Factors influencing acceptance of technology for aging in place: A systematic review

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international journal of medical informatics 83 (2014)235–248

jo u r n al ho m e p a g e :w w w . i j m i j o u r n a l . c o m

Review

Factors inﬂuencing acceptance of technology for aging in place: A systematic review

Sebastiaan T.M. Peek

^a^,^b^,∗

, Eveline J.M. Wouters

^a

, Joost van Hoof

^c

, Katrien G. Luijkx

^b

, Hennie R. Boeije

^d

, Hubertus J.M. Vrijhoef

^b^,^e

aChairofHealthInnovationsandTechnology,SchoolforAlliedHealthProfessions,FontysUniversityofAppliedSciences,TheNetherlands

bDepartmentofTranzo,SchoolofSocialandBehavioralSciences,TilburgUniversity,TheNetherlands

cCentreforHealthcareandTechnology,FontysUniversityofAppliedSciences,TheNetherlands

dFacultyofSocialSciences,DepartmentofMethodologyandStatistics,UtrechtUniversity,TheNetherlands

eSawSweeHockSchoolofPublicHealth,NationalUniversityofSingapore,Singapore

a r t i c l e i n f o

Articlehistory:

Received17June2013 Receivedinrevisedform 7January2014

Accepted10January2014

Keywords:

Independentliving Aged

Technology Review Behavior

Assistivetechnology eHealth

a bs t r a c t

Purpose:Toprovideanoverviewoffactorsinﬂuencingtheacceptanceofelectronictech- nologiesthatsupportaginginplacebycommunity-dwellingolderadults.Sincetechnology acceptancefactorsﬂuctuateovertime,adistinctionwasmadebetweenfactorsinthepre- implementationstageandfactorsinthepost-implementationstage.

Methods:Asystematicreviewofmixedstudies.Sevenmajorscientiﬁcdatabases(including MEDLINE,ScopusandCINAHL)weresearched.Inclusioncriteriawereasfollows:(1)original andpeer-reviewed research,(2)qualitative,quantitativeor mixedmethodsresearch,(3) researchinwhichparticipantsarecommunity-dwellingolderadultsaged60yearsorolder, and(4)researchaimedatinvestigatingfactorsthatinﬂuencetheintentiontouseorthe actualuseofelectronictechnologyforaginginplace.Threeresearcherseachreadthearticles andextractedfactors.

Results:Sixteenoutof2841articleswereincluded.Mostarticlesinvestigatedacceptanceof technologythatenhancessafetyorprovidessocialinteraction.Themajorityofdatawas basedonqualitativeresearchinvestigatingfactorsinthepre-implementationstage.Accep- tanceinthisstageisinfluencedby27factors,dividedintosixthemes:concernsregarding technology(e.g.,highcost,privacyimplicationsandusabilityfactors);expectedbenefitsof technology(e.g.,increasedsafetyandperceivedusefulness);needfortechnology(e.g.,perceivedneedandsubjectivehealthstatus);alternativestotechnology(e.g.,helpbyfamilyor spouse),socialinfluence(e.g.,influenceoffamily,friendsandprofessionalcaregivers);and characteristicsofolderadults(e.g.,desiretoageinplace).Whencomparingtheseresults

∗ Correspondingauthorat:DomineeTheodorFliednerstraat2,5631BNEindhoven,TheNetherlands.Tel.:+31683991191.

E-mailaddress:[email protected](S.T.M.Peek).

http://dx.doi.org/10.1016/j.ijmedinf.2014.01.004

Open access under CC BY-NC-ND license.

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toqualitativeresultsonpost-implementationacceptance,ouranalysisshowedthatsome factorsarepersistentwhilenewfactorsalsoemerge.Quantitativeresultsshowedthata smallnumberofvariableshaveasigniﬁcantinﬂuenceinthepre-implementationstage.

Fourteenoutofthesixteenincludedarticlesdidnotuseanexistingtechnologyacceptance frameworkormodel.

Conclusions:Acceptanceoftechnologyinthepre-implementationstageisinﬂuencedby multiplefactors. However, post-implementationresearch on technologyacceptanceby community-dwellingolderadultsisscarceandmostofthefactorsinthisreviewhavenot beentestedbyusingquantitativemethods.Furtherresearchisneededtodetermineifand howthefactorsinthisreviewareinterrelated,andhowtheyrelatetoexistingmodelsof technologyacceptance.

1. Introduction

Themajorityofolderadultsprefertoliveindependentlyfor aslongastheypossiblycan[1–4].Supportingolderadultsto remainintheirownhomesandcommunitiesisalsofavored bypolicy makers and health providers to avoid the costly optionofinstitutionalcare[5]. Researchshowsthatseveral interrelated factors can challenge the independence of olderadults:primarilyfunctionalandcognitiveimpairment,

chronicdiseases,adiminishingsocialnetwork,andalowlevel ofphysicalactivity [6–9].Technology mightprovidea solu- tionforsomeofthesechallenges,andparticularlyinthelast decade,muchefforthasbeen investedinthedevelopment of technology to support aging in place, such as sensor- based networksforactivity monitoring, fallandwandering detection,andvariouse-healthapplications.However,older adultsexplicitly reservethe right todecide forthemselves whattheyallowintotheirownhomes[10],andquestionshave been raised onthe readiness ofcommunity-dwelling older Open access under CC BY-NC-ND license.

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adultstoacceptanduse thesetechnologies[11–13].Accep- tance oftechnologies that are electronic or digital may be moredifﬁcultforthecurrentgenerationofseniorswhichdid notgrowupwiththesetypesoftechnologies[14–16].Inan effort to understandolder adults’ usage and non-usage of moderntechnology,researchersoftenturntotwotechnology acceptancemodels,stemmingfromtheﬁeldofinformation systems.

1.1. Technologyacceptancemodels

Technologyacceptanceresearchisdominatedbythe Tech- nologyAcceptanceModel(TAM)[17]andtheUniﬁedTheory ofAcceptanceandUseofTechnology(UTAUT)[18].Thekey variablesinTAMarePerceivedUsefulness(PU)andPerceived EaseofUse(PEOU).Systematicreviewshaveshownthatthese twovariables typicallyexplain40percentofanindividual’s intentiontouseatechnologyinavarietyofcontextsincluding healthcare[19–21],andthatintentiontousemay[22]ormay not[23]predictactualuseoftechnology.UTAUTiscapableof explainingupto70percentofintentiontouseattheexpense ofparsimonybyaddingtwoadditionalvariables(SocialInﬂu- enceandFacilitatingConditions)andfourmoderatingfactors (Gender,Age,ExperienceandVoluntarinessofUse)[18].

