How Technology-Based Interventions Can Sustain Ageing Well in the New Decade through the User-Driven Approach

Abstract

The worldwide population is undergoing a fundamental change in its age structure, which challenges the health- and social-services system. The need to migrate towards a more person-centered and coordinated model of care that supports the optimization of abilities and capacities for older people has to be matched. In this sense, eHealth technologies can play a fundamental role. In this paper, through a questionnaire-based data collection using 30 primary (older people) and 32 secondary (informal caregivers) end-users, we share our vision on how to sustainably develop a product by optimizing the user experience and ensuring adoption. We hypothesized that a technology-based intervention can promote healthy ageing through informed and active user involvement at all stages of the care process. Both older adults and caregivers consider the use of a smartphone and smartwatch to be very important; in addition, the use of digital devices for healthcare can be helpful. Seniors care about self-monitoring health parameters through the use of wearable devices, regardless of their health status, and would like to be included in the process of making good health decisions, because they need to feel in control of their healthcare process. Digital solutions in health and care can support the well-being of older adults in many areas of their daily lives, both at home and in their communities, but only if such innovation is designed around the natural voice of the intended target.

1. Introduction

The decade 2021–2030 is the Decade of Healthy Ageing [1], which aims to improve the quality of life of older adults and support independent living while using all the opportunities offered by new technologies.

Bringing up to date the classic definition of health that was launched by the World Health Organization (WHO) [2] in 1948—“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”—Rowe and Kahn [3] defined successful ageing as the absence of physical impairment and chronic diseases, as well as optimal social participation and mental well-being. Afterwards, the focus shifted from defining “a state” to defining “the ability”, since health is a dynamic progress, not only a static situation or condition. In 2011, Huber et al. [4] introduced a new concept of health as “the ability to adapt and to self-manage, in the face of social, physical and emotional challenges”.

Recent research [5] identified ten determinants related to healthy ageing, namely physical activity, diet, self-awareness, outlook/attitude, life-long learning, faith, social support, financial security, community engagement, and independence. It is a growing recognition of the influence of physical, mental/cognitive, and social well-being as determinants of healthy ageing, despite any influence of culture/customs, level of living, age, and varied geographical locations. In relation to mental/cognitive well-being, the studies mention self-awareness, viewpoint/attitude, life-long learning, and faith.

The recent COVID-19 pandemic especially shows us how vulnerable we are, regardless of age, and why health priorities change from treatment to prevention and early detection. Megatrends show that “the better uses of data and technology are transforming health outcomes for patients and citizens and enhancing our ability to detect threats. A focus on disease prevention, rather than cure, holds promise for a healthier future” [6].

In this regard, the WHO [7] defined Healthy Ageing (HA) as “the process of developing and maintaining the functional ability that enables wellbeing in older age”. Functional Ability (FA) (i.e., the health-related attributes that enable people to be and to do what they have reason to value) is determined by Intrinsic Capacity (IC) (i.e., the composite of all the physical and mental capacities of an individual), the environment (EN) (i.e., all the factors in the extrinsic world that form the context of an individual’s life), and the interactions between the two. FA is composed of the following domains: (1) ability to basic needs; (2) ability to learn, grow, and make decisions; (3) mobility; (4) ability to build and maintain relationships; and (5) ability to contribute to community/society. EN also includes five domains: (1) products and technology; (2) natural and human-made environment; (3) support and relationship; (4) attitudes; and (5) service, systems, and policies [8]. Then, the concept of IC is designed to have a “positive” connotation, focusing on the measurement of the residual biological capacities of the organism rather than on its impairments/deficits. Five different domains describe the IC framework: (1) cognition, (2) psychological (i.e., mood and sociality), (3) sensory function (i.e., vision and hearing), (4) vitality (i.e., homeostatic regulation, or balance between energy intake and energy utilization), and (5) locomotion (i.e., muscular function). Each domain closely interacts with the others as part of a dynamically interrelated environment [9]. Thus, IC decline is significantly associated with an increased risk of frailty, disability, falls, fractures, and death.

In summary, the combination of IC, FA, and EN gives life to an innovative model proposed by the WHO that has the potential to substantially modify the way in which clinical practice is currently conducted, shifting from disease-centered toward person-centered paradigms.

Study Objectives

This study is part of the CAREUP (Integrated Care Platform Based on the Monitoring of Older Individual Intrinsic Capacity for Inclusive Health) project that is dedicated to bringing innovation and the latest achievements of digital healthcare into people’s life. The aim of the project is to develop an intervention for the continuous improvement of the quality of life of older adults, leveraging on an ICT-based solution (the CAREUP platform) oriented toward health promotion and disease prevention in later life.

The WHO [10] defines eHealth as the use of ICTs for health. eHealth platforms have been popular in fostering adherence to active and healthy lifestyles and improving autonomy and self-management among older people [11]. These platforms aim to meet the aging population’s needs by supporting independent living and self-management, reducing social isolation, and promoting sustainable well-being [12].

