Health and Social Care in the Community (2016) doi: 10.1111/hsc.

12335

Review

Effects of digital engagement on the quality of life of older people

1 1 2 1
Jacqueline Damant Ph.D. , Martin Knapp Ph.D. , Paul Freddolino M.Div, Ph.D. and Daniel Lombard M.Sc.
1 2
Personal Social Services Research Unit, London School of Economics and Political Science, London, UK and School
of Social Work, Michigan State University, East Lansing, Michigan, USA

Accepted for publication 21 January 2016

Correspondence Abstract
Jacqueline Damant It is often asserted that older people’s quality of life (QOL) is improved
Personal Social Services Research when they adopt information and communication technology (ICT) such
Unit as the Internet, mobile phones and computers. Similar assumptions are
London School of Economics and made about older people’s use of ICT-based care such as telecare and
Political Science
telehealth. To examine the evidence around these claims, we conducted a
Cowdray House, Houghton Street
scoping review of the academic and grey literature, coving the period
London WC2A 2AE, UK
E-mail: [email protected] between January 2007 and August 2014. A framework analysis approach,
based on six domains of QOL derived from the ASCOT and WHOQOL
models, was adopted to deductively code and analyse relevant literature.
What is known about this topic The review revealed mixed results. Older people’s use of ICT in both
mainstream and care contexts has been shown to have both positive and
• Some research indicates that older
negative impacts on several aspects of QOL. Studies which have
people’s use of email and Skype
positively affects their quality of rigorously assessed the impact of older people’s use of ICT on their QOL
life (QOL) by enabling them to mostly demonstrate little effect. A number of qualitative studies have
keep in touch with friends and reported on the positive effects for older people who use ICT such as
relatives. email or Skype to keep in touch with family and friends. Overall, the
• Research suggests mobile phone review unearthed several inconsistencies around the effects of older
ownership can have a positive people’s ICT use on their QOL, suggesting that implicit agreement is
effect on older people’s sense of needed on the best research methods and instrumentation to adequately
safety and security. describe older people’s experiences in today’s digital age. Moreover, the
available evidence does not consider the large number of older people
What this paper adds
who do not use ICT and how non-use affects QOL.
• The empirical evidence
demonstrates that the effects of Keywords: Internet, older people, quality of life, technology, telecare,
older people’s use of ICT, for both telehealth
mainstream and remote care
purposes, on different domains of
QOL can be both positive and Introduction
negative, challenging common
assumptions that ICT is The impact of new information and communication technology (ICT),
unquestionably beneficial. such as mobile telephones, computers and the Internet, on the lives of
• Highlights the strengths and older people is unclear, with both positive and negative views expressed.
limitations of different research We review evidence on the impact of ICT on quality of life (QOL) of
methods used for generating older people, with respect to both their day-to-day lives in general and
evidence on the effects of their health and social care needs in particular.
technology use on QOL.

Methods
We undertook a scoping review, adhering to guidelines outlined in Ark-
sey and O’Malley (2005). Initial searches were conducted on 8 August
2012 in databases focused on relevant disciplines including ICT and com-
munications (Library, Information Science and Technology Abstracts,

© 2016 John Wiley & Sons Ltd 1

J. Damant et al.

Communications and Mass Media Complete), social Internet platforms used by large proportions of the
sciences (International Bibliography of Social Sciences, population in Britain as indicated by OfCom (2014).
PAIS International, SocIndex Full text, Web of Science It includes Internet networks, mobile phones, smart
Core Collections), psychology (PsycINFO), and health phones, computers and tablet computers.
and social care (CINAHL Full text, PubMed). The
database review was restricted to peer-reviewed jour-
What is remote care?
nal articles published between January 2007 and
August 2012. Searches were repeated on 15 August Barlow and Knapp (2014) define remote care as
2014 to identify articles (published between January ‘assisted living’ technologies which use ICT devices
2012 and August 2014). Boolean terms for the search and telecommunications network to deliver health and
are described in Table 1. social care remotely – often in someone’s home. It
Searches yielded 1129 unique references. After includes overlapping concepts such as ‘telecare’, ‘tele-
screening titles, abstracts and full texts, in turn, for health’, ‘telemedicine’ and ‘smart homes’ (Barlow et al.
relevance in terms of older people’s access to ICT and 2012), which represent the range of remote alert, moni-
effects on QOL, the final selection included 91 key toring and consultation services currently deployed
articles. We included articles discussing a broad within health and social care systems. Emerging con-
range of ICT used by adults explicitly described as cepts such as ‘mCare’, ‘mHealth’ and ‘wellness ser-
‘older’, ‘elderly’ or ‘senior citizens’. The main reasons vices’ also embody the notion of remote care. mCare
for exclusion included no reference to ICT usage, no (or ‘mHealth’) uses mobile devices as the gateway to
analyses of older adults and studies in tertiary care services (Telecare Services Association, 2013a). Wellness
settings. Studies were also excluded if the primary services refer to ICT applications that promote healthy
outcomes focused solely on technical feasibility of the living and include technologies which stimulate cogni-
ICT system, changes in vital signs, changes in use of tive and physical fitness, as well as ‘social robotics’
health and social care and use of ICT by care staff. designed to facilitate social exchange (Carretero 2015).
We supplemented the database search with hand- Telecare is defined as 24-hour remote support and
searches for policy documents and reports from assistance provided through alarm and monitoring
organisations such as Age UK, International Longev- equipment (e.g. pendent alarm, enuresis pad), permit-
ity Centre – UK, Department of Health, Social Care ting detection of (and response to) personal emergen-
Institute for Excellence (SCIE) and Ofcom. Other liter- cies (e.g. falling) and adverse home events (e.g.
ature sources were identified through bibliographies bathroom flood) in real-time (Telecare Services Asso-
of journal articles and reports. Supporting evidence ciation, 2013b). Smart homes refer to the range of ‘do-
was sought by using the Google search engine, with motics’ devices consisting of sensors, actuators and
search terms such as “quality of life” AND “older other wireless technologies, also referred to as
people” and “technology”. advanced forms of monitoring and alert telecare ser-
vices (Kubitschke & Cullen 2010). Telehealth is the
remote transmission of vital sign data (e.g. blood
Definitions
pressure) between patients and healthcare profession-
als. Data are transmitted using peripheral ICT devices
What is mainstream ICT?
(e.g. pulse oximeter) for clinical review via telephone
We define mainstream ICT to be contemporary gen- line or broadband Internet. Telehealth services facili-
eric technology devices, services, applications and tate detection of abnormal patterns in vital signs and
instigate interventions to prevent deterioration of
Table 1 Search strategy health (Telecare Services Association, 2013c), without
patients having to present themselves at face-to-face
Boolean terms appointments (Department of Health, 2011). Teleme-
dicine refers to use of ICT (e.g. video-conferencing)
Search 1 SU(“older people” OR “elderly”) between healthcare professionals and patients, for
Search 2 TX(“digital inclusion” OR “e-inclusion”
OR “digital divide”)
remote consultation, diagnosis and treatment services
Search 3 TX(“internet” OR “?phone” OR “computer” (European Commission, 2009).
OR “digital technology”)
Search 4 TX(“telecare” OR “telehealth” OR “telemedicine”
OR “smart?home”) Data analysis
Search 5 (Search 2 OR Search 3 OR Search 4)
Search 6 Search 1 AND Search 5
To analyse outcomes of using mainstream ICT and
ICT-based care, we adapted the Adult Social Care

2 © 2016 John Wiley & Sons Ltd

 Effects of digital engagement on the QOL of older people

Table 2 ASCOT domains

Domain Definition

Control over one’s life Ability to choose what to do and when to do it. Having control over daily activities
Personal cleanliness and comfort Being clean, dressed and groomed to the level that the person feel comfortable and
presentable
Food and drink Has enough food and drink, which is nutritious, varied and culturally acceptable
Personal safety Feeling safe and secure, free from abuse, harm or falling
Social participation and involvement Content with social interactions with family, friends, and feeling part of the community
Occupation Sufficiently occupied with a range of meaningful activities
Accommodation cleanliness and comfort Cleanliness and comfort of home environment
Dignity Psychological impact of using social care services according to users’ personal sense of
significance
Source: ASCOT: Main guidance, v2.1 (Netten et al. 2011).

