Sociological Abstracts, and Sociology Database), Ebsco (AgeLine, Academic Search Elite, and CINAHL Complete), Web of Science (Arts and Humanities Citation Index, Social Sciences Citation Index, Science Citation Index Expanded, and Emerging Sources Citation Index), and Scopus (Elsevier). Relevant articles were found using the search terms specified in
Older people:
Rural:
Use:
Digital technology:
Health:
Home:
Finally, full-text articles (31/489, 6.3%) that met the following criteria (
Academic paper published in a peer-reviewed scientific journal
Written in English
Published between 2010 and 2020
Had an empirical study design aimed at supporting older adults’ eHealth use
Was located in real home settings at the user’s home
Had participants with a mean age of 60 years
Completely or partially focused on users’ perspectives
Did not include older adult participants
Was not conducted in real home settings
Was conducted in a laboratory or included no user experience with eHealth
Was a review or theoretical study
Only had a biomedical or technical perspective
For the final set of full-text articles, a data extraction sheet was developed (
The selected 31 articles were published in 29 different journals representing multidisciplinary research. Of the 31 papers, 16 (52%) were quantitative, 4 (13%) were qualitative, and 11 (35%) were mixed methods studies. Most studies used >1 method; only 16% (5/31) used just one method. The most common qualitative data collection methods were surveys and questionnaires (20/31, 65%) and technical logs (12/31, 39%). The most common qualitative data collection methods were interviews (9/31, 29%) and focus groups (5/31, 16%). The studies were conducted in the following 12 countries: the United States (9/31, 29%), Canada (2/31, 6%), Italy (2/31, 6%), Spain (2/31, 6%), Sweden (2/31, 6%), the United Kingdom (2/31, 6%), France (1/31, 3%), Germany (1/31, 3%), Ireland (1/31, 3%), Lebanon (1/31, 3%), Norway (1/31, 3%), and Switzerland
The number of participants ranged from 1 to 4380, although not all were older adults. In all articles, either the mean or median age and SD or the age range was defined. However, in studies in which only the SD and mean or median age were given, it was not possible to strictly count the age of the youngest and oldest participants. In 90% (28/31) of articles, the mean or median age of the technology users was ≥60 years, and in 39% (12/31) of articles, the minimum age was >60 years. Some articles (6/31, 19%) included technology users aged<50 years, and it was possible to separate them from the older adults in the findings. This means that the findings were still based on participants who were aged >60 years or whose mean or median age was ≥60 years. In 42% (13/31) of articles, most participants were women, and in 35% (11/31) of articles, most participants were men. In 6% (2/31) of papers, female and male participants were equally represented, and in 16% (5/31) of papers, gender was not defined.
All participants used eHealth technologies in real home settings. The eHealth technologies that occurred most frequently were mobile apps (18/31, 58%), monitoring systems (12/31, 39%), web-based platforms (11/31, 35%), assistive technologies (2/31, 6%), and ambient awareness technology (1/31, 3%). No eHealth robots were included in this study. Most technologies were targeted at older adults with different noncommunicable diseases. Of those, the largest target groups were cardiac disease (5/31, 16%), diabetes (3/31, 10%), and cancer (3/31, 10%). In total, 2 technologies were used for older adults with polypharmacy issues and 2 for those in palliative care. In 16% (5/31) of studies, eHealth technologies were aimed at isolated older adults, and in 13% (4/31) of studies, the technology was for older adults with depression, anxiety, or apathetic qualities. In total, 1 eHealth technology was only for healthy older adults, and 5 were for older adults or adults of any age group in general. In some studies, the participants were veterans (4/31, 13%), and in others, they were older family caregivers (4/31, 13%).
The first research question focused on the barriers and enablers related to the learning and use of eHealth technologies in the domestication process among older adults living at home. Thematic analysis produced 111 subcategories related to these barriers and enablers. The subcategories were clustered into 4 dimensions of the domestication process [
Summary of the findings concerning the barriers to learning and use of eHealth technologies among older adults (N=31).