To date, some studies have been conducted on the planning and implementation of eHealth platforms. AGNES [13] is an ICT solution aimed at providing older adults with technological support to keep them in touch with family and friends, avoiding isolation and promoting social inclusion, through a home system equipped with sensors, and personalized web services and interfaces. PERSSILAA [14] is an ICT-supported platform that is used to assess, manage, and monitor community-dwelling older seniors. NESTORE [15] is a system that includes a wide range of wearable devices and environmental sensors which monitor different life domains (cognitive, physiological, social, and nutritional) through a user-centered approach. Among studies based on self-monitoring for promoting active lifestyles, the Activator [16] is an mHealth intervention in which self-monitoring aims to reduce seniors’ sedentary behavior.

In this study, the CAREUP platform will be useful to slow down the decline of intrinsic capacity (the totality of all physical and mental abilities that an individual draws on during his/her lifetime), which is very important for older adults and their families or caregivers. Moreover, it allows us to consider the healthcare process as a personalized, predictive, and integrative process, with a special focus on individual participation.

A major element of failure in the development and implementation of health information systems is the limited understanding of users, their needs, and the contexts in which the systems are used. Therefore, it is important to understand end-user needs from multiple perspectives [17,18]. Within this manuscript, we are interested in sharing the older adults’ challenges and perceptions as an underlying factor of their involvement in the use of the new CAREUP platform. Furthermore, we work to improve their experience as senior users and develop a ready-to-market product, according to their needs and interests. This is why studying people’s attitudes and experiences before, during, and after interacting with the ICT-based solutions is mandatory.

For this reason, we hypothesize that a technology-based intervention can promote healthy ageing through informed and active user involvement at all stages of the care process. Our research objective is to understand the primary (older adults) and secondary (caregivers and family members) end users’ perspectives on the proposed CAREUP platform by inquiring about their attitude to self-monitoring. This is the sustainable way to develop a product optimizing the user experience and ensuring adoption.

2. Materials and Methods

2.1. The CAREUP-Based Intervention

The CAREUP platform (Figure 1) is a system integrated with devices, sensors, and functionalities dedicated to assessing and compensating for the declines in the IC of individuals in relation to their specific environments. It is a tool for primary users (care plan performance to help to slow down IC declines), their caregivers (availability of the care plan reduces caregiver’s burden), and healthcare professionals (monitoring data help in primary user’s health status evaluation).

CAREUP will provide the user with a visualization of his/her health status in the form of an intuitively easy-to-interpret IC domains. Furthermore, CAREUP will visualize changes in health status and compare these with self-defined health goals.

The general practitioner (GP) is the older individual’s first point of contact with the platform. The GP together with the multidisciplinary team (i.e., group of persons involved in care, e.g., physicians, nurses, social care workers, etc.) and family members helps to identify the person-centered goals. Monitoring and IC evaluation results, goals, and EHR data are the basis for the development of the Personalized Inclusive Health Action Plan. The care planning process is focused on older individuals’ needs, values, and preferences. The plan defines activities to be performed and specifies tools to be used to compensate for identified IC declines, in particular, PH domains. Caregivers and coaches have access to monitoring data and the plan; their role consists in monitoring progress and supporting plan implementation. The elderly person can observe his/her results, thus increasing his/her awareness about health. The IC evaluation is carried out periodically at weekly intervals, based on the current sets of collected data.

The CAREUP platform architecture exhibits a modular and expandable design in which interoperability and standardization are considered together with a cost-effective selection of integrated technologies. The platform is composed of several subsystems. The indoor subsystem includes all sensing and controlling devices installed and used by the older adult at home. The system collects health and well-being data from healthcare devices (e.g., a blood pressure meter, a weight scale, a thermometer, and a glucometer) and sleep sensors. Wearable devices equipped with inertial sensors (accelerometers and gyroscopes) are used for user activity monitoring. In a more advanced subsystem version, user location is tracked with a Bluetooth-Low-Energy-based positioning system. Environmental sensors installed at the user’s home provide information on living conditions.

Data collected with devices and sensors are transferred to the Core Subsystem implemented in a cloud environment. The subsystem comprises software modules responsible for secure access to the platform, data storage, processing and interchange, and system management. The essential data processing leading to IC calculation and prediction of IC decline implements Artificial Intelligence/Machine Learning algorithms.

Access to the platform is provided with a portal web application that can be run on any computer or mobile device. The user interface allows users to browse the collected data, results of performance evaluation in IC domains, and Personalized Inclusive Health Action Plan. Additionally, for users of Android devices, the platform offers a mobile application collecting information on user well-being and a set of games.

An innovative approach in CAREUP is the gamification functionality. There are existing studies that show the benefits of gaming for older adults that are living in care facilities [19]. Moreover, games are known to improve verbal, nonverbal, and working memory for adults with cognitive impairment, as presented in [20]. In CAREUP, we propose to design and implement games that will evaluate the abilities of the user during each game session based on IC. Thus, we will correlate the score of the games with the IC. IC will integrate the mental capacities of an individual, determining the functional ability combined with their interaction, using the Guidelines on Integrated Care for Older People (ICOPE), as proposed by the WHO [7,21]. Specially designed gamification elements will aid in diagnosing and improving the physical and mental health of the primary users. The diagnosis part will mostly entail gamified tests (a core innovation of the project), while the mitigation part will focus on long-term adherence, the main challenge that many platforms for seniors struggle with nowadays, and one that AAL calls have intensively insisted on. Unity 3D will be mostly used for developing the games. It is a versatile development platform that is widely used in the game development industry.