Table 3 WHOQOL domains WHOQOL is based on a multidimensional per-

spective of QOL, applicable to varying circumstances
Domain Facets
and cultures throughout the world. It assesses how
individuals function across a range of living environ-
Physical Pain and discomfort
Energy and fatigue ments (Table 3).
Sleep and rest The capability approach in ASCOT can be used to
Psychological Positive and negative feelings assess effects of ICT use on individuals’ ability to live
Thinking, learning, memory and concentration the life they choose. Some ASCOT dimensions are
Self-esteem
less fully defined for our needs here; e.g. dignity
Bodily image and appearance
Level of Mobility focuses primarily on self-esteem, whereas other emo-
independence Activities of daily living tions (e.g. anxiety, fear, contentment and optimism)
Dependence on medication or treatments are also relevant. There is also no domain measuring
Work capacity QOL aspects which reflect physical capabilities. There-
Social Personal relationships
fore, we draw on the WHOQOL framework for
relationships Social support
Sexual activity domains and facets complementary to ASCOT.
Environment Freedom, physical safety and security Our combined QOL framework has six dimen-
Home environment sions (Table 4), four from ASCOT (control over one’s
Financial resources life, personal safety, social participation and involve-
Health and social care: accessibility and
ment, and occupation), slightly amended to incorpo-
quality
Opportunities for acquiring new information rate complementary facets of WHOQOL, and two
and skills (psychological well-being and physical health) pri-
Recreation and leisure activities marily based on WHOQOL. Psychological well-being
Physical environment (e.g. pollution, noise) is an expanded version of the ASCOT dignity dimen-
Transport
sion, including a broader scope of feelings suggested
Spirituality Religion, personal beliefs
by WHOQOL. The physical health dimension and
Overall QOL and general health perceptions
related facets combine the WHOQOL model and
items developed specifically for this research.
Source: WHOQOL revised version, 2012.
We used a framework analysis approach from
Gale et al. (2013) to examine the literature, coding
Outcomes Toolkit (ASCOT) (Netten et al. 2011) and deductively according to our six dimensions
WHOQOL (The WHOQOL Group 1998) models. (Table 4).
Both frameworks are internationally recognised and
incorporate similar dimensions and facets, but
Findings
diverge slightly in focus.
ASCOT measures social care-related QOL. Based Table 5 summarises studies which provided evidence
on Sen’s (1985) study of social capital and capabili- on effects of ICT use in both mainstream and remote
ties, it measures individuals’ choice and control with care contexts. A wide range of both qualitative and
respect to social care, rather than functioning. ASCOT quantitative research methods and instruments are
emphasises individuals’ capabilities (Table 2). employed across many studies with varying effects.

© 2016 John Wiley & Sons Ltd 3

J. Damant et al.

Table 4 Description of the combined ASCOT and WHOQOL model

WHOQOL facets not considered in

Domains of combined QOL model Facets of combined QOL model combined model

Control over one’s life Independence Dependence on medicine and treatment

Personal cleanliness and comfort Financial resources
Food and drink
Accommodation cleanliness and comfort/home
environment
Activities of daily living
Personal safety and security Feeling safe, secure, free from abuse and harm Availability of health and social care
Freedom from crime Transport
Privacy* Physical environment
Social involvement and participation Personal relationships with family, friends Sexual activity
Feeling part of the community
Occupation Paid employment/work capacity†
Caring for others
Volunteer work
Recreation and leisure
Information-seeking/opportunities for learning
new skills‡
Psychological well-being Dignity§
Sense of personal significance
Positive and negative feelings
Self-esteem
Obtrusiveness/bodily image and appearance¶
Physical capability** Indicators of health status
Physical activity
Memory and cognition††
Health-related behaviour
Spirituality‡‡ Health-related awareness and knowledge

*Privacy is an additional facet to the personal safety and security domain.

†
The ‘work capacity’ facet of the independence domain of WHOQOL is discussed in the context of ability to carry out paid employment
in the occupational domain of the combined QOL model.
‡
The opportunities for learning new skills is a facet of the environmental domain of WHOQOL is introduced as the ‘information-seeking’
facet of the occupational domain in the combined model.
§
The dignity domain of ASCOT is renamed the psychological well-being model after the WHOQOL psychological domain; dignity is a
facet of the psychological domain in the combined model.
¶
Obtrusiveness is related to the bodily image and appearance facet of the psychological domain of the WHOQOL model, and is
introduced to the psychological well-being domain in the combined model.
**Physical is not an original ASCOT domain and is taken from the ‘physical’ domain from WHOQOL.
††
Memory and cognition are normally included in the psychological well-being domain of WHOQOL, but are considered to be part of
the physical capability domain in the combined model.
‡‡
The spirituality and personal beliefs facet of the WHOQOL model is not included in the combined QOL model.

We now describe this evidence for each of the six Mainstream ICT
QOL domains in turn. Evidence suggests that using computers and the
Internet gives older people a greater sense of inde-
pendence and control over their daily lives (Selwyn
Control over one’s life
2004, Morris et al. 2007). Mason et al. (2012) discov-
Control over one’s life includes dimensions from ered a significant association between Internet use
ASCOT including ‘personal cleanliness and comfort’, and perception of control. Slegers et al. (2008) found
‘food and drink’ and ‘accommodation cleanliness and that older adults who used their computers often
comfort’ as well as elements from WHOQOL including showed a significant increase in sense of control over
‘independence’, mobility and activities of daily living life over 12 months, whereas those who used a com-
(ADLs). The domain therefore includes indicators of puter only occasionally had a significant decrease.
ability to manage ADLs (e.g. personal hygiene, dress- Martinez-Pecino et al. (2012) reported that older peo-
ing, feeding) and instrumental activities of daily living ple who own a mobile phone felt a sense of freedom
(IADLs) (e.g. shopping, cleaning, preparing meals). and independence.

4 © 2016 John Wiley & Sons Ltd

 Table 5 Summary of evidence on the effects of ICT use for mainstream and remote care purposes on six domains of QOL

Direction of QOL
‘Older person’ effect on QOL definitions/
Author (year) N participants definition (years) Countries Facet Technology Methodology domain instruments

Control over daily live – Mainstream

Harrod (2010) 8 58–72 United States Conducting IADL Internet Semi-structured Negative Symbolic
questionnaire (Qualitative) capital
(Bourdieu
1987)

© 2016 John Wiley & Sons Ltd

Koopman-Boyden 1680 65–84 New Zealand Physical environment Internet Structured No significant Study-specific
and Reid (2009) inside and outside Email telephone interview effect
of the house
Leppel and 188; 50+:97 18–25; 50+ United States Shopping Internet Structured postal No significant Study-specific
McCloskey (2011) questionnaire effect
Mason et al. (2012) 9001 50+ England Control over what General ICT Analysis of Positive Study-specific
happens in their ELSA (Wave 4) (Quantitative)
lives
Martinez-Pecino 165 Mean age: 62 Spain Autonomy, freedom, Mobile phone Ad hoc Study-specific
et al. (2012) independence (quantitative)
survey
Morris et al. (2007) 473 Scotland: 50+ UK Independence Internet Semi-structured Positive Study-specific
Derbyshire: 55+ Interviews (qualitative)
Selwyn (2004) 35 60+ UK Control over daily life General ICT In-depth semi- Positive Study-specific
structured (qualitative)
Independence Interviews Positive
(qualitative)
Slegers et al. 236 64–75 The Control over daily life Computer Randomised Positive Mastery Scale
(2008) Netherlands controlled trial (Pearlin &
Schooler
1978)
Control over daily live – Remote care
Brandt (2011) 13 studies n/a n/a Independence Telecare Systematic Positive n/a
Ability to carry Smart home review tendencies
out IADLs technology
Brownsell 52 Mean age: 75 UK Ability to carry out ADL Telecare Controlled trial No significant SF-36
et al. (2008) effect (Brazier
et al. 1992)
Damant 62 65+ Slovakia Control over daily life Remote alarm Semi-structured Positive ASCOT
et al. (2013) Spain and monitoring questionnaire (Quantitative) (Netten
Sweden Personal cleanliness Positive et al. 2011)
(Quantitative)
Shopping Positive
(Quantitative)
Meals and nutrition No significant
effect
Home cleanliness No significant
effect

5
Effects of digital engagement on the QOL of older people
 6
Table 5 (continued)

Direction of QOL
‘Older person’ effect on QOL definitions/
Author (year) N participants definition (years) Countries Facet Technology Methodology domain instruments
J. Damant et al.

