gms | German Medical Science

Using information and communication technologies (ICTs), new types of social participation and interaction are emerging [1], [2]. The cultural historian Stalder [3] even speaks of a culture of digitality. According to him, digitalization does not replace analog but rather reshapes it. One characteristic is the so-called ‘algorithmicity’: due to the digital participation of humans (e.g., social media), new cultural processes are emerging through machine-generated algorithms [3]. Thus, digital technologies, as an integral part of modern society, also influence the subjective living environment of older adults. Nevertheless, in technology development and research, the actual embedding of technology in the everyday lives of older adults is only partially considered, and images of old age and aging are insufficiently reflected in this context [4], [5], [6]. On the other hand, prevailing individual and societal stereotypes of older adults or aging affect health care structures. This is problematic given the increasing digitalization of health-related information, data, applications, and structures regarding participation processes and equal opportunities. Thus, treatment pathways are not customized to the individual’s needs and circumstances, and programs and technologies are not sufficiently classified or integrated to promote health [7]. Accordingly, there is still a lack of knowledge about how older adults in rural areas shape their support arrangements for using technology, including what they experience as helpful or obstructive.

We conducted this interview study in the context of the project “Dorfgemeinschaft 2.0” (further information see Funding) as a part of the development of a nurse-led educational management program focusing on promoting e-Health literacy among older adults (65 years and older). In this educational program, one approach is to provide older adults the opportunity to consult a technologically literate nurse who advises them on health and care-related issues and supports them using ICTs and e-Health applications [8], [9], [10]. In the project region, for the most part a sparsely populated area in Lower Saxony, located directly at the German-Dutch border, the (residential) living environments [11] and the intergenerational contact are subject to change. For example, a previous survey showed that respondents perceive their neighborhood as a functioning network of concerns in the region to be partly non-existent [8]. The projects’ approach is to solve it by enabling access to (newly) developed digital environments.

Accordingly, this article examines technology use among older adults (65 years and older) and highlights its impact on well-being and social inclusion. The focus lies on healthcare, specifically self-management, and use of e-Health applications as well as online partnership with their healthcare providers. We used a qualitative research approach to answer the following research questions in the context of a bio-psycho-social perspective on aging:

• How do older adults (65 years and older) in the project region experience technology in their everyday lives?
• What preconceived notions do they have towards technical devices (in the context of health)?
• What ideas of technology influence their behavior?
• What appropriation strategies result from their technology use?

This study is embedded in a multilevel exploratory research design. The episodic interviews were conducted based on Flick [12]. Data collection took place between October 2019 and December 2019. We recruited participants at project events, such as information sessions, and contacted a local mobile care service, which served as a gatekeeper. We intended this approach to ensure that we didn’t overlook persons who needed care and whose mobility might be restricted. Through purposive sampling [13], the sample included individuals living in the project region of various ages (65 years and older) and genders. Interviews took place at the participants' homes or the university campus, depending on their preferences.

We created an interview guideline based on the research questions (see Table 1 [Tab. 1]). Also, we did a pretest with two participants to determine whether the respondents would understand the questions and to ascertain the validity of these questions. No chances had to be made. Interviews followed topical trajectories, however, we allowed the conversation to pivot away slightly from the main questions to gain deeper insights into the participants’ views. Additionally, to generate technology-associated experiences, we used conversation stimuli as an entry point, e.g., a mechanical coffee grinder brought along and/or a technology story read out loud (storytelling). The tech-stories are short narrative passages related to technology perceptions from citizen workshops (associated with the multilevel research design) conducted in 2017/2018 [8].

The interviews lasted from 40 min. up to 1.5 hours and were digitally recorded, transcribed word for word [14], and anonymized. Furthermore, we prepared postscripts to capture the conversations before and after the recording [15]. We analyzed the data thematically at an individual case level. An open, then selective coding for each case followed [12]. The first step in this process is to briefly characterize the key themes that relate to the research topic and to present the context of meaning for the individual. Next, we generated a specific category system for the main categories.

In a second step, we compared the case analyses and used the resulting thematic structure to modify the analytical procedure for explicit or implicit experiences and interpretations. Finally, using guiding questions, we compared the conditions, the interactions between the actors, the strategies, and consequences. We evaluated the data in a research group (consisting of nursing scientists and gerontologists) using the software MAXQDA (2020). Figure 1 [Fig. 1] represents the framework of key aspects used in the analysis. In this context, ‘social representation’ is understood as the individual and social engagement with the object of technology [12].