2.2. The Method

According to the User-Centered Design approach [22], a dedicated phase of the CAREUP platform definition is the end users’ needs analysis reported in this study. For that purpose, a structured interview guide was used to gather information from both older adults and informal caregivers. We built two questionnaires with a predefined set of open-ended and closed-ended questions based on the UCD approach to understand and specify the context of the use of the CAREUP platform and the IC framework to catch data on health dimensions.

The questionnaires were formulated in English and then adapted to the language of the country leading the interviews. Closed-ended questions allow a limited range of answers. Options and responses are rated with 3–5 points Linkert scale that might measure the level of agreement or their feelings regarding the topic. Open-ended responses permit respondents to share their ideas and suggestions with us. Dimensions and sub-dimensions were used to build the tool for older adults and caregivers. The questionnaire designed for older adults consists of the following topic dimensions: sociodemographic characteristics and self-reported health status, attitude toward health and integrated care from home (i.e., self-monitoring), perceived benefits, intention to use, and adherence to the care plan. The questionnaire for caregivers consists of the following topic dimensions: attitude toward monitoring the loved one and perceived barriers.

2.3. The End Users’ Involvement and Recruiting Strategy

According to the CAREUP project activities, primary end users are older adults, the ones for whom the platform is envisioned, with the main aim of helping them live longer and improve their life quality as they age. Secondary users are adults who directly benefit from the implementation of the platform, especially informal caregivers (family members and friends).

For this research, convenience sampling of older adults and caregivers was used. The recruitment was performed in three European countries (Austria, Italy, and Romania) at the headquarter of the organizations (EURAG for Austria, INRCA for Italy, and AAIF for Romania). Inclusion and exclusion criteria were defined for both groups of end users.

The inclusion criteria for primary end users are age over 65 years, living independently in their home or care facilities, having basic ICT skills, and able to agree and to sign the informed consent. The exclusion criteria included the following: failure to meet the inclusion criteria, severe cognitive impairment, severe behavioral syndromes not compensated by medications, significant visual or hearing impairment, or incapacity to give informed consent.

The inclusion criteria for secondary end users are age over 18 years old, willingness to participate voluntarily in the investigation, and capacity to sign the informed consent. The exclusion criteria are failure to meet the inclusion criteria or the incapacity to give informed consent. In this research, we involved especially informal caregivers (family members and persons listed as trusted contact) who help older adults in performing daily activities, shopping, meal preparation, money management, light housework, laundry, etc.

These criteria were set up by the three organizations based on the specificities of the CAREUP project activities and were assessed by professional staff (i.e., psychologists and researchers) before the enrolment in the study at each site.

The individuals that took part in the study were provided with and asked to sign a written informed-consent form to data treatment and data publication, in accordance with the ethical standards on human experimentation (institutional and national), the GDPR 2018, and the national legislation on privacy and data protection.

Different recruiting strategies were used in the three centers. We first pre-selected to reach those participants who can give us valuable feedback for the purpose of our study.

In Austria, various tools were used by EURAG to recruit participants, such as mailings, telephone calls, and an article in the EURAG newsletter. In the calls for the study for primary users, the project idea was briefly explained, as well as what requirements must be met for participation (inclusion criteria) and how long the interview will take. The interested parties responded to these calls, appointments were made for the interviews (either in the office of the organization or in the homes of the participants), and queries or open questions were clarified. Interviews were held in compliance with special safety measures, such as keeping distance and disinfecting hands and objects used in the study. As secondary users are quite busy, because most of them work full-time or cannot leave the person they care for alone or with a relative, only some interviews (5) could be conducted in person; for others (7), an online questionnaire was set up and sent by email and filled in by the informal caregivers.

In Italy, 10 primary and 10 secondary users were informed of the project objectives, methods, and timing, and we underlined to them that their participation in the study was completely voluntary and that they could leave the study at any time without providing any explanation. The staff then asked the participants specific screening questions to check their inclusion characteristics. Nobody refused to attend, and participants signed a written document giving their informed consent for the processing of their data, in accordance with the GDPR 2016 and national legislation on privacy and data protection. After the signature, each participant watched the slides presentation and then responded to the interview. The recruitment was performed in both a rural and urban context.

In Romania, most participants were recruited using an internal social network of seniors and, after that, contacting each one by phone. People were informed using social media (e.g., posts on the AAIF Facebook page, website, etc.), mailings, and person-to-person contacts. Before their enrollment, information was offered to targeted people. The features and services of the CAREUP platform were explained. People were informed about the purpose of the survey, how the interview was conducted, and how the results were collected and used.

2.4. The Interview Administration

In Austria, 8 interviews with seniors were conducted, including individual interviews, one of which was conducted via telephone (due to a last-minute scheduling conflict of the participant). The interviews took place in the EURAG office and participants’ homes. Some of the 12 interviews with secondary users (5) took place on EURAG’s premises, as individual interviews and (7) responses were received via an online questionnaire (Lime Survey).