Milligan Panels: 64–80 Above UK Independence Telecare Deliberative panels; Positive Study-specific
et al. (2011) Interviews: 8 ‘retirement ethnographic
age’ interviews
Nijland 713; 50+: 344 50+ The Control over/access Email Online (quantitative) No significant Study-specific
et al. (2009) Netherlands to care services: consultation survey effect
Contacting GP with GP
Personal safety and security – Mainstream
Gatto and Tak 58 60+ United States Privacy Internet Semi-structured Negative Study-specific
(2008) questionnaire (qualitative)
Hill et al. (2008) 78; 17 50+ Wales Personal security Internet Workshop participant Negative Study-specific
interviews observation and (Qualitative)
individual interviews
Koopman-Boyden 1680 65–84 New Zealand Personal safety Internet Structured phone No significant Study-specific
and Reid (2009) Email interview effect
Martinez-Pecino 165 Mean age: 62 Spain Personal safety Mobile phone Ad hoc Positive Study-specific
et al. (2012) (quantitative) survey
Walsh and Callan Focus group: 21 65+ Republic of Personal safety Mobile phone Focus group Positive Study-specific
(2011) Interviews: 60 Ireland discussions/
face-to-face survey
interviews
Williams 158 55+ Belgium Security 24-hour Postal (quantitative) Positive Study-specific
et al. (2010) Czech monitoring questionnaire
Republic services
Greece
UK
Personal safety and security – Remote care
Brownsell 52 Mean age: 75 UK Personal Safety Telecare Controlled trial Positive Study-specific
et al. (2008)
Chou et al. (2013) 105 Mean age: Taiwan Personal safety Telehealth (Quantitative) Positive WHOQOL-
77.8 questionnaire BREF
Taiwan
version
(Yao 2005)
Damant 62 65+ Slovakia Safety Alarm/ Semi-structured Positive Adaption of
et al. (2013) Spain monitoring questionnaire (Quantitative) Falls Efficacy
Sweden Security services Positive Scale
(Quantitative) (Tinetti 1990)
Garceau 4 Mean age: 77 Canada Personal safety Remote Focus groups Positive Study-specific
et al. (2007) and security monitoring
(telecare)
Milligan Panels: 64–80 Above UK Privacy Telecare Deliberative panels; Negative Study-specific
et al. (2011) Interviews: 8 ‘retirement ethnographic
age’ interviews

© 2016 John Wiley & Sons Ltd

 Table 5 (continued)

Direction of QOL
‘Older person’ effect on QOL definitions/
Author (year) N participants definition (years) Countries Facet Technology Methodology domain instruments

Nijland 18+: 713; 50+ The Privacy Email Online (quantitative) Not significant Study-specific
et al. (2009) 50+: 344 Netherlands consultation survey
with GP
Turgeon-Londei 25 65+ Canada Safety Video- Semi-structured Positive Study-specific
et al. (2009) Privacy monitoring interviews (qualitative)

© 2016 John Wiley & Sons Ltd

Negative
(qualitative)
Walsh and Callan Focus group: 21 65+ Republic of Reassurance Pendant alarm Focus group Positive Study-specific
(2011) Interviews: 60 Ireland discussions/
face-to-face
survey interviews
Williams 158 55+ Belgium Privacy 24-hour Postal (quantitative) Negative Study-specific
et al. (2010) Czech monitoring questionnaire
Republic services
Greece
UK
Social involvement and participation – Mainstream
Bailey and 88 50+ Jamaica Intergenerational Telecentres In-depth semi- Positive Study-specific
Ngwenyama relationships (Community structured (qualitative)
(2011) Making new multimedia interviews; Negative
friendships centre) participant (qualitative)
observations
Blaz
un 58 57+ Finland Loneliness* Skype Open-ended/closed Not statistically Study-specific
et al. (2012) Slovenia questions significant
Loneliness* Email Not statistically
significant
Loneliness* Computer Positive
training (quantitative)
Making new Email Positive
friendships (quantitative)
Making new Computer Positive
friendships training (quantitative)
Erickson and 122 60+ Canada Loneliness* Internet Structured Positive UCLA
Johnson (2011) questionnaire Loneliness
Scale
(Russell
et al. 1980)
Social support Positive Social Support
Appraisal
Scale (Vaux
et al. 1986)
Gatto and 58 60+ United Contact with family Internet Semi-structured Positive Study-specific
Tak (2008) States and friends Email questionnaire (Qualitative)

7
Effects of digital engagement on the QOL of older people
 8
Table 5 (continued)

Direction of QOL
‘Older person’ effect on QOL definitions/
Author (year) N participants definition (years) Countries Facet Technology Methodology domain instruments
J. Damant et al.

Hill et al. (2008) 78; 17 50+ Wales Intergenerational Internet Workshop participant Positive
interviews relationships observation and
individual interviews
Hurme et al. (2010) 60 56–89 Finland Intergenerational Mobile phone Structured Positive Study-specific
relationships questionnaires
Koopman-Boyden 1680 65–84 New Satisfaction with Internet Structured No significant Study-specific
and Reid (2009) Zealand contact with family Email phone interview effect
and other people
Martinez-Pecino 165 Mean age: 62 Spain Keeping in touch Mobile phone Ad hoc (quantitative) Positive Study-specific
et al. (2012) with relatives survey
Mason et al. (2012) 9109 50+ England Loneliness* Internet Analysis of ELSA Positive Study-specific
(Wave 4) (Quantitative)
McMurtrey 182 65+ United States Keeping in touch with Internet Postal (quantitative) Positive Study-specific
et al. (2011) family and friends survey
Morris et al. (2007) 473 Scotland: 50+ UK Keeping in touch with Internet Semi-structured Positive Study-specific
Derbyshire: 55+ family and friends interviews (qualitative)
Sayago and 388 65–80 Spain Intergenerational Email Ethnographic Positive Study-specific
Blat (2010) relationships interviews
Keeping in touch with Positive
family and friends
Making new friends Negative
Slegers 236 64–75 The Loneliness* Computer Randomised No significant UCLA
et al. (2008) Netherlands training controlled trial effect loneliness
and use Scale (De
Jong Gierveld
& Van
Tilburg 2006)
Meeting friends No significant Study-specific
effect
Sum et al. (2008) 222 55+ Australia Social loneliness* Internet as a Online (quantitative) Positive Social and
Communicating with communication survey Negative Emotional
new people tool Loneliness
Social loneliness* Time spent on Negative Scale
the Internet (Ditommaso
et al. 2004)
Tsai et al. (2010) 57 60+ Taiwan Loneliness* Video- Quasi-experimental Positive UCLA
conferencing design Loneliness
service Scale
(Russell
et al. 1980)

© 2016 John Wiley & Sons Ltd

 Table 5 (continued)

Direction of QOL
‘Older person’ effect on QOL definitions/
Author (year) N participants definition (years) Countries Facet Technology Methodology domain instruments

Walsh and Callan Focus group: 21 65+ Republic Social involvement Mobile phone Focus group Positive Study-specific
(2011) Interviews: 60 of Ireland with family and discussions/
friends face-to-face survey
interviews
Weaver 83 55+ New Zealand Social involvement Computer Focus groups Negative Study-specific

© 2016 John Wiley & Sons Ltd

et al. (2010) with family and
friends
Woodward et al. 83 60+ United States Perceived support ICT training Randomised Positive Multidimensional
(2011) from friends controlled trial Scale of
Perceived
Social
Support scale
(Zimet et al.
1988)
Loneliness* ICT training No significant De Jong
effect Gierveld and
Van Tilburg
(2006)
Intergenerational Skype Interviews and Positive Study-specific
relationships Focus group
Social involvement and participation – Remote care
Brownsell et al. 52 Mean age: 75 UK Social functioning Telecare Controlled trial Positive SF-36 scale
(2008) (Brazier 1992)
Damant 62 65+ Slovakia Receiving visitors Alarm alarms Semi-structured No significant Study-specific
et al. (2013) Spain and monitoring questionnaire effect, positive
Sweden tendency
Loneliness* No significant
effect,
negative
tendency
Speaking to people No significant
effect, positive
tendency
Garceau 4 Mean age: 77 Canada Receiving visitors to Remote Focus groups Negative Study-specific
et al. (2007) the home/keeping monitoring
in touch with family (telecare)
and friends
Meeting people outside Negative
the home
Kim et al. (2009) 70; 60+:44 60+ United States Face-to-face meetings Electronic (Quantitative) Positive Study-specific
with healthcare patient questionnaire tendency,
practitioners records low
response
rate

9
Effects of digital engagement on the QOL of older people
 Table 5 (continued)

10
Direction of QOL
‘Older person’ effect on QOL definitions/
Author (year) N participants definition (years) Countries Facet Technology Methodology domain instruments
J. Damant et al.