Whilebeingpowerfulandrobust,TAMandUTAUThave alsoreceivedcriticismfordisregardingthefactthattechnol- ogyacceptancemayfluctuateovertime[24–27].Furthermore, severalstudiesdemonstratethattheinfluenceofPU,PEOU, and other relevant factors is different between the pre- implementation stage (when a technology has not been used yet) and the post-implementation stage (when users haveusedandexperiencedatechnology)[28,29].Acceptance researchisalsocriticizedforbeingtooreliantonTAMand UTAUT, overlooking essential determinants [30,31,26]. In a recentliteraturereview,Chenand Chandiscussed19 stud- iesthatusedTAMorrelatedmodelsandconstructstoexplain technologyacceptancebyolderadults[32].Theyfoundthat specificbiophysical(e.g.,cognitiveandphysicaldecline)and psychosocial (e.g., social isolation, fear of illness) factors relatedtoagingareoverlookedinthecurrentliterature.

ChenandChanalsonotethatthefactorcost(price)oftech- nologyisneglectedinmanystudies,althoughitseemstobe acritical factorin determininganolderadult’s acceptance oftechnology[32].Furthermore,mostresearchhasfocused on communication- and assistive technology in the home domain,neglectingothertypesoftechnology[32].Thesecon- cernsindicatethatmoreresearchisneededtodevelopabetter understandingofacceptanceofvarioustypesoftechnologyby olderadults.

1.2. Researchquestion

Thissystematicreviewofqualitative,quantitative,andmixed methodsstudiesexaminesthefollowingresearchquestions:

whichfactorsinﬂuencetheacceptanceofdifferenttypesof technologyforaginginplacebycommunity-dwellingolder adults, and how do these factors differ between the pre- implementationstageandthepost-implementationstage?

Theaimofthis study istoprovide an overviewoffac- torsthatcanfacilitatetheimplementationoftechnologyfor

community-dwellingolderadults,andtoprovidedirections forfurthertechnologyacceptanceresearchwithinthisspeciﬁc group.

Technologyacceptanceinthisstudyisdeﬁnedastheinten- tion to usea technologyor theactual use ofatechnology [17]. Technology foraging in placeis deﬁnedas electronic technologythatisdevelopedtosupporttheindependenceof community-dwelling olderadultsbyalleviating orprevent- ingfunctionalorcognitiveimpairment,bylimitingtheimpact ofchronicdiseases,orbyenablingsocialorphysicalactivity.

Community-dwellingolderadultsaredeﬁnedasolderadults whoarenotlivinginalong-termcareinstitution.

2. Methods

2.1. Searchstrategy

InJanuary2012,sevendatabases(ACMDigitalLibrary,CINAHL, IEEEXplore,MEDLINE,PsycINFO,ScopusandWebofScience) were searched using acombination of four groups ofkey- words: (1) “older”,“senior” and synonyms for theseterms;

(2)“livingindependently”,“community-dwelling”andsimilar search terms; (3) search terms to ﬁnd electronic technology that is aimed atsupporting aging in place. Since this typeoftechnologyisstudiedinmanydifferentﬁelds,itwas decided to be broadly inclusive and include search terms suchas“system”,“e-health”,“gerontechnology”,“telemoni- toring”,“smarthome”,“assistivetechnology”,and“robotics”;

and (4) search terms that are related to “acceptance” and similar terms such as “use”, “adoption”, “adherence” and

“rejection”.Afulllistofall150searchterms,includingoptions and limitsthat were selectedinthe differentdatabases,is available as supplementary material in the online version (http://dx.doi.org/10.1016/j.ijmedinf.2014.01.004).

2.2. Articleselection

Titles,abstractsandfullarticlesweresubsequentlyscreened byoneauthor[SP]applyingtheinclusioncriteriamentioned inTable1.Incaseofdoubt,threeauthors[SP, EWandJvH]

discussedtheselection.Inaddition,referencesoftheincluded articleswerecheckedforotherarticleseligibleforthisreview (snowballmethod).

2.3. Dataextraction

Threeauthors [SP,EWandJvH]eachreadall includedarticles,andseparatelyentereddatausingadataextractionform,

Table1–Inclusioncriteria.

Inclusioncriteria:

•Originalandpeer-reviewedresearchwritteninEnglish;

•Qualitative,quantitativeormixedmethodsresearch;

•Researchinwhichparticipantsarecommunity-dwellingolder adultsaged60yearsorolder;and

•Researchaimedatinvestigatingfactorsthatinﬂuencethe intentiontouseortheactualuseofelectronictechnologyfor aginginplace.

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whichisavailableassupplementarymaterialintheonline version(http://dx.doi.org/10.1016/j.ijmedinf.2014.01.004).The ﬁrstpartoftheextractionformincludesentriesoninclusion and exclusion criteria, quality assessment, methods used, typeoftechnologystudied andimplementation stage(pre- implementation/post-implementation). Articles were also checkedforworkingdeﬁnitionsofacceptanceandtheuseof existingtechnologyacceptancemodels.

Articles under review used either qualitative methods, quantitativemethodsoracombinationofboth(mixedmethods).Inordertoextractfactorsfromalltypesofarticles,the dataextractionformcontainsasectionforfactorsextracted fromqualitativedataandasectionforfactorsextractedfrom quantitativedata.

In the case of qualitative articles and qualitative data from mixed methods articles, factor names and their per- ceivedinfluenceonacceptancewerecodedandsubsequently enteredinthequalitativesectionoftheform.Inthecaseof quantitativearticlesandquantitativedatafrommixedmeth- odsarticles, the following informationwas entered in the dataextractionform:variablename,standardizedorunstan- dardized regression coefficients, level of significance, and proportionofvarianceexplained.

2.4. Dataanalysis

Inthefirst stageofthe analysis,the threeauthors[SP, EW andJvH]hadtoreachconsensusoneveryentryinthedata extractionform,foreacharticle.Thiswasdoneinweeklyses- sions, andarticles were discussed inrandom order. Inthe second stage, thematicsynthesis [33]was used tosynthe- sizequalitativedataonfactors.Multiplesessionswereheldto groupfactorsderivedfromqualitativearticlesandqualitative datafrommixedmethodsarticlesindescriptivethemesfor acceptanceinthepre-implementationstage,andforaccep- tanceinthepost-implementationstage.Additionally,SP,EW andJvHeachcreatedaconceptualmodeloftherelationships betweenthemes,andsubsequentlyonecombinedmodelwas developed. Inthe final stage, factors derivedfrom qualita- tivearticlesandqualitativedatafrommixedmethodsarticles werecomparedtofactorsinquantitativearticlesandquan- titativedatafrommixedmethodsarticles.Thiswasdoneto determinewhetherfactorspresentinqualitativeresearchare statisticallytestedinquantitativeresearchandtofindsignif- icantfactorsinquantitativeresearchthatarenotpresentin qualitativeresearch.