INRCA conducted only individual interviews in Italy, half performed by telephone and the other half at participants’ homes.

In Romania, AAIF conducted 12 interviews with older adults. Seniors were invited to AAIF premises after a short description of the meeting. The CAREUP project, platform, and objectives of the meeting were explained. There were 3 groups of people, but the questionnaires were administered to each person individually by AAIF researchers.

In total, we collected responses from 30 primary end users and 32 secondary end users. Only one older adult was withdrawn.

3. Results

All data are reported in

Table 1. Raw data from the data collection of older adults.

	Total (N = 30)	Austria (N = 8)	Italy (N = 10)	Romania (N = 12)
Self-monitoring of health parameters
Very important	21	4	6	11
Moderately important	5	0	4	1
Not important	4	4	0	0
Assessing physical activity
Very important	10	1	1	8
Moderately important	15	2	9	4
Not important	5	5	0	0
Assessing mental activity and mood
Very important	17	3	4	10
Moderately important	10	3	5	2
Not important	3	2	1	0
Use one of the above-mentioned functions on a digital platform
I would like to do this together with a healthcare professional	14	2	6	6
Yes, I would like to use it independently	11	3	3	5
No, and I do not want to do this	5	3	1	1
Willing to wear body sensors to measure your health parameters, e.g., blood pressure, blood glucose values, etc.
Yes, I agree	22	5	9	8
No	6	2	1	3
Don’t know	1	1	0	0
Including the older adult in the decision-making about their own care would be beneficial
Very important	26	7	10	9
Moderately Important	2	1	0	1
Unimportant	2	0	0	2
Useful characteristics/functionalities to integrate into the proposed CAREUP platform
Measure health parameters, periodically	28	7	10	11
Signal (alert) and send a message when a decline is detected	26	8	10	8
Having a person-customized care plan	23	6	9	8
Permit to the Care Team to send recommendations	22	7	9	6
Early detection of any medical conditions/disorders	22	7	8	7
Having “self-defined health goals”	20	4	10	6
Prediction of their physical and mental capacities declines	19	5	8	6
Intention to use
Very difficult	4	0	4	0
Difficult	7	2	3	2
Ok	7	2	1	4
Easy	10	3	1	6
Perceived barriers
Poor technology experience	16	5	6	5
Ease of use of the system	14	3	8	3
Refusal of the GP to work with health data that he has not collected himself and does not rely on	9	4	0	5
Concerns for my safety and personal data protection	6	2	0	4
Preference for traditional medicine and visiting the doctor’s office	5	2	0	3
No motivation to adopt (use) new technologies	5	3	0	2
Lack of trust in the benefits of digital healthcare	4	1	0	3
No barriers, none of these	3	2	1
No interest to monitor my health parameters and adopting new goals and healthy behaviors	2	1	0	1
Feeling of stigma when using such a system	0	0	0	0
Lack of trust in the benefits of digital healthcare	0	0	0	0
The Care Plan desire features
Signal when a quick intervention is needed (i.e., send an alert)	22	6	6	10
Allow you to review it regularly or when your situation changes	17	6	1	10
A care plan is based on your collected health parameters and your physical and mental capacities decline	17	8	0	9
Allow quick intervention when needed	16	7	3	6
Is developed by a multidisciplinary care team	15	6	4	5
Would keep you motivated and engaged	11	3	2	6

and

Table 2. Raw data from the data collection of caregivers.

	Total N = 32	Austria (N = 12)	Italy (N = 10)	Romania (N = 10)
Self-monitoring of health parameters by the older adults
Very important	29	12	10	7
Moderately important	3	0	0	3
Not important	0	0	0	0
Assessing physical activity
Very important	12	7	4	1
Moderately important	17	2	6	9
Not important	3	3	0	0
Assessing mental activity and mood by questionnaires
Very important	19	7	6	6
Moderately important	9	2	3	4
Not important	4	3	1	0
Assessing social engagement and interaction
Very important	20	9	9	2
Moderately important	10	1	1	8
Not important	2	2	0	0
Would be beneficial for you (and your care receiver) to use a digital platform
Easing the caregiving process	25	8	7	10
Reducing stress	22	9	5	8
Increasing the quality of life	19	7	8	4
Which of these perceived benefits seem important to you
Encourage self-care and self-monitoring	23	10	5	8
Health prevention, early detection of any condition based on I.C. declines	21	10	3	8
Overcome the stigma today applied to individuals experiencing the age-related condition	12	10	0	2
Relieve the burden on relatives and family members	12	7	2	3
Improve the compliance/adherence to treatment	11	9	0	2
Facilitate informing and understanding of treatment	5	0	0	5

and discussed narrowly in the following sections.