Dimension of domestication and barriers | Papers, n (%) | |||
|
||||
|
|
|||
|
|
Lack of connectivity | 9 (29) | |
|
|
Technical problems | 8 (26) | |
|
|
Difficult to use | 6 (19) | |
|
|
Unclear instructions | 5 (16) | |
|
|
Cost | 4 (13) | |
|
|
Technical limitations | 4 (13) | |
|
|
Difficult to learn to use | 3 (10) | |
|
|
No feedback | 2 (6) | |
|
|
Lack of effectiveness | 1 (3) | |
|
|
Lack of technical device | 1 (3) | |
|
|
Technology was unexpected | 1 (3) | |
|
|
|||
|
|
Health-related difficulties | 17 (55) | |
|
|
Lack of previous experience | 5 (16) | |
|
|
Uncertain with the technology | 5 (16) | |
|
|
Irritation or frustration | 4 (13) | |
|
|
Lack of motivation or interest | 2 (6) | |
|
|
Personal factors | 2 (6) | |
|
|
Fatigue | 2 (6) | |
|
|
Being intimidated | 1 (3) | |
|
|
Lack of digital competence | 1 (3) | |
|
|
Skeptical | 1 (3) | |
|
|
Unwilling to use the technology | 1 (3) | |
|
||||
|
|
|||
|
|
Design | 2 (6) | |
|
|
Placement in the home | 2 (6) | |
|
|
Ergonomics | 1 (3) | |
|
|
|||
|
|
Concerns about security or privacy | 4 (13) | |
|
|
Lack of reliability | 2 (6) | |
|
||||
|
|
|||
|
|
Unsuitable for everyday life | 3 (10) | |
|
|
Time constraints or power dynamics | 3 (10) | |
|
|
Lack of utility | 2 (6) | |
|
|
Inappropriate technology | 1 (3) | |
|
|
Logistical difficulties | 1 (3) | |
|
|
Not meaningful information | 1 (3) | |
|
|
Not meaningful service | 1 (3) | |
|
|
Technology used only occasionally | 1 (3) | |
|
||||
|
|
|||
|
|
Need for face-to-face contact | 7 (23) | |
|
|
Lack of support | 3 (10) | |
|
|
Family relationships | 2 (6) | |
|
|
Feeling like an outsider | 1 (3) | |
|
|
Lack of communication | 1 (3) | |
|
|
Lack of patient–professional communication | 1 (3) | |
|
|
Shyness | 1 (3) | |
|
|
unable to use independently | 1 (3) | |
|
|
|||
|
|
Older age | 4 (13) | |
|
|
Not culturally relevant | 3 (10) | |
|
|
Living in rural area | 2 (6) | |
|
|
Lower socioeconomic status | 1 (3) | |
|
|
Being female | 1 (3) |
Summary of the findings concerning the enablers of learning and use of eHealth technologies among older adults (N=31).
Dimension of domestication and enablers | Papers, n (%) | |||
|
||||
|
|
|||
|
|
Usability | 18 (58) | |
|
|
Personalization or flexibility | 13 (42) | |
|
|
Familiarity | 9 (29) | |
|
|
Feedback | 7 (23) | |
|
|
Accessibility | 3 (10) | |
|
|
Automated service | 1 (3) | |
|
|
Novelty effect | 1 (3) | |
|
|
Offers personal challenge | 1 (3) | |
|
|
Positive experiences of others | 1 (3) | |
|
|
|||
|
|
Satisfaction | 14 (15) | |
|
|
Confidence or self-esteem | 4 (13) | |
|
|
Self-efficacy | 4 (13) | |
|
|
Feeling of success | 3 (10) | |
|
|
Open-minded | 3 (10) | |
|
|
Digital competence of the user | 2 (6) | |
|
|
Interest in electronic devices | 1 (3) | |
|
|
No feeling of privacy loss | 1 (3) | |
|
|
Own choice | 1 (3) | |
|
||||
|
|
|||
|
|
Placement in the home | 2 (6) | |
|
|
Design | 1 (3) | |
|
|
|||
|
|
Technology’s security or safety | 2 (6) | |
|
|
User privacy | 2 (6) | |
|
|
Reliability | 1 (3) | |
|
||||
|
|
|||
|
|
Suitable for everyday life | 10 (32) | |
|
|
Service provided educational information | 8 (26) | |
|
|
Active part of user’s own care, self-care | 7 (23) | |
|
|
Playful | 7 (23) | |
|
|
No logistical barriers | 7 (23) | |
|
|
No temporal barriers | 6 (19) | |
|
|
Improve quality of daily life | 6 (19) | |
|
|
Useful service | 6 (19) | |
|
|
Increased security | 5 (16) | |
|
|
Systematic use of the technology | 4 (13) | |
|
|
Extends one’s own habitat | 3 (10) | |
|
|
Healthier lifestyle | 3 (10) | |
|
|
Meaningful service | 3 (10) | |
|
|
No financial barriers | 3 (10) | |
|
|
Brings joy | 2 (6) | |
|
|
Fewer clinical visits | 2 (6) | |
|
|
Technology provides freedom | 2 (6) | |
|
|
Helpful | 1 (3) | |
|
|
Not in a hurry | 1 (3) | |
|
||||
|
|
|||
|
|
Support practices | 27 (87) | |
|
|
Social connectedness and belonging | 10 (32) | |
|
|
Patient–professional communication | 9 (29) | |
|
|
Visual contact | 4 (13) | |
|
|
Shared experience | 3 (10) | |
|
|
Face-to-face meeting | 2 (6) | |
|
|
Group assignments | 2 (6) | |
|
|
Social comparison | 2 (6) | |
|
|
Feeling less lonely | 1 (3) | |
|
|
Individual attention | 1 (3) | |
|
|
Loneliness | 1 (3) | |
|
|
Relationship with technology | 1 (3) | |
|
|
|||
|
|
Cost-effectiveness | 8 (26) | |
|
|
Cultural relevance | 4 (13) | |
|
|
Supports independence | 2 (6) | |
|
|
Feeling of being equal | 2 (6) | |
|
|
Being female | 2 (6) | |
|
|
User feels like an active citizen | 1 (3) | |
|
|
Being considered |
1 (3) | |
|
|
Educated or employed | 1 (3) | |
|
|
Older age | 1 (3) |
Of the 31 articles, 30 (97%) reported barriers and enablers in the appropriation phase of the domestication process; this dimension had more barriers than the others. Older users’
Objectification was the least-coded dimension, and there was not a big difference between the different subcategories. The
Of the 31 articles, 24 (77%) reported barriers and enablers during the incorporation phase. As reported in 32% (10/31) of articles, the most common enabler was that the eHealth technology was
The conversion dimension had more enablers than the other dimensions. The most common enabler in the conversion phase and the entire domestication process was
Regarding society and culture,
In addition, o
To understand how older adults were supported while domesticating eHealth technologies, the thematic analysis produced 25 subcategories related to their learning to use and the use of technology. The subcategories were clustered into two upper-level categories: social network support (22/31, 71%) and nonsocial support (3/31, 10%). Of the 31 articles, 27 (87%) reported that support was provided to users during the domestication process [