2.5. Qualityassessment

QualitativearticleswerescreenedusingtheCriticalAppraisal SkillsProgram(CASP)[33],whichcontains10criteriaonitems suchasstudydesign,recruitmentstrategy,the relationship betweenresearcherandparticipants,ethicalconsiderations, dataanalysisand explicitnessofthe ﬁndings.Quantitative articleswere screenedusing the HealthEvidence Bulletins Wales checklist [34]. This checklist covers 11 criteria on cross-sectionalstudiesincludingtheappropriatenessofsam- pling,the levelofprotectionagainstbiases and conﬁdence intheuse ofstatisticalmethods.Themixedmethodsarti- cleswerescreenedusingtheMixedMethodsAppraisalTool

(MMAT)[35]which,inadditiontospecificcriteriaforqualita- tiveandquantitativeresearch,alsocontainsspecificcriteria ontherelevanceoftheuseofamixedmethodsdesignand theintegrationofdifferenttypesofresults.Itwasdecidednot toexcludearticlesbasedonqualityassessmentbecausethere islittleempiricalevidenceonwhichtobaseexclusiondeci- sions inmixedstudies systematicreviews[35–37]. Instead, itwasdecidedtoreportonthequalityofthereviewedarti- clesandtoapplyindependenttriangulation:factorshadtobe presentinatleasttwostudiesinordertobeincludedinthe results.Furthermore,wedecidedthatintheeventofanarticle notmeetingtheminimalscreeningcriteriaofachecklist,we wouldexaminethecontributionofthatarticletoourfindings.

3. Results

The search in seven databases for factors inﬂuencing the acceptanceofelectronictechnologiesthatsupportagingin placebycommunity-dwellingolderadultsgeneratedatotal of4692results.Aftertheremovalofduplicateresults,atotal of2841uniquearticleswereidentiﬁed(Fig.1).Theselection processinitiallyledtotheinclusionof15articles[38–52].The snowball methodadded one article[53], bringing the total numberofarticlesincludedinthisreviewto16.

3.1. Characteristicsofreviewedarticles

The includedarticles were aimed atexploringfactors that influencethe willingnessofolder adultsto usetechnology foraginginplace,aswellastheirperceptionsandexpecta- tionsofthistypeoftechnology.AsshowninTable2,articles describedacceptanceofdifferenttypesoftechnology,andsix articlesdescribedcombinationsoftypesoftechnology.Tech- nologythatenhancessafety(e.g.,monitoringtechnologyand personal alarms)was themostprominenttypeoftechnol- ogy,followedbytechnologythatprovidessocialinteraction (e.g.,videotelephony).Technologythatsupportsolderadults intheirActivitiesofDailyLiving(ADL)orInstrumentalActiv- itiesofDailyLiving(IADL)(e.g.,electronicmemoryaids)was lessprevalent.Resultsalsoshowthat12ofthearticlessolely describeacceptanceoftechnologyinthepre-implementation stage.Inthesepre-implementationstudiesresearcherstypi- callyusepresentations,vignettesorscenariostoexplainone ormoretypesoftechnologyforaginginplacetothepartici- pants.Inthreestudies,participantswereallowedtointeract with prototypes [38,42,44]. Evaluation of acceptancein the post-implementationstage(onearticle)oracombinationof evaluationinthepre-andpost-implementationstage(three articles)wasfarlesscommon.Elevenofthe16reviewedarti- clesusedqualitativeresearchmethods(usinginterviewsor focus groups),four articlesused a combination ofqualita- tiveandquantitativeresearchmethods(mixedmethods),and onearticlewasbasedonquantitativemethodsalone(usinga cross-sectionalsurvey).Convenienceandpurposivesampling wasusedbyallarticleswiththeexceptionofthearticleby Zimmeretal.[53],whichusedstratifiedsampling.Twoarti- clesmadeuseofatheoreticalframeworktoguidethesearch orinterpretationoffactorsinfluencingacceptance:Steeleetal.

[42] used TAM and UTAUT [17,18], and Zimmer et al. [53]

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Table2–Characteristicsofthe16reviewedarticles.

Article Technologytype(s) Implementation

stage

Method

Firstauthor,year[reference] (I)ADL Safety Interaction Pre Post Type Instrument N Country

Lorenzen-Huberetal.,2011[38] × × × × – Qualitative Focusgroups 65 USA

vanHoofetal.,2011[39] – × × × × Qualitative In-depthinterviews 18 TheNetherlands

Laietal.,2010[40] – × – × – Mixedmethods Face-to-facesurvey 333 China^d

Steggelletal.,2010[41] × × × × – Qualitative Focusgroups 32 USA

Steeleetal.,2009[42] – × – × – Qualitative Focusgroups 13 Australia

Courtneyetal.,2008[43] – × – × – Qualitative Focusgroups,in-depthinterviews 14 USA

Demirisetal.,2008[44] – × – × – Qualitative Focusgroups 14 USA

Horton,2008[45] – × × × × Qualitative In-depthinterviews 35 England

Mahmoodetal.,2008[46] – × × × – Qualitative Focusgroup 9 USA

Mihailidisetal.,2008[47] × × × × – Mixedmethods^c In-depthinterviews,face-to-facesurvey 15^a Canada

Wildetal.,2008[48] – × – × – Qualitative Focusgroups 23^b USA

Cohen-Mansﬁeldetal.,2005[49] × – – × – Mixedmethods Face-to-facesurvey 100 USA

Porter,2005[50] – × – – × Qualitative In-depthinterviews 7 USA

Ezumietal.,2003[51] – – × – × Mixedmethods^c Face-to-facesurvey 28 Japan

Porteretal.,2002[52] – × – × – Qualitative In-depthinterviews 11 USA

Zimmeretal.,1999[53] – × – × – Quantitative Face-to-facesurvey 1406 USA

×,presentinarticle;–,notpresentinarticle.

a Asecondgroupof15olderadultsthatdidnotmeetouragecriterionwasexcludedfromthereview.

b Asecondgroupof16familymembersandfriendswasexcludedfromthereview.

cStatisticalmethodswerenotusedonquantitativedatainthisarticle.

dResearchwasconductedintheHongKongspecialadministrativeregion.

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Fig.1–Flowdiagramofthearticleselectionprocess.

usedAndersen’sModelofHealthServicesUtilization[54].The majorityoftheincludedresearchwascarriedoutinAnglo- Saxoncountries.

3.2. Qualityofreviewedarticles

Lookingatthequalityofthequalitativearticles,themajority ofthearticlesmetmostofthecriteria.Therewasonecriterion thatwasonlymetbyonearticle[38].Inthiscriterionitwas assessedwhetherresearcherscriticallyexaminedtheirown role,potentialbiasandinﬂuenceintheprocessofconducting thestudy.Acriterionontheconsiderationofethicalissues wasmetbyhalfoftheincludedarticles.