Milligan Panels: 64–80 Above UK Isolation* Telecare Deliberative panels; Negative Study-specific
et al. (2011) Interviews: 8 ‘retirement ethnographic
age’ interviews
Occupation – Mainstream
Cresci 1410 60+ United States Volunteering/ Computer Structured telephone Positive Study-specific
et al. (2010) participating interviews
in groups and
organisations
Harrod (2010) 8 58–72 United States Volunteering Email Semi-structured Positive Symbolic capital
questionnaire (qualitative) (Bourdieu, 1987)
Koopman-Boyden 1680 65–84 New Zealand Work status Internet Structured phone Positive Study-specific
and Reid (2009) Leisure and Email interview Positive
recreation
Mason et al. (2012) n/a 50+ England Participating in groups Internet Analysis of ELSA Positive Study-specific
and associations (Wave 4) (quantitative)
Mukherjee (2011) 22 53–67 United States Volunteering Internet (Qualitative) interviews Positive Study-specific
Weaver et al. (2010) 83 55+ New Zealand Occupying time Computer Focus groups Positive Study-specific
Occupation – Remote care
Damant et al. (2013) 62 65+ Slovakia Leisure activities and Remote alarms Semi-structured No significant Study-specific
Spain entertainment monitoring questionnaire effect
Sweden
Garceau et al. (2007) 4 Mean age: 77 Canada Leisure activities and Remote Focus groups Neutral Study-specific
entertainment monitoring
(telecare)
Psychological well-being – Mainstream
Cresci et al. (2010) 1410 60+ United States Optimism Computer Structured telephone Positive Study-specific
interviews
Erickson and 122 60+ Canada Life satisfaction Internet Structured Positive Life satisfaction
Johnson (2011) questionnaire Index
(Neugarten
et al. 1961)
Depression* Positive Beck Depression
Inventory
(Beck et al.
1996)
Gatto and 58 60+ United States Confidence, Internet Semi-structured Positive Study-specific
Tak (2008) self-esteem training questionnaire (qualitative)
Hill et al. (2008) 78; 17 50+ Wales Sense of pride Internet Workshop participant Positive Study-specific
interviews observation and
individual interviews
Huang (2010) 40 studies; n/a n/a Well-being Internet Systematic review; Negative n/a
21,258 meta-analysis

© 2016 John Wiley & Sons Ltd

 Table 5 (continued)

Direction of QOL
‘Older person’ effect on QOL definitions/
Author (year) N participants definition (years) Countries Facet Technology Methodology domain instruments

Independent n/a n/a UK Overall well-being Internet Case study Positive Study-specific
Age (2010) Email
Koopman-Boyden 1680 65–84 New Zealand Overall well-being Internet Structured Positive World Values
and Reid (2009) Email phone interview Survey
WHOQOL

© 2016 John Wiley & Sons Ltd

Mason et al. (2012) 781 50+ England Anxiety* Internet Analysis of ELSA Positive Study-specific
(Wave 4) (P = 0.045)
Sayago and 388 65–80 Spain Sense of Email Ethnographic Positive Study-specific
Blat (2010) accomplishment/ interviews
enjoyment
Tsai et al. (2010) 57 60+ Taiwan Depressive status* Video- Quasi-experimental Positive Geriatric
conferencing design Depression
service Scale
(Yesavage
et al. 1982)
Slegers et al. (2008) 236 64–75 The Anxiety* Computer Randomised Positive 90-item
Netherlands controlled trial Symptom
Check List
(Arrindell &
Ettema 1986)
Woodward 83 60+ United States Perceived ICT training Randomised Positive Quality of life
et al. (2011) quality of life controlled trial Scale
(Flanagan
1978)
Depression* No significant Geriatric
effect Depression
Scale
(Yesavage
et al. 1982)
Psychological well-being – Remote care
Bowes et al. (2009) 303 Mean age: 75 United States Depression* Tele-monitoring Prospective No significant Patient Health
(telehealth) randomised study effect Questionnaire
(Kroenke
et al. 2001)
Brandt (2011) 13 studies n/a n/a Self-perceive QOL Telecare Systematic review Positive n/a
Self-esteem Smart home tendencies
Happiness technology
Brownsell et al. 52 Mean age: 75 UK Mental health Telecare Controlled trial No significant SF-36
(2008) effect (Brazier
et al. 1992)

11
Effects of digital engagement on the QOL of older people
 Table 5 (continued)

12
Direction of QOL
‘Older person’ effect on QOL definitions/
Author (year) N participants definition (years) Countries Facet Technology Methodology domain instruments
J. Damant et al.

Cartwright (2013) 1573 Mean age: 70 England Anxiety* Telehealth Cluster randomised No significant SF-12
Depression* controlled trial effect CESD10
(Nested (Andressen
questionnaire) 1994)
Chou et al. (2013) 105 Mean age: Taiwan Eases worry about Telehealth (Quantitative) Highly rated TAM (Davis
77.8 health problems questionnaire 1989)
Experiences Moderately WHOQOL-
negative feelings* rated BRIEF
Taiwan version
Damant et al. 62 65+ Slovakia Anxiety* Remote alarms Semi-structured Positive WEMWBS
(2013) Spain and questionnaire (Quantitative) (Tennant
Sweden Feeling optimistic monitoring Positive et al. 2007)
about the future (Quantitative)
Hirani et al. (2014) 1189; 65+: 920 65+ UK Anxiety* Telecare Cluster randomised No significant Brief-STAI
controlled trial effect (Marteau &
(Nested Bekker 1992)
Depression* questionnaire) Small, positive CESD-10
effect (Andersen
et al. 1994)
Milligan Panels: 64–80 Above UK Obtrusiveness* Home security Deliberative panels; Negative Study-specific
et al. (2011) Interviews: 8 ‘retirement ethnographic
age’ interviews
Sanders (2012) 22 Mean age: 71 England Obtrusiveness* Telecare/ Semi-structured Negative Study-specific
telehealth interviews (Qualitative)
Sheaves 38 60+:23 60+ UK Self-confidence Internet Quasi-experimental Positive; no Study-specific
et al. (2011) significance
reported
Walsh and Focus group: 65+ Republic Obtrusiveness* Pendent alarm Focus group Negative Check
Callan (2011) 21; of Ireland discussions/
Interviews: face-to-face survey
60 interviews
Williams et al. (2010) 158 55+ Belgium Obtrusiveness* 24-hour Postal (quantitative) 41% ‘very Study-specific
Czech monitoring questionnaire concerned’ or
Republic services ‘concerned’
Greece vs. 48%
UK ‘not
concerned’
or ‘don’t know’
Physical capabilities – Mainstream
Cresci et al. (2010) 1410 60+ United States Health (general) Computer Structured telephone Positive SF-12
interview (Kosiniski 1997)
Gracia and Herrero 709 55–74 Spain Health (general) Internet Online structured Positive Study-specific
(2009) questionnaire

© 2016 John Wiley & Sons Ltd

 Table 5 (continued)

Direction of QOL
‘Older person’ effect on QOL definitions/
Author (year) N participants definition (years) Countries Facet Technology Methodology domain instruments

Gatto and Tak (2008) 58 60+ United States Resource for Internet Semi-structured Negative Study-specific
exercise and diet questionnaire (qualitative)
Heart and Kalderon 123 60+ Israel Health (general) Computer Structured Positive Selwyn et al.
(2013) United States questionnaire (2003)
Koopman-Boyden 1680 65–84 New Zealand Health (general) Computer Structured phone Positive Study-specific