3.1. Primary Users

3.1.1. Sample Description

The questionnaires were applied to 30 older adults, of which 8 were in Austria, 10 in Italy, and 12 in Romania. The distribution by age category is balanced so that we had 7 participants (a percentage of 23%) between 65 and 70 years old, 7 (23%) aged between 71 and 75 years old, 9 (30%) aged between 76 and 80 years old, and 7 (23%) aged over 80 years. The respondents were primarily women: 19 females and 11 males. Most older adults (70%) are retired, and one-third (30%) are retired and still working. A total of 63% of the respondents live in urban areas, less (36%) in rural areas, and only three individuals (10%) spend the summer in the countryside. One-third of the respondents live alone, and two-thirds live with someone else.

3.1.2. Attitude to Health and the Use of eHealth Technology

To gain information about the attitude to health of the involved primary end users, the questionnaire contained specific items about self-assessment of the health status. According to the WHO guidelines [23], the respondents appear physically active; for example, there are 12 older adults who do physical activity for 6–7 days a week. Ten seniors engaged in physical activity for 4–5 days a week, whereas eight respondents engaged in it for less than three days a week.

On mood, out of 30 participants, 12 seniors (40%) said they have no problems with anxiety or worrying. Fifteen respondents (50%) declared that they feel anxious 5–6 days a week, and three stated that they feel anxious every day. While 19 respondents (63%) said they do not experience depression, 9 seniors (30%) stated that they feel hopeless, with no interest or pleasure in doing things for 5–6 days a week. Moreover, two older adults (7%) said they feel down and depressed almost every day.

The participants declared that they have social interactions “always” (10%) or “often” (60%); only nine seniors interact “sometimes” (20%). Few respondents said that they interact “rarely” (7%) or “never” (3%).

• The use of technology

About the type of technology that older adults consider important to have in use, most of them (18) considered it as “extremely important” to use a smartphone or a smartwatch. Then, it is “very important” (16 seniors) to use digital devices for healthcare and “slightly important” (10) to use a tablet or other touchscreen devices. The respondents believed that it is “not important” to use virtual assistants (15 seniors) and a laptop or personal computer (PC) (11).

The smartphone was most valued. More than half of the participants (18) considered it to be “extremely important” (60%), and 6 older adults considered it ‘’very important”. On the other hand, only three seniors said that it is “slightly important”, and another three that it is “not important at all”. The breakdown by country shows broadly the same distribution; most people in each country consider the use of smartphone/smartwatch to be extremely important or very important.

In second place at the top of the user preferences were the digital devices used in healthcare; thus, 12 respondents considered their use to be “extremely important”, and 16 deemed their use “very important”. The least appreciated was the use of virtual assistants. The distribution by country closely follows the total distribution. Thus, most people in Austria (5 out of 8) and Italy (6 out of 10) considered that it is “very important” to use digital devices in healthcare, and in Romania, most people (7 out of 12) said that the use of digital devices is “extremely important” or “very important”. Not a single person declared that the use of digital devices is “not at all” important in any of the considered countries. This is significant because it shows awareness of the importance of using devices for healthcare such as the proposed solution (CAREUP platform).

• Cognitive games

Regarding the interest in cognitive games, out of a total of 30 people, 16 used digital devices to play games, and 14 did not use devices for this purpose. Among the players, eight seniors played boardgames (e.g., crosswords, cards, solitaire, sudoku, Remi, monopoly, Bridge, and chess); six played digital games on a PC, mobile phone, or tablet (e.g., solitaire, sorting balls, Mhajong, Hexa Block Puzzle); and two played both types of games. Among those who play, the majority (11 people) said they would like to receive a score after the game, only 2 respondents said “no”, and 3 said “don’t know”.

Most players (11) declared that “it is exciting to get a price for their performance or a token to use in future games”, only 2 said “no”, and only 1 said “doesn’t know”. Moreover, 10 players replied that “they like to receive a score and consider it exciting to get a token”. Finally, on average, they spend 1 h and a half playing PC games.

• Self-reported health status

Self-perceived health status is central to our study because the indicator has been linked to the increased use of health services. Only a third of the participants said that their health is “very good” (10 people, respectively 31%), and no one called it “excellent”. On the other hand, the respondents declared that their health is “good” (38%) or “fair” (28%), and one person assessed his/her health as “poor”.

• Attitude to health (self-care) and integrated care from home

Studying whether people are interested in self-care, we asked “would these features help you take care of your own health at home?” About 2/3 of the respondents (70%) declared that the self-monitoring of health parameters is very important for their health. Half of them live in Romania. Only five seniors (17%) said that self-monitoring is moderately important, mostly in Italy, and four (13%) said that it is not important at all. If we analyze the attitude (or intention) toward self-monitoring according to the health status, we notice that there is no strong correlation. Regardless, all people whose health is just “fair” declared that the self-monitoring of health parameters is very important. Thus, we can assume that people care about the self-monitoring of health parameters regardless of their health status. Only 10 older adults considered that the assessment of physical activity by tests is very important, mostly in Romania. On the other hand, 15 participants thought that it is moderately important, mostly in Italy. Then, five seniors stated that the physical assessment is not important, with most of them coming from Austria. More than half of the respondents, namely 17 people, said that the assessment of mental activity and mood by questionnaires is very important. Most of them are seniors from Romania. Moreover, 10 participants thought that the mental assessment is moderately important, and only 3 said that it is not important at all.