The one quantitative article [53] met all the criteria except for a criterion on the consideration of alternative explanationsforeffects,andacriteriononthevalidationof surveyquestions.

Lookingatthemixedmethodsarticles,thequalityofone article [51] could not be assessed completely because we

considered the researchquestion ofthis articleambiguous and it therefore did notmeetthe screening criteria ofthe MMAT[35].Theothermixedmethodsarticlesmetthemajor- ity ofthe criteria, butnone ofthearticles metthe criteria onconsiderationtowardtheinﬂuencebytheresearcher,the validityofquantitativemeasurementsandconsiderationof thelimitationsassociatedwithintegrationofqualitativeand quantitativedata.

3.3. Qualitativeresultsonpre-implementation acceptance

Qualitative resultsshow that acceptance oftechnologyfor aginginplaceinthepre-implementationstageisinﬂuenced by27factors,dividedinto sixthemes(Table3).Thelargest themecontainsconcernsthathaveanegativeinﬂuenceon the pre-implementationacceptanceoftechnologyforaging inplace(Fig.2).

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Table3–Pre-implementationacceptancefactors.

Theme Factor Numberofarticles References

Concernsregardingtechnology Highcost 7 [40–42,45,47,49,52]

Privacyimplications 7 [38,41–44,47,48]

Forgettingorlosingtechnology 4 [41,42,48,49]

Falsealarms 3 [44,45,47]

Obtrusiveness 3 [42,44,48]

Burdeningchildren 2 [38,41]

Ineffectiveness 2 [40,52]

Impracticality 2 [47,49]

Loweaseofuse 2 [42,49]

Negativeeffectonhealth 2 [41,42]

Nocontrolovertechnology 2 [42,47]

Stigmatization 2 [42,49]

Beneﬁtsexpectedoftechnology Increasedsafety 6 [38,40,41,44,46,48]

Perceivedusefulness 3 [38,42,47]

Increasedindependence 2 [39,41]

Reducedburdenonfamilycaregivers 2 [38,48]

Needfortechnology Perceivedneed 9 [38,41–45,47,48,52]

Subjectivehealthstatus 2 [43,44]

Alternativestotechnology Helpbyfamilyorspouse 5 [40,42,44,47,52]

Currenttechnology 2 [43,48]

Socialinﬂuence Inﬂuenceoffamilyandfriends 3 [38,43,52]

Inﬂuenceofprofessionalcaregivers 2 [38,43]

Usebypeers 2 [44,52]

Characteristicsofolderadults Desiretoageinplace 6 [38,39,42,46–48]

Culturalbackground 2 [40,41]

Familiaritywithelectronictechnology 2 [42,47]

Housingtype 2 [42,43]

3.4. Concernsregardingtechnology

Community-dwellingolderadultsexpressvariousconcerns whentheyconsidertechnologyforaginginplacethatthey havenotyetused.Oneoftheirmajorconcernsishighcost, whichismentionedinhalfofthearticles.Whenitisdescribed, it has a prominent role: “Costliness was identiﬁed as the

Fig.2–Modelofpre-implementationacceptance.

major concern most often” (p. 15) [49] and “Cost was the mostsigniﬁcantconcerntotheelderlyparticipants...andis themostlikelytopicforparticipantstoreferbacktoregard- lessofwhatissuewasbeingdiscussed.”(p.793)[42].Privacy implications are another concernmentioned inhalf ofthe articles, although participants from different studies men- tionthattheywouldbewillingtogiveup(some)privacyas long astheuse oftechnologywould bebeneﬁcialtothem;

forinstance:“You’dhavetocometoanagreement.Yougive up someofyourprivacyand giveupsomeofthesethings in ordertostay whereyou are.”(p. 242) [38]. A numberof concernsarerelatedtousability;community-dwellingolder adultsmentionthattheyfearthattechnologymaybehardor impracticaltouse.Someparticipantsarealsoconcernedthat theyhavenocontrolovertheactivationandde-activationof thetechnology:“You’vegottobeabletohavecontrolofit.I thinkyoushouldhaveascreensomewhere,thatmaybeyou cancheckifyouthinkyoumayhavesetitoff,wellyoucan goseeifyouhaveornot...”(p.795)[42].Inaddition,partici- pantsregularlyexpressconcernsregardingtheconsequences ofusingtechnology,suchastheburdenitmightputontheir childrenintheirroleasfamilycaregivers,orthepossibleneg- ativeeffectsontheirpersonalhealth:“Couldthesensorradio wavesgiveyoucancer?IthinkthisiswhatIwouldbewor- riedabout.”(p.793)[42]. Othersareconcernedthatthe use oftechnologymight failtoachieveits goal and mayprove to be ineffective. Regarding the appearance of technology, community-dwellingolderadultsexpressconcernsthatthe technologymightbetoonoticeableorobtrusivewithintheir homes.

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Inarelatedconcern,participantsareworried thatother peoplemayperceivethemtobeinpoorhealthorfrail,once theyareseenwearingtechnologythatisspeciﬁctofrailolder adults.Thisfearofstigmatizationcanbeverypowerful,and oneparticipantdescribed wearingapersonalalarmbutton aslikewearinga“badgeofdishonor”(p.31)[50].Whenolder adultsthinkaboutusingpersonalalarmbuttonsorportable healthmonitoringsensors,theyareconcernedthattheymight forgettousethemorlosethem.Inthecaseofhealthorsafety monitoringtechnology,participantsareconcernedaboutfalse alarms:“...ifyou’reintheshowerandyoubendovertopick upyoursoapanditthoughtyou’dfallen—therecouldbefalse alarms...andIdon’twantitsendingfortheambulanceifI’ve onlybumpedmyknee.”(p.793)[42].

3.5. Beneﬁtsexpectedoftechnology

Althoughcommunity-dwellingolderadultsexpresstechnol- ogyrelatedconcerns,theyalsoexpecttheuseoftechnology foraginginplacetobebeneficial.These expectedbenefits haveapositiveinfluenceontheirpre-implementationacceptance.Olderadultsmentionthattheywouldusetechnology whentheyperceiveitasuseful,althoughoftenitisnotmade clearwhatconstitutesthisperceivedusefulness:“Ifthething isgood,andit works,thenwegoforit.However,ifwesee somethingthat isuseless,and obtrusive,andischangefor change’ssake,thenno.NotInterested.”(p.796)[42].Inother cases,thebenefitsaremoreconcrete,andthemostfrequently mentionedbenefitisanexpectedincreaseinsafety:“Itwill increasethelifetimebecauseifyougetintoanaccident... youwillbediscoveredsoonerandcangettoemergencyroom beforeitistoolate...”(p.442)[41].Additionally,participants mentionthattheyexpectthattheuseoftechnologyforaging inplacewillincreasetheirindependenceorreducetheburden onfamilycaregivers.