© 2016 John Wiley & Sons Ltd

and Reid (2009) interview
Sheaves 38 60+:23 60+ UK Health-related Internet Quasi-experimental Positive; no Study-specific
et al. (2011) knowledge significance
reported
Slegers et al. (2008) 236 64–75 The Engaging in Computer Randomised Inconsistent Study-specific
Netherlands physically active controlled trial results
sports
Physical capabilities – Remote care
Aalbers et al. (2011) 12 studies; 50+ n/a Health-related Internet- Systematic review Positive n/a
4984 knowledge mediated tendencies
Control over health interventions
Bowes et al. (2009) 303 Mean age: 75 United States Medication Tele-monitoring Prospective No significant Omaha System
compliance (Telehealth) randomised study effect Problem Rating
Scale for
Outcomes
(Martin 2005)
Medication Positive SF-36
knowledge
Self-rated health No significant Study-specific
effect
Brownsell 52 Mean age: 75 UK Self-rated health Telecare Controlled trial No significant SF-36
et al. (2008) effects (Brazier
et al. 1992)
Cartwright (2013) 1573 Mean age: 70 England Telehealth Telecare/ Cluster randomised Positive n/a
telehealth controlled trial tendencies
(Nested
questionnaire)
Chou et al. (2013) 105 Mean age: 77.8 Taiwan Health knowledge Telehealth (Quantitative) Positive TAM (Davis
questionnaire 1989)

13
Effects of digital engagement on the QOL of older people
 Table 5 (continued)

14
Direction of QOL
‘Older person’ effect on QOL definitions/
Author (year) N participants definition (years) Countries Facet Technology Methodology domain instruments
J. Damant et al.

Damant 62 65+ Slovakia Managing medication Remote alarms Semi-structured Negative Study-specific
et al. (2013) Spain and monitoring questionnaire (Quantitative)
Sweden Feeling energetic Negative WEMWBS
(Quantitative) (Tennant
Memory Negative et al. 2007)
(Quantitative)
Managing pain No significant EQ5D
effect (Rabin
Negative et al. 2011)
tendencies
Hirani et al. (2014) 1189; 65+: 920 65+ UK Self-rated health Telecare Cluster randomised No significant EQ5D
controlled trial effects (EuroQOL
(Nested Group 1990)
questionnaire)
van den Berg et al. 68 studies n/a n/a Medication 24-hour Systematic review Positive n/a
(2012) compliance monitoring
services
Williams 158 55+ Belgium Medication 24-hour Postal (quantitative) Positive Study-specific
et al. (2010) Czech compliance monitoring questionnaire
Republic services
Greece
UK

IADL, instrumental activities of daily living; ADL: activities of daily living.

ELSA: The English Longitudinal Study of Ageing. Available at: http://www.elsa-project.ac.uk/ (accessed on 7 July 2015).
*The definition of these facets (loneliness, obtrusiveness, anxiety) is integrally negative. The reported effects of ICT use on these facets are opposite to the overall effect on the
overarching QOL domain, e.g. positive obtrusiveness represents a negative effect on psychological well-being; negative loneliness is a positive effect on social involvement and
participation.

© 2016 John Wiley & Sons Ltd

 Effects of digital engagement on the QOL of older people

With respect to specific IADLs, Selwyn (2004) ability to carry out ADLs. Nijland et al. (2009) found
described anecdotal evidence of perceptions of how no difference between older and younger people
ICT helped individuals to keep their house in order using an email consultation service to contact their
and do shopping. Koopman-Boyden and Reid (2009) GP in terms of felt control. Damant et al. (2013) noted
on the other hand, found no significant relationship that more people participating in the MonAMI study
between Internet and email use and satisfaction with perceived telecare services to be helpful rather than
physical environment, and Harrod’s (2011) qualitative unhelpful in performing day-to-day tasks, shopping
evidence suggested that older people felt pressured and personal care; there were no statistical differences
to demonstrate their ability to use ICT for shopping between the number of respondents who found the
and banking to deflect the societal stigma of being services helpful – and unhelpful – in the areas of
dependent. meals and nutrition; or maintaining their home envi-
Leppel and McCloskey (2011) found no significant ronment.
differences in attitudes concerning usefulness of
online shopping between younger and older groups.
Personal safety and security
They also found that adults aged 50–69 made more
online purchases than those aged 18–25 and those The ‘personal safety and security’ domain is derived
aged over 69. Those in the older age group rarely from the ASCOT ‘personal safety’ dimension, and the
made online purchases, but did search the Internet WHOQOL ‘freedom, personal safety and security’
for information about goods and services. facet from the environmental domain. ‘Privacy’ was
An emerging theme around independence and added as it is related to issues of security, particularly
control was use of mainstream ICT to prepare for the regarding the Internet.
future. Selwyn (2004) discovered that older people
sometimes adopted mainstream ICT applications (e.g. Mainstream ICT
email, Internet shopping and banking) pre-emptively. Several studies reported large proportions of older
In other words, some younger–older people adopted people owning a mobile phone for emergency use,
ICT in preparation for a future when they might have with positive effects on sense of personal safety
less control over their ADLs and IADLS as a result of (Plaza et al. 2011, Walsh & Callan 2011, Martinez-
being less mobile or having more financial con- Pecino et al. 2012). Conversely, several sources found
straints. negative effects of ICT on sense of privacy and per-
sonal security (Garceau et al. 2007, Gatto & Tak 2008,
Remote care Leppel & McCloskey 2011, Mason et al. 2012). Some
Underpinning ‘ageing in place’ policies is the promo- authors further exposed fears about becoming victims
tion of independence, enabling older people to con- of abuse and crime when using ICT, and subsequent
tinue to live in their own homes supported by ICT- negative effects on personal sense of security.
based care (Sixsmith & Sixsmith 2008, Matthews et al.
2010). Remote care
Frost et al.’s (2010) review of ICT-based care Under ‘ageing in place’ principles, providing older
reported qualitative evidence showing positive effects people with a sense of personal safety and security is
of ICT-based care on independence, in terms of a fundamental purpose of ICT-based care (Mahony &
improved mobility and ability to carry out ADLs. Mahony 2010, Milligan et al. 2011, Plaza et al. 2011).
Brandt et al.’s (2011) review of telecare and smart Several studies described the positive effects of ICT-
home services found few studies which assessed based care on older users’ perception of safety. Wil-
effects of ICT-based care on IADLs. Overall, ICT- liams et al. (2010) reported that 76% and 65% of
based care interventions tended to have positive respondents rated the localisation and emergency
effects on independence and ability to perform IADLs. alarm applications respectively as ‘important’. Brown-
Age UK (2010), Milligan et al. (2011) and Matthews et sell et al. (2008) found that people in receipt of fall
al. (2010) also noted that ICT-based care empowered detection and lifestyle monitoring services reported
(older) people with disabilities by compensating for improved feelings of safety compared to people with-
some physical impairments, which otherwise pre- out such services. Participants in a study by Walsh
vented them from managing their ADLs. and Callan (2011) felt reassured by having pendant
Quantitative evidence concerning the effects of use alarm services. Turgeon-Londei et al. (2009) found
of ICT-based care on ability to carry out ADLs and that 96% of participants were favourable to video-
IADLs was limited. Brownsell et al. (2008) noted that monitoring services that ensured personal safety in
using telecare services had no significant effects on their homes. Chou et al. (2013) reported high ratings