• Intention to use the proposed platform and smart sensors

To evaluate the intention to use the CAREUP solution, respondents were asked the following question: “Do you think you would use one of the above-mentioned functions on a digital platform, if you were offered the opportunity?” Out of a total of 30 people, only 11 older adults (36%) intended to use the CAREUP solution independently at home, whereas 14 (47%) would have liked to use it together with a healthcare professional, mostly in Italy and Romania. Then, only five seniors said that they do not intend to use technology even if they are offered the opportunity. In general, most people (76,6%) stated that they would agree to wear sensors to measure health parameters. The distribution by countries shows that more respondents from Italy and Romania agree on sensor technology compared to Austria, but the numbers are too small to generalize such conclusions. Out of 22 people who would agree to wear sensors, 9 said that they want to wear it during the day, 3 during the day and night, and 10 affirmed that they would wear sensors just for a quick health assessment. Out of these 22 people who agree to wear sensors and share health information and data with someone, 16 older adults would have trusted medical doctors or experts, 4 would have relied on family and medical doctors, and 2 would have shared data with anyone if the platform was safe and transparent. Thus, people trust health specialists and rely on their medical guidance and advice, especially when it comes to their own health, as well as assistance in monitoring or sharing health data with someone.

• The perceived benefits

We then investigated the perceived benefits of the CAREUP solution in order to improve the platform in response to user expectations and needs. In total, 7 respondents considered it relevant that wearable sensors allow multiple health parameters to be collected and measured at the same time, and 16 seniors appreciated the real-time monitoring of health parameters, mostly in Romania. The majority, 22 people, considered the opportunity to signal and receive a message when abnormal values are recorded as being relevant, especially in Austria and Italy. It would seem that older adults see benefits in using wearable devices (e.g., wristbands and smartwatches) to collect information and monitor their physical activity. Thus, 12 seniors said that keeping track of physical activity meets their needs, 18 especially appreciated the opportunity to monitor movement and prevent falls, and 14 considered it relevant to receive a report about their physical activity progress. Only two participants from Austria said that none of these features is relevant to meet their needs. The respondents considered that monitoring mental and emotional health meets their needs. Nineteen people best valued the activities recommended by medical professionals to maintain their emotional balance, self-control, stress management, etc., mostly in Romania and Austria. Then, 15 seniors considered that it is important to keep track of mental activity and mood changes, even more than tracking physical activity. Similarly, 14 seniors were interested in maintaining their mental health by receiving smart games and cognitive activities designed for older adults to improve their cognitive function. In summary, seniors see immediate benefits in (1) reporting and receiving a message when outliers are recorded; (2) detecting movement to prevent falls; (3) offering recommendations to maintain emotional balance, self-control, stress management, etc.; (4) real-time monitoring of health values; and (5) receiving a progress report; (6) evaluating and improving cognitive function.

3.1.3. Care Plan: Decision-Making Process, Desired and Useful Features, and Perceived Barriers

Most of the respondents (26) thought that it is very important to be included in the process of making good health decisions, because they need to feel in control of their healthcare process. Only two seniors said that their involvement is moderately important, and another two said that it is not important at all—both of them come from Romania. It is also true that these two people self-assessed their physical health as “good”, and they would not have been willing to wear body sensors. About the care plan’s desired features, most seniors (22) wanted to know when a quick intervention is needed by signaling a situation of risk by receiving an alarm or alert message. Moreover, 17 people appreciated that the intervention is personalized, based on collected health parameters and physical and mental capacities’ decline, and another 17 said that it is relevant that the care plan allows them to know when their situation changes. Similarly, 16 older adults were interested in receiving a quick intervention when needed. Only 15 people appreciated that the care plan is developed by a multidisciplinary team, and 11 agreed that the care plan would keep them motivated and engaged.

• Useful features/functionalities

About the care plan’s useful features, most respondents (28) said that they were interested in measuring their health parameters, and 26 were interested in receiving a signal or an alert message when a decline in the IC is detected. Moreover, 23 people were interested in having a personalized care plan, and 22 said that they want to allow the care team to send recommendations for investigations, specialist medical consultations based on health assessment, medical advice, etc. Similarly, they were interested in the prevention or early detection of any medical conditions/disorders that could be based on their physical and mental capacities’ decline. Moreover, 20 participants were interested in having self-defined health goals according to their health status and vulnerability, and only 19 people wanted to get information about the prediction of their physical and mental capacities’ decline. The use of the digital platform and smart sensors could be hindered by real obstacles or perceived barriers.

• Practical application and perceived barriers

We investigated the opinion of users regarding these difficulties to know how to develop the CAREUP platform and facilitate its adoption. First, 16 respondents considered that a poor experience in using technology could be an important barrier. The second perceived barrier was that the platform would not be easy to use (16 people). On the other hand, nine seniors were worried about the possible doctor’s refusal to work with data that he/she has not collected him/herself and does not rely on. Moreover, six older adults were concerned for their safety and personal-data protection. Fewer participants (five) considered that the preference for traditional care and visiting the doctor’s office could be a barrier. Moreover, one senior from Austria explained that “advice from GP is more trustworthy than the advice from the platform”. It is good that not one person said that the lack of confidence in the benefits of technology would be a barrier, and neither did they mention the feeling of stigma when using such a system.