3.6. Needfortechnology

Whetherornotcommunity-dwellingolderadultsarewilling tousetechnologyalsodependsontheirperceived personal needfortechnology.Perceived needisthemostfrequently mentionedfactoroverall,andwhenitispresenttheaccep- tanceoftechnologyismorelikely.However,inmostarticles participantsstatethattechnologyforaginginplaceisneeded forahypotheticalotherolderperson,ratherthanforthem- selves:“Idon’tneedthisnow,butperhapsatalaterpoint—I havefriendswho’dbenefitfromthisagreatdeal,Iamnotthere yet...”(p.122)[44].Insomeinstances,anolderadult’snega- tivesubjectivehealthstatuspositivelyinfluenceshisorher perceivedneedandacceptanceoftechnology;forexample,in thecaseofaparticipantwhorecentlyfell:“Ifyouhadtoldme twomonthsago[aboutthesetechnologies]I’dsaywhoneeds it,butafterwhatIhavebeenthrough,Iseethebenefits.”(p.

122)[44].Inothercases,however,anegativehealthstatusdoes notincreasetheperceivedneedfortechnology:“Onewoman whohadbalanceissuesandahistoryoffallsdescribedher healthconditionandthen statedthatshedidnotneedfall detectiontechnologyatthistime.”(p.199)[43].

3.7. Alternativestotechnology

Available alternatives to technologyfor agingin place can negatively inﬂuence its acceptance. For instance, help by family members or a spouse can reduce the need for technology-basedmonitoring[44].Additionally,certaintypes oftechnologythatarecurrentlyusedcanmakeothertypesof technologyseemredundantintheperceptionofparticipants.

Anexample ofthis isthe reducedneedforafall-detection systemwhenapersonalalarmbuttonisavailable[43].

3.8. Socialinﬂuence

Community-dwelling older adults are also influenced by key figures within theirsocial environmentwhen deciding whetherornottousetechnologyforaginginplace.Anexam- pleofthisistheinfluenceoftheirchildren:“Severalnotedthe importanceoftheirchildren’sconcernswhendeterminingif theyneededaserviceoratechnology.”(p.199)[43].Insome cases,thechildren’sinfluencecanbecompelling:“Iamvery compliantaboutthesekindsofthings.Iamnotcompliantwith thethoughtsofmymind,butIamcompliantaboutfollowing directions[frommyadultchildren].”(p.241)[38].

Besideschildren,professionalcaregiversandfriendsand familycanalsopositivelyornegativelyinﬂuenceacceptance.

Furthermore,community-dwellingolderadultsareinﬂuenced bytheacceptanceoftechnologybytheirpeers:“EverybodyI’ve talkedtothat’strieditout,theydon’tcareforit...Mygeneral feelingisthatpeopledon’tcareforthem.[Areyouthinking aboutgettingitnow?]Notatthispoint.”(p.195)[52].

3.9. Characteristicsofolderadults

Several characteristics of community-dwellingolder adults canpositivelyornegativelyinﬂuenceacceptanceofaging-in- placetechnology.Oneofthemoreprominentfactorsisthe desiretoageinplace:“Alltherespondentsinthisstudywant tostayintheircurrentdwellingbecauseofattachmenttothe own home,memoriesofthepast,and theirpossessionsin thehome,aswellasthequalityoftheneighborhood.”(p.318) [39],and“Iwouldchoosehome,Ithinkmostpeoplewould... Nobodychoosestogotoanursinghome.”(p.792)[42].The desiretoageinplacesometimesleadstoacceptanceoftech- nologyforaginginplace,butnotinallcases.Otherfactors arethefamiliarityoftheolderadultwithmodernelectronic technology,andtheﬁtbetweenhousingtypeandcertaintypes oftechnology.Lastly,thereistheissueofwhetherornotthe technologyiscompatiblewiththeolderadult’sculturalback- ground:“AuniquelyKoreanvalueemergedinthediscussion ofthesleepmonitor.Dyingwhilesleepingisconsideredvery luckyintheKoreantradition.Participantswereconcernedthat technologymightinterferewiththeirluck.”(p.442)[41].

3.10. Comparisonwithqualitativeresultson post-implementationacceptance

Analysisofqualitativeresultsonpost-implementationaccep- tanceshowsthatsomepre-implementationfactorsarealso presentinthepost-implementationstage.Forexample,when older adults have used and experienced technology, they

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are still concerned about privacy implications [39,45] and stigmatization [50,51]. Furthermore, many participants are still not sure if they themselves actually need technology foraginginplace,andtheperceivedpersonalneedofthese community-dwelling older adults [39,45] continues to play arole intheir technology acceptance. Lastly,the expected beneﬁt of increased safety [39,50] continues to positively inﬂuenceacceptance.

At the same time, new factors emerge in the post- implementation stage. Some of the older adult’s pre- implementation concerns turn into real life problems; for exampletheoccurrenceoffalsealarms[39,50]:“I’venotbeen verysuccessfulwithit.Idon’tthinkitreallyworkedforme;

itkeptgivingthesefalsealarmsandtheybecamequiteanui- sancethatI’dneverbotheredtowearitafterawhile.”(p.1188) [45].Thisalsohappenswiththeconcernofforgettingorlosing personalalarmbuttonsorothertypesofportabletechnology [39,45,50]:“...Iwasgoodfortheﬁrstfewmonths,thenIwent awayforafewdays,andIcouldn’thaveitwithmebecauseit wouldn’tworkinmydaughter’shouse.ThenIcamehomeand Isupposeit’slikemostthings,youtryitforawhileandthen youforgetit.”(p.1189)[45].Besidesconcernsbecomingreality, thereisalsotheproblemoftechnologynotworkingincertain locations[50,51],therebyloweringitsacceptance.Anexam- pleofthisisportable technologythatdoesnotwork inthe shower.Anotherinhibitoroftechnologyacceptancethatwas notmentionedinthepre-implementationstage,istheavail- abilityofhomecareasanalternativetotechnologyforaging inplace[39,50].Lastly,thelevelofsatisfactionwiththenew technology[45,51]andtheaffecttowardthenewtechnology asaresultofusingit[39,50]inﬂuencetechnologyacceptance inthepost-implementationstage.

3.11. Comparisonwithquantitativeresultson pre-implementationacceptance

Analysisofquantitativeresultsshowsthatseveralvariables thataresimilartoqualitativefactorshavebeenstatistically testedonpre-implementationdata,usingregressionanalysis.

Atthe sametime,asmall numberofvariablesnotpresent inthereviewedqualitativepre-implementationresearchwere alsotested.Inthissection,signiﬁcantresultsarepresented (Table4).