© 2016 John Wiley & Sons Ltd 15

for ‘feeling safe in daily life’ among telehealth recipi- Walsh & Callan 2011, Martinez-Pecino et al. 2012),
ents. The MonAMI evaluation (Damant et al. 2013) Skype (Woodward et al. 2011), email (Gatto & Tak
showed that a significantly greater number of partici- 2008, Sayago & Blat 2010, Bla zun et al. 2012,
pants perceived the technology services to be helpful Mason et al. 2012) and the Internet more generally
rather than unhelpful for improving sense of safety (Adams et al. 2005, Morris et al. 2007, Gatto & Tak
and security in terms of falling, intrusion in the home 2008, Hill et al. 2008, Sum et al. 2008, Independent
and protecting belongings. Age, 2010, McMurtrey et al. 2011).
Several sources discussed intrusiveness of ICT- A secondary benefit of use of ICT to maintain
based care and related effects on privacy and per- involvement with families was described in terms of
sonal security. Monitoring services, in particular, improving intergenerational relationships (Adams
raised suspicions that ‘Big Brother was watching’, et al. 2005, Holladay & Seipke 2007, Hill et al. 2008,
which could impinge on sense of personal freedom Hurme et al. 2010, Sayago & Blat 2010, Bailey &
(Chan et al. 2009, Demeris et al. 2009, Age UK, 2010, Ngwenyama 2011, Plaza et al. 2011, Woodward et al.
Mahony & Mahony 2010, Matthews et al. 2010, 2011).
Wright & Wadhwa 2010, Lorenzen-huber et al. 2011, The effect of use of ICT on reducing loneliness
Milligan et al. 2011). was also a prominent theme in the literature. Mason
Concerns regarding safeguarding of privacy were et al. (2012) reported that older non-users of the
reflected in anxieties. Williams et al. (2010) found that Internet were significantly more likely to say that
63% of participants were either ‘very concerned’ or they felt lonely compared to users. Similarly, older
‘slightly concerned’ about lack of privacy from 24- Internet users stated significantly more often that
hour monitoring services. A further 59% expressed they hardly ever felt lonely, compared to older non-
concern about sending data to non-medical staff for users. Tsai et al. (2010) found that older people liv-
fear of crime and maleficence. Turgeon-Londei et al. ing in residential care significantly decreased their
(2009) reported that 60% of their sample expressed a level of loneliness from baseline to follow-up when
sense of intrusiveness into their private lives when using video-conferencing equipment. Bla zun et al.
considering the use of video-monitoring equipment. (2012) found that older people who used email and
Results from Nijland et al. (2009) also showed that online forums, and who participated in a computer
46% of the total sample (including younger adults) training course, significantly reduced their levels of
had doubts about the level of privacy of the email loneliness. However there was no reported change
consultation (telemedicine) service. There was no sig- in level of loneliness among participants who used
nificant difference between older and younger Skype. Erickson and Johnson (2011) report a signifi-
respondents. cant negative correlation between use of Internet
applications such as email and online forums and
loneliness. They also found a significantly positive
Social involvement and participation
relationship between Internet use and perceived
Social involvement and participation refers to the social support.
types and extent of personal relationships in which However, not all studies found a resoundingly
individuals engage, and how they maintain these positive association between older people’s use of
relationships. ICT and their social involvement and participation.
Weaver et al. (2010) found that only a small minority
Mainstream ICT of people used a computer to keep in contact with
Several sources noted that the primary benefit of family; and they often did so reluctantly as it was the
older people’s use of ICT was ability to maintain rela- only way to remain in contact with their grandchil-
tionships with friends and family, and thereby gain dren. Koopman-Boyden and Reid (2009) found no
social support (Age UK, 2010; Choudrie et al. 2010, significant relationships between use of the Internet
Weaver et al. 2010, Wright & Wadhwa 2010, Bobillier and email and contact with family and other people.
Chaumon et al. 2013). Slegers et al. (2008) revealed no significant effects
There was considerable evidence of the positive between computer usage and training on the one
effects of a range of ICT on social involvement with hand, and loneliness and meeting with friends on the
friends and family. Woodward et al. (2011) found an other. And Woodward et al. (2011) found that there
increase in perceived support from friends from older were no statistically significant improvements in lone-
people participating in ICT training. Positive effects liness among participants who took part in an ICT
on social networks were associated with their use of training programme, although baseline loneliness
mobile phones (Hurme et al. 2010, Plaza et al. 2011, levels were low.
 Effects of digital engagement on the QOL of older people

There was also evidence of negative effects from networking. Although participants tended to perceive
ICT use on social involvement and participation. For the services as helpful in terms of speaking to people
instance, Huang’s (2010) meta-analysis (was not and receiving visitors, there was a tendency for par-
restricted to studies exclusively of older people) ticipants to find the services unhelpful for reducing
found an association between high Internet use and loneliness. Garceau et al. (2007) reported that one of
high levels of loneliness. Sum et al. (2008) demon- four participants reported that telecare allowed them
strated that social loneliness was positively correlated to continue receiving visitors to their home and to
with the amount of time older people spent using the stay in contact with close friends and family; no par-
Internet. ticipants found the services helpful towards meeting
Thus, there were potentially both positive and people outside of their home.
negative outcomes for social networking for older
people using ICT. At best, it could reinforce existing
Occupation
relationships, but there is no clear evidence of its
impact on expanding social networks. For instance, Occupation includes all the many meaningful activi-
Sayago and Blat (2010) and Bailey and Ngwenyama ties in which people engage, including work, infor-
(2011) found that older people did not use email to mation-seeking, hobbies and pastimes, leisure and
make new friends, but rather relied on traditional entertainment.
methods perceived to be ‘safer’. Sum et al. (2008)
noted that using the Internet to communicate with Mainstream ICT
new people was associated with increased levels of There was strong evidence to suggest that using ICT
loneliness. On the other hand, Bla zun et al. (2012) had a positive effect on older people’s ability to carry
found significantly positive correlations between out work, leisure, hobbies and information-seeking
making new friends and sending emails and attend- activities (Selwyn 2004, Morris et al. 2007, Gatto &
ing computer training respectively. The authors also Tak 2008, Slegers et al. 2008, Choudrie et al. 2010,
noted a link between level of sociability at baseline Independent Age, 2010, McMurtrey et al. 2011).
and ability to establish new friendships using ICT ICT use has had an impact on the active participa-
during the study. tion in associations of all kinds including social, reli-
gious, political and tenant associations, clubs and
Remote care organisations. Koopman-Boyden and Reid (2009)
The topic of social involvement and participation in noted that older Internet users were significantly
relation to ICT-based care services frequently centres more likely to take up leadership roles in social and
on the face-to-face contact between (older) patients community organisations. Participants were also
and care practitioners. Many studies discussed reluc- more significantly likely to use the Internet if still
tance among older adults to adopt ICT-based care employed, compared to those not employed. Harrod
services for fear of losing the ‘human touch’ of tradi- (2010) and Mukherjee (2011) presented qualitative
tional care services (Boonstra & van Offenbeek 2010, findings on use of email and the Internet to co-ordi-
Independent Age, 2010, Matthews et al. 2010; van nate volunteering activities. Mason et al. (2012) found
Offenbeek & Boonstra 2010, Lorenzen-huber et al. a significant association between using the Internet
2011, Sheaves et al. 2011, Walsh & Callan 2011, Chou and being a member of political, religious, environ-
et al. 2013). Indeed, Milligan et al. (2011) pointed out mental, tenant and resident associations and groups.
that some older people deliberately made false alarms Cresci et al. (2010) found that older computer users
to gain social contact with care practitioners. were significantly more likely than non-users to join
There is limited quantitative evidence of the effects community organisations and do volunteer work.
of ICT-based care on social involvement. Kim et al. Weaver et al. (2010) reported that ‘younger’ older par-
(2009) found that face-to-face meetings between ticipants perceived computers to be useful to occupy
(older) patients and care practitioners were improved their time in the future, when they would be less
with use of electronic patient records. However, physically active. Plaza et al. (2011) discussed the
results were based on a very small sample (n = 11). potential for ICT to enable older people to continue
Brownsell et al. (2008) found a slight improvement in pursuing their hobbies at times when they have phys-
the social functioning of older people using telecare ical limitations.
at follow-up compared to baseline, but improvements
waned between 6- and 12-month follow-up periods. Remote care
Damant et al. (2013) found no significant impact of Only one small study reported on the effects ICT-
remote alarm and monitoring services on social based care on occupation: Garceau et al. (2007) noted