3.2. Secondary Users

3.2.1. Sample Description

The group of caregivers consisted of 32 people, of which 12 were in Austria, 10 in Italy, and 10 in Romania. We included only informal caregivers who could help older adults by using the proposed CAREUP platform. Mostly they are very close to seniors, and they know their needs and expectations better. A majority of the caregivers (26/32 individuals) are active employees, only 4 are retired, and 2 are retired and still working. A total of 29/32 respondents live in urban areas, whereas only 3 live in rural areas. For two-thirds of the respondents (22/32), the use of a smartphone or smartwatch is considered “extremely important”, but also, the use of digital devices for healthcare (17/32) can be helpful. Only a few caregivers prefer to use a laptop (8/32), tablet, or other touchscreen devices and services, such as virtual assistants. Half of the respondents (15/32) said that their care receiver monitors their health parameters at home at least once a week, especially people from Austria, whereas Romanian older adults monitor their parameters once a month, or a few times a year, especially in Italy. Most respondents (29/32) declared that the self-monitoring of health parameters is very important for their care-receiver’s health. According to the respondents’ preferences, it would be relevant to assess the activities of their beloved related to social engagement and interaction (30/32), physical activity (29/32), cognitive activities (28/32), and mood changes (30/32).

3.2.2. Perspective on the CAREUP Solution

Out of a total of 32 respondents, 25 caregivers said that using the CAREUP platform would help to improve the caregiving process. Two-thirds (22/32) said that the use of the platform would lead to stress reduction and increased quality of life (19/32). The majority of caregivers, 27/32, stated that they agree to support the older adult to use the platform correctly and effectively since it will offer a lot of information and measurements that could help them to better evaluate the current health status of the older adult. Most respondents (28/32) appreciated that the system could send information on the values of health parameters and their variation over time. Indeed, caregivers believe that using the platform could have an impact on the health status of older adults, as it encourages self-care and self-monitoring (23/32) and treatment adherence (11/32), thus making the care process easier. Another benefit is that caregivers could have early information on the deterioration of health and IC decline (21/32). Some respondents (12/32) mentioned that using the CAREUP platform could have positive consequences on overcoming the stigma today applied to individuals experiencing age-related decline. In terms of barriers that might prevent them from using the technology-based solution to its maximum capacity, most caregivers (18/32) are concerned about the fact that collected data are not reliable due to different circumstances, such incorrect usage of the devices. Moreover, 14 people said that older adults are unable to make the best decision for the benefit of their health. Thirteen people are concerned about potential emergency situations that could appear and that the older adult might have to face, including life-threatening emergencies. Ten people said that using the platform could confuse the doctors in their diagnosis or place pressure on them as to determining whether the collected data are reliable or not.

4. Discussion

To make a sustainable product that optimizes the user’s experience and ensures adoption, in the proposed technology-based solution, we engage users throughout the development process, according to the ISO standard [22]. The aim was to understand seniors’ and caregivers’ perceptions, needs, and habits; interpret the motivations behind their behaviors; and uncover the barriers or frustrations that they face during the interaction with the system. We aim to create systems that are usable and useful by focusing on the users and their needs and requirements and ensuring the sustainability of the eHealth product.

Indeed, electronic health tools provide little value if the intended users lack the skills to engage with them effectively. Engaging with eHealth requires a skill set, or literacy, of its own. The concept of eHealth literacy is defined as the ability to seek, find, understand, and appraise health information from electronic sources and apply the knowledge gained to addressing or solving a health problem [24].

Seniors over 65 years are not a heterogeneous group; instead, they are a very diverse one regarding health status, attitudes, and interests. There are personal limitations related to age and health problems, from diminishing physical capabilities and cognitive difficulties to the skill to use digital devices and the related self-confidence. That is exactly why older adults’ personal experiences, social interactions, and familiarity with technology are relevant. The results show that most seniors in each country consider the use of technology to be important. Such use is related to the benefits they perceive and value, such as receiving a message when outliers are recorded, detecting movement to prevent falls, monitoring health values in real time, and evaluating and improving cognitive function. According to Leung [25], perceived benefit refers to the perception of the positive consequences that are caused by a specific action. In behavioral medicine, the term “perceived benefit” is frequently used to explain an individual’s motives of performing a behavior and adopting an intervention or treatment. In this regard, self-perceived health status is important, not only because it plays a key role in health, but also because it is related to adopting a lifestyle that promotes health itself [26]. Older adults are aware of the many benefits that using technology has on living a healthy life. Still, its use in daily life depends on several factors, such as receiving immediate help or feeling able to master such use [27]. In fact, some of them would use the self-monitoring techniques independently, but more of them would need a piece of advice because people trust healthcare specialists and rely on their medical guidance, especially regarding health technology [28]. However, it can be assumed that there are different situations in which older adults may have problems finding the help they need. For example, due to progressive social isolation, some seniors experience anxiety and depression, which are often difficult to treat due to relapses and/or cognitive deterioration [29].