In the study by Cohen-Mansfield et al. [49], the number of concerns regarding using a device (including high cost,loweaseofuse,impracticality,andstigmatization)has asignificant negativeinfluenceon the acceptance ofelec- tronicmemoryaids.Furthermore,theimportanceattributed tofunctionsofthedevice,whichresemblesthequalitativefac- torofperceivedusefulness,positivelyinfluencesacceptance.

Cohen-Mansﬁeldetal.[49]alsofoundthatacceptanceofelec- tronicmemoryaidsispositivelyinﬂuencedbythenumberof differentprescriptionstaken;avariablethatisnotpresentin thereviewedqualitativeresearch.

Lai et al. [40]studied community-dwelling older adults’

acceptanceofavitalsignsmonitoringsystemandtheiraccep- tanceofamotionmonitoringsystem. Theyfoundthatthe numberofself-reportedchronicillnesses,whichbearsresem- blance tothe qualitativefactor ofsubjective healthstatus, positivelyinﬂuencesacceptanceofavitalsignsmonitoring

system.Atthesametime,thisvariablehasnosignificantinflu- enceontheacceptanceofamotionmonitoringsystem.This alsoappliestoage,whichwasfoundtonegativelyinfluence theacceptanceofavitalsignsmonitoringsystem,butnotthe acceptanceofamotionmonitoringsystem.Inadditiontoage, twoothervariablesthatarenotpresentinthereviewedqual- itativeresearchwerestudied:genderandlevelofeducation.

Bothnegativelyinﬂuencetheacceptanceofamotionmonitor- ingsystem,butnottheacceptanceofavitalssignsmonitoring system.Laietal.didnotspecifywhetherthemotionmonitor- ingsystemwasmoreacceptedbymalesorfemales.

Lastly, in the study by Zimmer and Chappell [53], the acceptance of electronic safety devices is positively influenced by two variables that are similar to the qualitative factorofsubjectivehealthstatus:thenumberofself-reported health symptoms and the number ofself-reported dexter- ity problems. The number ofsafety and security concerns (whichcorrespondstoperceived need)alsopositivelyinflu- encesacceptance.Finally,threevariablesthatarenotpresent inthereviewedqualitativeresearchalsoinfluenceacceptance ofelectronicsafetydevices:age(negativeinfluence),levelof education (positiveinfluence),and rural residency(positive influence).

4. Discussion

4.1. Mainﬁndings

Thisistheﬁrstsystematicreviewtoidentifyfactorsthatinﬂu- enceacceptanceofelectronictechnologyforaginginplace.

Sincetechnologyacceptancefactorsﬂuctuateovertime,adistinctionwasmadebetweenfactorsinthepre-implementation stageandfactorsinthepost-implementationstage.Sixteen articlesbasedonqualitative,quantitativeormixedmethods wereidentiﬁed.Mostarticlesinvestigatedacceptanceoftech- nology that enhances safety or provides socialinteraction.

Themajorityofthedatawasbasedonqualitativeresearch investigatingfactorsatthepre-implementationstage.Results showthatacceptanceoftechnologyatthisstageisinfluenced by 27 factors, divided into six themes: concerns regarding technology(e.g.,highcost, privacyimplications andusabil- ity factors), expectedbenefitsoftechnology(e.g.,increased safety and perceived usefulness),needfortechnology(e.g., perceivedneedandsubjectivehealthstatus),alternativesto technology(e.g.,helpbyfamily orspouse),socialinfluence (e.g.,influenceoffamily,friendsandprofessionalcaregivers) and characteristics of older adults (e.g., desire to age in place).Whencomparingtheseresultstoqualitativeresultson post-implementationacceptance,analysisshowsthatsome pre-implementationconcerns,suchasthefearofforgetting orlosingtechnology,turnintoreallifeproblemsinthepost- implementationstage.Furthermore,factorssuchasperceived need and stigmatization are persistent. New factors also emerge,forexamplesatisfactionwithtechnologyandaffect toward technology. Quantitative results show that a small numberofvariables,suchassubjectivehealthstatus,thatare similartoqualitativefactors,haveasignificantinfluencein the pre-implementationstage.Resultsforbackgroundvari- ables,suchasageandlevelofeducation,aremixed.Fourteen

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internationaljournalofmedicalinformatics83(2014)235–248 Table4–Signiﬁcantpre-implementationvariablesandsimilarqualitativepre-implementationfactors.

Signiﬁcantquantitativevariables Similarqualitativefactors

Ref. Variable Technologystudied Signiﬁcancelevel Theme Factor

[49]^a Numberofconcerns regardingusingadevice (includinghighcost,low easeofuse,

impracticality,and stigmatization)

Electronicmemoryaids p<.05,Beta=−.17,R²=.30 Concernsregarding technology

Highcost,lowease ofuse,

impracticality,and stigmatization

Importanceattributed tofunctionsofthe device

Electronicmemoryaids p<.05,Beta=.44,R²=.30 Beneﬁtsexpectedof technology

Perceivedusefulness

Numberofdifferent prescriptionstaken

Electronicmemoryaids p<.05,Beta=.25,R²=.30 – –

[40]^b Numberofself-reported chronicillnesses

Vitalsignsmonitoringsystem p<.001,B=1.718,R²=.22 Needfortechnology Subjectivehealth status

Motionmonitoringsystem Notsigniﬁcant

Age Vitalsignsmonitoringsystem p<.001,B=−1.284,R²=.22 – –

Motionmonitoringsystem Notsigniﬁcant

Gender Vitalsignsmonitoringsystem Notsigniﬁcant – –

Motionmonitoringsystem p<.05,B=−0.785,R²=.13

Levelofeducation Motionmonitoringsystem p<.05,B=−0.911,R²=.13 – –

[53] Numberofself-reported healthsymptoms

Electronicsafetydevices p<.05,Beta=.06,R²=.15 Needfortechnology Subjectivehealth status

Numberofself-reported dexterityproblems

Electronicsafetydevices p<.05,Beta=.06,R²=.15 Needfortechnology Subjectivehealth status

Numberofsafetyand securityconcerns

Electronicsafetydevices p<.01,Beta=.27,R²=.15 Needfortechnology Perceivedneed

Age Electronicsafetydevices p<.01,Beta=−.08,R²=.15 – –

Levelofeducation Electronicsafetydevices p<.05,Beta=.06,R²=.15 – –

Ruralresidency Electronicsafetydevices p<.01,Beta=−.09,R²=.15 – –

–,notdescribedinqualitativearticles.

a Signiﬁcancelevelsforthisstudywereconﬁrmedbycontactingthecorrespondingauthorbecausethesewerenotreportedintheoriginalarticle.

b DataonaPersonalEmergencyLinkService(PELS)wasexcludedbecauseonlysubscriptionstatuswasanalyzed,andnotactualuseorintentiontouse.