© 2016 John Wiley & Sons Ltd 17

J. Damant et al.

that two out of four participants mentioned that the Remote care
services had a positive effect on ability to carry out A few small-sample qualitative studies have explored
leisure activities. effects of older people’s use of ICT-based care on
their sense of dignity. Age UK (2010) and Boonstra
and van Offenbeek (2010) reported that telecare users
Psychological well-being
perceived an increase in psychological well-being
Psychological well-being includes dignity, self-esteem from using services. Matthews et al. (2010), Cardozo
and self-worth, and positive and negative feelings. and Steinberg (2010), and Walsh and Callan (2011)
discussed the reassurance that older people and their
Mainstream ICT carers obtained through using ICT-based care.
Several qualitative studies described direct positive Sheaves et al. (2011) found that all participants agreed
effects of using ICT on older people’s well-being. For to some degree that the Internet increased confidence
instance, Sayago and Blat (2010) recounted the enjoy- in dealing with their long-term condition. Brandt
ment and sense of purpose experienced when using et al.’s (2011) review of telecare and smart home tech-
email to communicate with loved ones. Sayago and nology identified seven studies which considered the
Blat (2010), Hill et al. (2008), Gatto and Tak (2008) impact of the services on self-esteem, happiness and
and Independent Age (2010) also provided data self-perceived QOL, the results demonstrating that
about older people experiencing a ‘sense of accom- overall, the services had positive effects.
plishment’, ‘pride’, feelings of empowerment and Quantitative studies showed mixed effects with
increased self-esteem from using email and the Inter- respect to psychological well-being. Damant et al.
net, and taking part in ICT training. (2013) reported that significantly more participants of
In addition, the Independent Age report (2010) sug- the MonAMI trial felt that remote monitoring and
gested reported that older people felt mentally alert alert services were helpful (rather than unhelpful) in
and challenged, and subsequently more youthful as a enabling them to feel optimistic about their future
result of going online. and reducing anxiety. The Whole Systems Demonstrator
The effects of ICT use has also been measured (WSD) trial reported that both telecare and telehealth
quantitatively. Koopman-Boyden and Reid (2009) services had no significant effect on anxiety or
reported a significant positive relationship between depression symptoms from baseline to 12-month fol-
using the Internet and email and overall well-being. low-up (Cartwright et al. 2013), but telecare had
Woodward et al. (2011) found older people who fol- small, significant effects on reducing the rate of
lowed an ICT training programme had significantly decline of mental health-related QOL and depressive
higher self-rated QOL compared to those who did symptoms, although not on anxiety (Hirani et al.
not receive training. Tsai et al. (2010) reported a sig- 2014). Chou et al. (2013) suggested that telehealth
nificant drop in depressive status for older people in enabled participants to experience less anxiety about
residential care using a video-conferencing service at their illness and experience fewer negative feelings
3-month follow-up. Erickson and Johnson’s (2011) more generally, but no tests of significance were
correlation analyses suggested a significant positive reported.
link between use of the Internet and life satisfaction, On the other hand, both Brownsell et al. (2008)
and a significant negative correlation between Inter- and Bowes et al. (2009) found no significant effects on
net use and depression. Slegers et al. (2008) found mental health scores from using telecare and tele-
that older people who were interested in – and used monitoring services.
– a computer had significantly lower anxiety at base- Closely related to dignity are feelings associated
line than older people who were not interested in with the obtrusiveness and subsequent stigmatising
using ICT. Finally, Cresci et al. (2010) found signifi- effects of using ICT-based care. Zweijsen et al. (2011)
cantly higher levels of ‘senior optimism’ in older broadly defined obtrusiveness of ICT-based care as
computer users compared to non-users. care which is disruptive or invasive of users’ physical
On the other hand, Mason et al. (2012) found only space, leading users to feel stigmatised or experience
a weak association between anxiety and Internet use: loss of dignity (Karunanithi 2008, Age UK, 2010).
older people who experienced anxiety were more Several sources discussed how some monitoring ser-
likely to be non-Internet users. Woodward et al. vices and wearable devices implied to older users
(2011) found no significant differences in depression that they were becoming increasingly frail, disabled
between older adults who did or did not participate and dependent (Sixsmith & Sixsmith 2008, Roberts
in ICT training, although their participants started 2009, Turgeon-Londei et al. 2009, Lloyd 2010, Ding
with low depression levels. et al. 2011, Zweijsen et al. 2011, Wagner et al. 2012).

18 © 2016 John Wiley & Sons Ltd

 Effects of digital engagement on the QOL of older people

For instance, Walsh and Callan (2011) and Milligan & Ngwenyama 2011, McMurtrey et al. 2011, Olson
et al. (2011) reported that older people were reluctant et al. 2011, Robertson-Lang et al. 2011, Mason et al.
to wear their pendent alarms because they felt stig- 2012, Chou et al. 2013).
matised as needing care and assistance. Williams Gatto and Tak (2008) measured older people’s per-
et al. (2010) found that 41% of respondents were ‘very ceptions of the helpfulness of online health informa-
concerned’ or ‘concerned’ about ‘carrying a device all tion as a means of gaining knowledge about illness,
day’. Sanders et al. (2012) found that many people treatments and therapies; approximately 50% of
withdrew from the WSD trial because they associated respondents found the Internet helpful. Similarly,
telecare and telehealth with being dependent and in Sheaves et al. (2011) found that the majority of their
poor health, and they wanted to distance themselves participants were satisfied to some degree with the
from negative inferences of old age and illness. online information they obtained about their long-
The obtrusiveness of ICT also spurred discussions term condition.
concerning the disappearing boundaries between the Apart from the above, the literature on ICT and
home and institutionalised care (Milligan et al. 2011). health information focuses on barriers faced by older
Palm (2013) noted that a growing number of older people when conducting health-related online
people with care needs lived at home because they searches, such as their level of health and ICT-related
used ICT. However, as their needs grew and became literacy and accessibility of websites.
more complicated, the ‘home’ space became occupied On the other hand, there were observations from
by more equipment, aids and, indeed, care staff. Mil- several countries concerning how older people’s self-
ligan et al. (2011) and Sixsmith and Sixsmith (2008) rated health correlated with use of mainstream ICT.
suggested that there is a risk that the home can shift For instance, Gracia and Herrero (2009) found that
from being an individuals’ personal sanctuary to an older people living in Spain who use the Internet had
impersonal place of hurried activity. significantly better self-rated health than non-users.
In New Zealand, Koopman-Boyden and Reid (2009)
found a significant positive relationship between
Physical capability
Internet and email usage and self-rated health. An
Physical capability is the sixth domain of the com- American study by Cresci et al. (2010) showed that
bined QOL model. In this research, it captures how computer users were significantly healthier than com-
use of ICT affects individuals’ physical abilities to puter non-users. Heart and Kalderon’s (2013) Israeli-
carry out their daily activities. This extends to how American study also indicated a major effect of good
ICT services effect individuals’ health-related beha- health on computer use when interacting with age.
viour and knowledge, as well as their awareness of
health issues that directly affect physical capabilities. Remote care
By design, ICT-based care devices, services and sys-
Mainstream ICT tems compensate to some extent for physical, senso-
Very few associations have been found between older rial and cognitive limitations (Age UK, 2010;
people’s use of mainstream ICT and their physical Matthews et al. 2010). Moreover, several ICT-based
capabilities. Deloitte Centre for Health Solutions care services provide health-related information or
(2012) reported that approximately a third of all UK include behaviour-modification applications to assist
homes have a Wii Fit system at home and argued self-management of illness and care (van den Berg
that this could be considered a form of telehealth if et al. 2012). Williams et al. (2010) found that 56% and
the vital sign data were transmitted to health clini- 50% of respondents (respectively) rated medicine
cians. Gatto and Tak (2008) noted that most respon- reminder and vital sign monitoring features of remote
dents found information on the Internet of little or no care services as ‘important’. However, evidence of the
help as a resource for diet and exercise. Slegers et al. effects of ICT-based care on behaviour, knowledge
(2008) found no consistent impact from older people’s and control over health issues is limited and at times
use of ICT on participation in physically active sports. contradictory.
We searched for evidence on the extent to which van den Berg et al. (2012) and Aalbers et al. (2011)
older people used the Internet to carry out health conducted comprehensive systematic reviews of ICT-
information searches, as an indicator of health aware- based home care and Internet-mediated interventions
ness and knowledge and self-managed care. Several respectively. They concluded that there was a trend
studies indicated that seeking health and medical towards improvement in health-related behaviour
information was one of the most common uses of such as medication compliance, weight and disease
ICT among the older population (Harrod 2010, Bailey management for older service users, although