It is also true that if seniors think that it is very easy to use a certain technology, then it is likely that they will try to use it [30]. The initial difficulty lies probably in the solution’s novelty and the need to learn a new health-related behavior. Indeed, the adoption of a new health-related behavior is often determined by experience and personal resources, as well as social influence. However, if people think it is worth it for their health, they will more easily choose to learn and adopt a new behavior [31,32].

In addition to the perceived benefits and the ease of use, another factor that influences the intention of older adults to use the CAREUP platform in their daily lives seems to be linked more to the attitude of self-confidence and the perception of control over their state of health, for example, through the self-monitoring of health parameters. Self-confidence and empowerment trigger positive feelings toward themselves and control over their life and/or life satisfaction [33]. Moreover, autonomy concerns a person’s right to make his/her own decisions about life independently [34], and, for seniors, this is highly associated with the care, housing, social activities, and even the end-of-life decisions that they face [35]. Taking an active role in their healthcare is the best way for them to adhere to healthy ageing. According to Bernardo et al. [36], the importance of engaging older people in their own care is gaining increasing attention from health professionals and researchers, as their involvement in health promotion and disease prevention is essential to successful health management. An active older adult is an effective ally in care. This framework suggests that older adults benefit from being engaged, and current healthcare delivery requires them to have the skills to participate constructively in designing their healthcare plan.

Regarding the involvement of secondary users, our study shows that caregivers want to know that their loved ones are well and are available to help them use the proposed solution. Considering that people act according to their interests and beliefs, if caregivers feel that healthcare is important, then it is likely that they will encourage older adults to use the CAREUP platform [37].

Moreover, the use of multiple and heterogeneous data-driven decision-making systems can drive the transformation of preventive and healthcare pathways toward the real needs of individuals and society. In order to drive such process ethically, it is fundamental to involve citizens in a participative process that requires the increase of health literacy and the empowerment of citizens as data owners [38].

This study confirms that the acceptance and use of technology rely on the active involvement of people and professionals, responding to the real needs of end users and building a responsible perception of positive health, prevention, and integrated care [39,40]. Despite the benefits of collecting and comparing these different perspectives, the specific national centrality of Italy, Romania, and Austria, as well as gender disparities in the sample size, could be seen as bias and have significant limitations that do not allow for the generalization of results. Furthermore, the sole use of a questionnaire is also a limitation: a mixed-methods approach could have guaranteed a broad understanding of thoughts. These limitations can be assumed as suggestions for future research in the field.

5. Conclusions

Digital solutions in health and care can support the well-being of older adults in many areas of their daily lives, both at home and in their communities. As a matter of fact, to guarantee this support, health and social services need to be reoriented toward a more person-centered and coordinated model of care that supports the optimization of abilities and capacities for older people. In such a scenario, empowering older adults to learn to take care of their health because it fits with and is integrated with their personal life-centered goals. Indeed, before proposing empowering and coaching, with or without eHealth devices, we still need to understand how to support all the ageing needs and changes by listening to the authentic voice of older adults facing their life every day in their community. Even if much research has explored this field, nowadays, the innovative tools are still far from wide acceptance and usage, and the silver market is still a landscape to explore. Once again, it is mandatory to underline the adoption of technical solutions and services, and finally, its commercialization requires users’ involvement in almost every stage of development and testing. This mission is pursued by initiating and conducting collaborative, multisectoral, and transdisciplinary research, as well as adapting person-centered integrated care that focuses on the needs of older people. Indeed, the use of well-designed technologic platforms has the potential to create individually tailored public health messaging. All stakeholders in healthcare should utilize technology to expand the reach and impact of initiatives and interventions. Of course, healthcare represents a service ecosystem of multiple actors that is more complex than a simplistic consideration of the doctor/patient model that covers four levels [41]: clinicians and patients working together with nurses and allied health professionals to collaboratively design a healthcare package, as well as collaborating with family, friends (micro level), hospitals, clinics, and local health support agencies (meso level); health authorities who determine funding allocation; professional associations of doctors and nurses; and health insurers (macro level) and government agencies who collaboratively determine aspects of health policy, as well as regulatory and health-funding bodies (mega level). Worldwide, there is a need for health systems that enable the provision of higher-quality and safer healthcare, reflect population needs, and facilitate better assessment and management of population health. This challenge requires appropriate organizational and methodological paradigm changes that are supported by technological innovations: a transition from organization-centric through disease-specific process-controlled care to sustainable person-centric care where all the actors are active protagonists of their health journey. Future research directions will certainly strengthen the collaboration between micro, meso, and macro levels, as well as underlying the importance of methodological frameworks to prove the efficacy of technology-based interventions (i.e., mixed methods approach, feasibility studies, and randomized control trials). This field of research still needs to demonstrate what digital solutions have to offer and how they can improve the effectiveness of interventions through evidence-based progress. Therefore, there is an urgent need to strengthen data, research, and innovation around e-health interventions to meet the needs of an ageing society and the future healthcare system’s requirements.