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245

articlesdidnotuseanexistingtechnologyacceptanceframe- workormodel.

4.2. Strengthsandlimitations

Thisreview’sstrengthsliesinits extensivesearchstrategy, covering databases in the ﬁelds of social sciences, health careand technology.Thissystematicand multidisciplinary approachisalsoreﬂectedin theextractionoffactors from qualitativeresearch,whichwasdonebythreeindependent reviewersfromdifferentbackgrounds(psychology,medicine and engineering). Another strength is the inclusion of all typesofavailableevidence,regardlessofthetypeofresearch method(qualitative,quantitativeormixedmethods).

Onemixedmethodsarticle[51]didnotmeetthescreen- ing criteria of the checklist that was used [35], due to an ambiguousresearchquestion.Howeveritdidcontaindatathat helpedusanswerourresearchquestion.Whenwelookatthe contributionofthisarticletoourdata,itshowsthatthreepost- implementationfactorswereextractedfromthisarticle.Each ofthesefactorswerealsomentionedbyoneotherarticle.This indicatesthatthecontributionofthisstudytotheﬁndings wassupportiveratherthandecisive.Thisisinaccordancewith ﬁndingsbyThomasandHarden,whoshowedthatthecontri- butionofstudiesthatwereassessedashavingalowerquality wasmodestcomparedtostudiesthatwereassessedashaving ahighquality[37].

Thisreviewprovidesanoverviewoffactors,butitdoesnot differentiatebetweentypesoftechnology.Furthermore,mod- eratingormediatingrelationshipsbetweenfactorshavenot beeninvestigatedduetoa lackofavailabledata. Thisalso impliesthatthesetypesofrelationshipsare notcoveredin thepresentedmodelofpre-implementationacceptance.

4.3. Relationtootherstudies,reviewsandmodels

The majority of the included articles lack a theoretical approach,whichhampersinterpretationandcomparisonof findingsbetweenstudiesinthisfield.Asimilarproblemhas beenreportedbyauthorsreviewingtechnologyacceptanceof consumerhealthinformationsystems[55]andtelemedicine [56]. When relating the results of this review to TAM and UTAUT,it appearsthat acceptance oftechnologyforaging in place by community-dwelling older adults in the pre- implementationstageisinfluencedbymorefactorsthanjust thekeyconstructsoftheTAMandtheUTAUT.Oneexample ofthisisthefactthatcommunity-dwellingolderadultsmen- tionmorebenefitsoftechnologyforaginginplacethanjust PerceivedUsefulness.¹

However, it is possible that the other beneﬁts that community-dwellingolderadultsmention,suchasincreased safetyandincreasedindependence,areinfactantecedentsto PerceivedUsefulness.Analternativeexplanationisprovided bytheauthorsofthevalue-basedadoptionmodel(VAM)[57], whostatethatTAMisveryusefulinorganizationalcontexts, butnotinthecontextofconsumerswhohavetomaketheir

1 Davis[17]andVenkatesh[18]deﬁnePerceivedUsefulnessof PerformanceExpectancyas“Thedegreetowhichanindividual believesthatusingthesystemwillhelphimorhertoattain gainsinjobperformance.”

ownpersonalevaluationofthecostsandbenefitsofusinga technology.Therefore,intheVAMmultiplePerceivedBenefits andmultipletypesofPerceivedSacrificestogetherdetermine thePerceivedValueofatechnologytotheconsumer,whichin turninfluencesanindividual’sintentiontouseatechnology.

Perceivedsacriﬁcescanbemonetaryornon-monetary.Exam- plesofnon-monetarycostsaretimecosts,effort costsand psychologicalcosts.InVAM,TAM’sPerceivedEaseofUsecon- structisconsideredtobeaPerceivedSacriﬁce[57].Thetheme

“concerns”inthisreviewresemblestheconstructofPerceived Sacrifices.UpuntilnowVAMhasbeenusedsuccessfullyin explainingconsumersacceptanceofmobileinternet[57]and InternetProtocolTeleVision[58].AtthesametimeVenkatesh, ThongandWuhaveproposedandtestedUTAUT2,whichis also aimedatexplaining consumerbehavior,and contains theconstructofPriceValuewhichisdefinedas“acognitive tradeoffbetweenthe perceived benefitsofthe applications andthemonetarycost”[59].Thestudy byCohen-Mansfield etal.[49]thatisincludedinthisreviewprovidessomesta- tisticalsupportfortheroleofcost-benefitevaluations,butto ourknowledgeVAMandUTAUT2havenotbeentestedinthe contextofolderusers.

This reviewalso shows that other mechanisms besides cognitivecost-beneﬁts tradeoffscomeintoplaywhenolder adultsareconsideringtheuseoftechnology.Whetherornot olderadultsfeeltheneedfortechnologytosupporttheiraging inplaceisimportantintheiracceptanceoftechnology,both inthe pre-implementation andpost-implementation stage.

Perceived Need playsa similarrole inAndersen’sModelof HealthServicesUtilization[54],whereitisthemostimmedi- atepredictorofhealthserviceuse.Thearticlesinthisreview indicatethatmanycommunity-dwellingolderadultsdonot feel the need for supportive technology. This is in accor- dancewithsomeofthestrategiesforcopingwithdeclinethat community-dwellingolderadultsemploy,suchas“tryingto keep one’s’ mind from focusingon oneself and one’s own vulnerability”[60]and “focusing onthe present”[61]. More researchisneeded tounderstandhowolder adults’coping strategiesarerelatedtotheuseofsupportivetechnology,espe- ciallysincethisreviewalsoshowstheambiguousrelationship betweenolderadults’desiretoageinplaceandtheuseoftech- nology designedtosupportthatsamegoal.Perceived Need hasalsoproventobeaninﬂuentialfactorinresearchonthe acceptanceofnon-electronicassistivedevicesaccordingtoa systematicreviewbySteelandGray[62].Otherfactorsinthis reviewarealsosimilartofactorsinourreview,suchasfearof stigmatization,effectiveness,andcost.Additionally,Steeland Graystressthatacceptanceoftechnologycanbeimprovedby trainingusersandmakingsurethattechnologymatchesan individual’sleveloffunctioning,goals,preferencesandneeds [62].Thesetypesofimplementationfactorshavepossiblynot receivedmuchattention inthereviewedliteraturebecause the majority oftheincluded studies wasperformed atthe pre-implementationstage.