© 2016 John Wiley & Sons Ltd 19

J. Damant et al.

reported changes were often not significant or were The analyses for personal safety and security fur-
short-term. Bowes et al. (2009) found that telehealth ther confirmed that the benefits of ICT use are often
users did not have significantly different medication uncertain. Several sources claimed that ICT use, in
adherence compared to a control group receiving different contexts, improved perceptions of personal
more face-to-face nurse visits. safety and security, especially from using a mobile
Chou et al. (2013) showed that older people felt telephone. However these claims are not completely
that they had improved knowledge about, and more substantiated upon closer investigation of the evi-
control over, their health by using telehealth. Partici- dence, as there were several issues around privacy,
pants highly rated the services in terms of ‘distraction intrusiveness and data protection that many older
due to pain’. Bowes et al. (2009) also observed signifi- people are uncomfortable with, particularly when
cant improvements in medication knowledge among considering ICT services using the Internet and video
users of telehealth services who also received fre- equipment.
quent nurse visits. Evidence on psychological well-being for ICT use
In terms of self-rated health, Brownsell et al. (2008) in a care context was similarly mixed. While the over-
and Hirani et al. (2014) reported no significant all effects of ICT use on this domain in mainstream
improvements for older people using telecare over a contexts are positive, the effects of ICT in care con-
year. Similarly, Bowes et al. (2009) and Cartwright texts are more negative. This division between main-
et al. (2013) did not find significant effects on self- stream and care-related applications may link to
rated health for people using telehealth services. The findings regarding physical capability, which sug-
MonAMI evaluation showed that significantly more gests a positive association between older people’s
participants found the telecare services to be ‘unhelp- health state and ICT use. In the same vein, partici-
ful’ than ‘helpful’ in terms of feeling energetic, pants in studies of ICT-base care services have care
managing their medication and memory. A similar needs and likely some form of limiting illness or dis-
trend was observed for perceptions of the services’ ability that may influence access to, and use of ICT,
lack of helpfulness for managing pain (Damant et al. suggesting that the observed effects of ICT use on
2013). psychological well-being could reflect a person’s state
of health or general favourable disposition, rather
than the use of ICT itself. This sustains Koopman-
Discussion
Boyden and Reid (2009)’s queries about the direction
Our review suggests that older people’s use of ICT of causality, where the QOL outcomes associated
brings many benefits to QOL. In particular, some with technology use may be shrouded by users’ base-
older people achieve a sense of control and indepen- line conditions for adopting ICT in the first place.
dence over their daily lives, reinforce their social net- Overall, the mixed findings on effects on QOL
works, gain a sense of safety, pursue pastimes and lend support to the conclusions of Dickinson and
other meaningful activities, and improve overall psy- Gregor (2006), Weaver et al. (2010) and Plaza et al.
chological well-being. (2011), who challenged the common assumption that
Yet the benefits were not universal. Findings were older people’s use of ICT enhances QOL. It would be
especially varied for social involvement and partici- wrong to assume that there is a technology solution
pation, personal safety and security, and psychologi- to every social problem, particularly with respect to a
cal well-being. For social involvement and generation of older ‘digital immigrants’, for many of
participation, while overall the results from qualita- whom ICT plays only a tangential role in their daily
tive studies suggested that ICT use had positive lives (Hernandez-Encuentra et al. 2009, Vodanovich
impacts on family contacts and intergenerational rela- et al. 2010, Dutton & Blank 2013).
tionships, weak, negative or insignificant effects on
loneliness, visiting and general social functioning
Implications
were most often reported in quantitative studies. In
fact, some findings implied that ICT use could nega- The complicated nature of relationships between ICT
tively affect QOL by exacerbating feelings of loneli- use and QOL suggests that trade-offs are made: bene-
ness. Therefore, contrary to the assumption that fits of using ICT in one domain are weighed against
engagement with ICT is essential for older people to disadvantages in another domain (Wright & Wadhwa
remain socially active and to combat loneliness, the 2010). Several reports discussed concessions some
evidence could be said to imply that use of ICT posi- people are willing to make in terms of privacy and
tively reinforces existing social networks, but gener- security in order to live independently in their own
ally has no effect on building new ones. homes with the use of monitoring services (Sixsmith

20 © 2016 John Wiley & Sons Ltd

 Effects of digital engagement on the QOL of older people

& Sixsmith 2008, Blaschke et al. 2009, Turgeon-Londei can be addressed by technology, especially given their
et al. 2009, Matthews et al. 2010, Gonz alez-Vega et al. overlap and interconnectedness (Dickens et al. 2011).
2011, Zweijsen et al. 2011, Wagner et al. 2012). Gain- A limitation of our model lies in its usefulness in
ing a level of independence and sense of security detecting the effects of ICT use on physical capabili-
might be achieved at the expense of face-to-face con- ties. Overall, there was little evidence which corre-
tact with care practitioners. Continuous surveillance sponded to how the physical capabilities domain was
and monitoring services which offer security and defined in the combined QOL framework. Agree and
independence could force older people to sacrifice Freedman (2011) pilot-tested the Assistive Technology
personal autonomy as they lose the ability to choose Quality of Life Scale, yielding similarly ambiguous
when to use services and what personal information results on the role of assistive technologies in reduc-
is shared with others. Mahony and Mahony (2010) ing pain, fatigue and ability to carry out day-to-day
commented on the trade-off between the reliability of activities. The findings may be attributable to difficul-
wearable monitoring services and the stigmatising ties of directly attributing alleviation of physical
effects of services for people living with dementia. symptoms to use of ICT-based devices or services.
In the Care Act 2014 (Department of Health, 2014), Results may also be an artefact of sample selection,
the English government renewed its commitment to where the baseline health state of participants is rela-
personalised care, and promoted ICT-based care as a tively good, causing a ceiling effect. Difficulties with
way to achieve this aim. However, the evidence anal- evaluating the relationship between ICT use and
ysed here suggests widespread concerns that ICT- physical capabilities also lie with the available body
based care intended to promote independence (and of instrumentation, which is neither adequately sensi-
save costs) could inhibit older people’s pursuit of tive nor specific to assess QOL outcomes.
human contact and social involvement (Lloyd 2010), Second, in several cases, quantitative measure-
and could have a detrimental effect on overall QOL ments of older people’s QOL yielded mostly insignifi-
(Sixsmith & Sixsmith 2008). cant results highlighting methodological challenges in
The lack of resoundingly positive evidence also uncovering causal relationships between technology
reflects challenges in integrating social outcomes use and the subjective aspects of QOL. Both device
within ICT-based care, as the primary aim of the lat- use and psychological well-being, for instance, are
ter is not to provide human care, but rather to com- affected by some extraneous factors which cannot be
plement existing face-to-face services (Demeris et al. easily isolated or explained using strict research pro-
2009, Boonstra & van Offenbeek 2010, Independent tocols typically associated with quantitative research
Age, 2010; Milligan et al. 2011, Sanders et al. 2012). (Robson 2011, p. 21). For instance, Hirani et al. (2014)
Given that on balance the results on the effects of suggested the mixed quantitative findings for the
ICT use on a singular domain of QOL are inconclu- effects of using ICT-based care on psychological well-
sive, introducing the concept of trade-offs offers an being could reflect the complexity of emotions that
alternative for understanding QOL in this context. many older people experience when managing an ill-
Providing a more balanced and realistic description ness or long-term need. Therefore, unpicking these
of the benefits could help ICT service developers and complex human experiences through exploratory
providers to build appropriate support services which qualitative research may provide better insight into
would both encourage the uptake of ICT as well as the effects of ICT (Pawson et al. 2005).
compensate for aspects of QOL compromised by the Finally, the many older people who do not use
technology. ICT are underrepresented in research, making it diffi-
cult to ascertain how their QOL and ability to partici-
pate in their communities are improved or
Future research
compromised by not using ICT, as well as to hypoth-
Our findings expose a number of topics around QOL esise how their QOL would change if they used ICT.
and ICT which need further exploration. First, the Indeed, we found evidence that many older people
combined QOL framework used in our review do not participate in ICT-based leisure and diversion
proved useful in organising evidence. It helped activities or use social networking sites (Choudrie
underscore that the evidence on ICT-based care is et al. 2010, Weaver et al. 2010, McMurtrey et al. 2011,
limited and inconsistent. van den Berg et al.’s (2012) Plaza et al. 2011), although these are older studies
review of ICT-based care services also showed that and the context is changing rapidly. There is a need
fewer than a fifth of 68 eligible studies measured for a concerted effort to include older non-users in
QOL. This may be attributable to the difficulties in empirical research and to investigate their QOL
both defining and isolating the social outcomes which within the context of the digital society.

© 2016 John Wiley & Sons Ltd 21

J. Damant et al.

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