Social network support was provided in 87% (27/31) of articles. During the learning process at the beginning of domestication,
During the domestication process, eHealth technology users distributed their digital competence [
Nonsocial support practices in the learning process were
The focus of the third research question was on the meanings attached to eHealth technologies for older adults living in rural and remote areas. The terms
Of the 17 articles, 14 (82%) reported that different eHealth technologies, such as home telehealth monitoring and videoconferencing for consultation, were needed in rural and remote areas. A total of 2 meanings clearly stood out: first, 71% (12/17) of articles [
Although eHealth technology was principally seen as needed for rural and remote areas, 24% (4/17) of articles identified sources of inconvenience and concern. Here, the most commonly coded meanings are related to internet connectivity and use. Approximately 18% (3/17) of studies reported that rural areas
To advance the understanding of older adults’ (aged ≥60 years) eHealth learning and use during its domestication, a systematic literature review of 31 empirical studies published between 2010 and January 2020 was conducted. The aim was to summarize the literature on the barriers and enablers that older adults encounter when learning to use and using eHealth technology and how they are supported in real home settings. The main targets were rural and remote older adults. The key findings of this review confirmed that social networks supporting older adults are important enablers for learning how to use and using eHealth technology. In addition, this review revealed that health-related difficulties often prevent older adults from domesticating eHealth technologies. Various eHealth technologies have been reported as necessary for older adults in rural and remote areas, although some sources of inconvenience and concern related to internet connectivity and use were found.
One of the goals of this review was to find out which barriers and enablers are related to learning how to use and using eHealth technologies in the domestication processes among older adults living at home. The findings were divided into 4 dimensions (appropriation, objectification, incorporation, and conversion) of the domestication process [
In addition, this systematic review asked how older adults living at home are supported during the domestication of eHealth technology. In most cases, older adults distributed their digital competences with their social networks, which supported the domestication of eHealth technology. The social network included
This review’s final aim was to better understand the meanings attached to eHealth technologies for older adults living in rural and remote areas. Although the literature includes few studies set in rural and remote areas, this review confirms that eHealth technologies are needed in rural and remote areas for several reasons. eHealth technology is seen as solving many problems related to limited access to health care services, such as logistical, temporal, financial, and weather-related barriers. In addition, eHealth technologies can foster a sense of belonging in older rural residents by reducing feelings of isolation and by connecting them with peers or care providers. Previous research has also shown that ICT services can reduce social isolation and promote social connectivity in older adults experiencing physical and cognitive decline or living in remote areas [
This review reveals several gaps that suggest directions for future research. First, a stronger focus on older adults’ learning processes is required in research on the domestication of eHealth technology. In the literature search, numerous articles focused only on older adults and the use of eHealth technology from a biomedical [
This review has several limitations. First, as there was only 1 reviewer involved, this review’s quality and reliability were somewhat weakened. Additional reviewers would have challenged the decisions made by the author. Second, although the selected studies were conducted in 12 countries, Western countries and English-speaking countries dominated, and studies not written in English were excluded. As noted in earlier reviews [
This literature review provides information and practical implications for designers, health care providers, and policy makers. eHealth technology targeted at older adults should be easy to use, and adequate support and training should be provided to users [
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses), a 27-item checklist.
An example search string for Scopus (Elsevier).
Summary of included articles.
information and communication technology
Preferred Reporting Items for Systematic Reviews and Meta-Analyses
This study was part of a larger research project called HARVEST—eHealth and Aging in Rural Areas: Transforming Everyday Life, Digital Competences, and Technology (2018-2021). The project is nationally supported by the Academy of Finland (318835) as part of the international JPI MYBL (Joint Programming Initiative More Years, Better Lives) call. JPI MYBL is supported by the J-AgeII. J-AgeII is funded by Horizon 2020, the EU Framework Program for Research and Innovation, under grant agreement 643850, the JPI MYBL.
None declared.