It is clear that pre-implementation acceptance of technology alsodependsonsocialfactorssincefamily,friends, professional caregivers and peersare all described as hav- inganinﬂuence.Socialinﬂuencealsoplayanimportantrole in severalofthe theoriesthat are mentioned inthis para- graph[59,18,54,63].Someofthealternativesthatpreventolder

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adultsfromusingtechnologyforaginginplace,suchashelp by a spouse or help by a family member, are also social factors.Additionally, alternative technology that isalready acceptedcanpreventtheuseofnewtechnology.Thisreview alsopointstootherpre-existingconditionsthatcaninﬂuence acceptance,suchasfamiliaritywithelectronictechnologyand culturalbackground.Thesepre-existing conditionsare also describedinTriandis’TheoryofInterpersonalBehavior[63].

ResearchbyWilsonandLankton[64],thatisbasedonTrian- dis’theory,showsthatpre-existingconditionssuchasageand presenceofchronichealthconditionshaveadirecteffecton e-health use bypatients. Thisispartlyconﬁrmed bystud- ies inthis reviewthat found signiﬁcant effectsofage and the number ofchronicillnesson the acceptanceofa vital signs monitoring system [40]and electronic safety devices [53],butnotontheacceptanceofamotionmonitoringsystem [40].

4.4. Implicationsforpracticeandresearch

Professional caregivers,productdevelopers,managers, pol- icymakers, and family members who are interested in stimulatingcommunity-dwellingolder adultstostartusing technologyforaginginplace,needtobeawarethataccep- tancedependson alargenumber offactors thatmay vary foreachindividual.Mostofthetime,anolderadultwillhave anumberofspeciﬁctechnology-relatedconcerns,whilethe perceived beneﬁtsofa technologymightbemoreabstract.

Therefore,itisnecessarytocommunicateconcretebenefits totheolderadultand,atthesametime,reducetechnology- relatedconcernsspecificforthatindividual.Demonstration of the technology, the opportunity to try out the technol- ogyinarisk-freeenvironment,andtrainingorcoachingcan beused for this purpose.It is advisableto involve professional caregivers, family members, and peers who already use thenewtechnologyinthese interventions,sinceolder peoplearesensitivetotheirinfluence.Whenanolderadult doesnotseetheneedforatechnology,itishighlyunlikely that he or she will be inclined to start using it. How- ever, at this time it is uncertain if perceived need can be influenced, and if it is desirable to do so. It is, therefore, recommended to keep track of an older adult’s perceived needfortechnologyinordertocoordinatetheintroduction oftechnology accordingly. It is also advisable tobe sensi- tivetothefactthatcommunity-dwellingolderadultsdonot exclusivelylookattechnologyasameanstoenableagingin place; theyalsoconsider alternatives such ashelp byoth- ersortheuseoftheircurrenttechnology.Infact, available alternativesmightpreventthemfromusingnewtypesoftech- nology.

Meanwhile,severalgapsregardingresearchontheaccep- tanceofelectronictechnologyforaginginplacebycommunity dwellingolderadultscanbeidentiﬁed.First,whiledataonfac- torsinﬂuencingacceptanceinthepre-implementationstage arecomprehensive,resultsregardingacceptanceinthepost- implementation stage are limited by the small number of studies.Inordertosupporttheindependenceofcommunity- dwellingolderadultsforlongperiodsoftime,moreresearch isneededtounderstandwhatdrivescontinuedorsustained useoftechnologyonceithasbeenimplemented.Thisrequires

longitudinalresearchinvestigatingtheinﬂuenceoffactorsin multiplestagesofuse,suchasthoseproposedbyRogers[65]

or Chiu and Eysenbach [66]. Secondly, there isa dearthof quantitative researchin thepre-implementation stage and quantitative research in the post-implementation stage is nonexistent.Morequantitativeresearchisneededtounder- standwhichfactorsaremoreinfluentialthanothersandto investigate moderating ormediating relationshipsbetween factors.Thirdly,researchuntilnowhasprimarilyfocusedon technologythatprovidessafetythroughmonitoring,andto alesserextentontechnologythatsupports(I)ADLorsocial interaction. More researchis needed on the acceptanceof othertypesofelectronictechnologyforaginginplace,such as technologyforchronicdisease managementor technol- ogythatstimulatesphysicalactivity.Thisisalsonecessary in orderto gain abetterunderstanding ofwhich core fac- torsareinfluentialinexplainingtheacceptanceofmultiple typesoftechnology,suchasperceivedneed,andwhichfac- torsaremoretechnologyspecific.Lastly,authorsinvestigating technologyacceptancebycommunity-dwellingolderadults are encouragedtomakeuseofexistingtheoriesontheuse of technologyand to developtheoriessuitable to the con- textofcommunity-dwellingolderadults.Inconclusion,more research isneededtocapturethe complexity and timeline of the acceptance process of different types of electronic technologyforaginginplacebycommunity-dwellingolder adults.

Author contributions

Allauthorshavemadeasubstantial,direct,intellectualcon- tributiontothisstudy.Peek:studyconceptanddesign,data analysis and drafting ofthe manuscript. Wouters and van Hoof: analysis and interpretation of data, critical revision ofthemanuscriptforimportantintellectualcontent.Luijkx, Boeije and Vrijhoef: critical revision ofthe manuscriptfor importantintellectualcontent.

Allauthorsprovidedapprovaloftheﬁnalversion.

Competing interests

Theauthorsdeclaretheyhavenoconﬂictofinterestforthis study.

Acknowledgements

The RAAK (Regional Attention and Action for Knowledge circulation) scheme, which is managed by the Foundation InnovationAlliance(SIA–StichtingInnovatieAlliantie)with funding fromtheDutch MinistryofEducation,Cultureand Science (OCW), is thanked for their ﬁnancial support (SIA projectnumberPRO-3-37).RAAKaimstoimproveknowledge exchangebetweenSMEsandUniversitiesofAppliedSciences intheNetherlands.SIA-RAAKhadnoroleinstudydesign,in thecollection,analysisandinterpretationofdata,inthewrit- ingofthereport,orinthedecisiontosubmitthepaperfor publication.WewouldliketothankPaulWilmsandEllenvan Yperen(FontysUniversityofAppliedSciences)fortheirhelpin

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Summarypoints

Whatwasalreadyknownonthetopic:

• Technologymaysupportaginginplace,butquestions have been raised on the readiness of community- dwellingolderadultstousethesetechnologies,andit isunclearwhichfactorsplayaroleintheiracceptance oftechnology.

• Research from other ﬁelds shows that technology acceptance varies between the pre-implementation stageandthepost-implementationstage.

Whatthisstudyadds:

• A comprehensive overview of factors inﬂuencing acceptanceofelectronictechnologyforaginginplace inthepre-implementationstage,basedonqualitative research.

• A comparisonbetween qualitative research onpre- implementation factors and qualitative researchon post-implementationfactors,andacomparisonwith quantitativeresearch.

ﬁndingandretrievingarticles.RienkOverdiep(FontysUniver- sityofAppliedSciences)isacknowledgedforhismanagerial support.

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