Through numerous analytical steps [12], we assigned individual categories to biographical experiences, current life situations, usage strategies, and consequences. We formed four main categories: subjective understanding of technology, appropriation and usage strategies, experiences with the handling of technology, and e-Health. These categories are illustrated in the following interview passages. We condensed each case into short descriptions [16], which contain different information exemplifying the perception and every day (non-)use of technology. Table 2 [Tab. 2] shows the brief description of the participants. The following interview quotes are referenced by “Mrs./Mr.: line number”.

The interviewees’ subjective understanding of technology reveals different points of origin. Thus, their respective perception of technology can be linked to a particular purpose. Furthermore, specific properties are assigned to technology, e. g. that of a ‘tool’ (Mrs. A: 46,125; Mr. B: 145,153). The interviewees also declare technology as to be something fundamentally ‘modern’ (Mrs. E: 61; Mr. C: 93). For example, some interviewees perceive the mechanical coffee grinder as non-technical.

On the one hand, there is a deeply rooted perception of technology as being something ‘normal’ (Mrs. H: 55,101) and ‘just there’ a ‘part of life’ (55,75; Mrs. I: 53) and that you don’t even think about it anymore’ (101;163). On the other hand, some assigned attributes like ‘coldness’ and ‘normativity’. In one case, technology was even perceived as an antagonist.

‘Technology is structured. (...) But it is cold, it is normative.’ (Mrs. A: 136)

A broad spectrum of technology use is evident in the participants’ everyday lives. When their technological competence is limited, the interviewees resort to various strategies for technical appropriation. These include ‘writing things down’ (Mrs. G: 72; Mrs. F: 9,63) and ‘always asking’ (Mrs. H: 195). Furthermore, access to technology is dependent on personal resources. For example, Mrs. H regularly uses the regional educational program ‘Schoolchildren Explain Technology’, and Mrs. F uses the ‘Beginner’s Course for Older Adults’. Mrs. E turns to her husband for questions and Mrs. G to her grandson.

Sometimes there is also the strategy of deliberately not using technology because of ‘little interest’ (Mrs. E: 87; Mrs. I: 83) or ‘no desire’ (Mrs. E: 105) to use it. But when the individual benefit of a certain technology is recognizable, they will then use it.

‘A good societal achievement. But I don’t have to do everything with it.’ (Mrs. I: 55)

The use of technology increases personal agency and the interviewees perception of safety resulting in visible relieving effects and autonomy gains. In addition, there are the phenomena of ‘fun’ (Mrs. F: 83; Mr. C: 9,119; Mr. D: 69) and ‘stress’ (Mr. J: 82), which the interviewees experience when dealing with technology.

It is also clear that the interviewees assume certain roles and are concerned about others when dealing with technology. For example, Mr. B says of himself: ‘I was always (...) the contact person.’ (9,17).

As there are no shopping opportunities in her village, Mrs. F orders online for those, she knows can’t do it themselves. The use of technology constitutes one’s self-conception through the assumption of roles by which it creates identity-forming spaces and emancipatory experiences.

‘I think it’s fabulous that I can do that. Now I am taking three online workshops for about one hour every day for a week. (...) Without that, I wouldn’t be able to be here on my own. That fulfills me that gives me grounding. I also see for myself: Ok, my thinking is correct. I am not crazy. Like this, I am not an outsider here, lonely. I am alone. I stay that way. (...) Without the internet, I couldn’t do this.’ (Mrs. K: 123)

‘We were poor back then. With three people we bought one of those irons together, my brother-in-law, a neighbor. It cost 30 marks. We didn’t have any money so we each gave ten marks so we could afford such an iron. Well, that was 60 years ago. It broke. I bought a new one a few years ago, which I paid for all by myself.’ (Mrs. F: 85)

The results also show the fundamental openness of the interviewees towards technology, also regarding e-health. The interviewees predominantly accept the use of health-related technologies. For example, the use of a digital blood glucose meter is integrated into the lives of Mr. C and Mr. D, and they perceive it as an everyday occurrence. In the wake of the digitalization of the healthcare system, the interviewees do not yet use digital health data, but appeared to be open in this regard.

‘Whenever technology fits the health context and the person responsible can use it adequately, it’s great. I think this can help immensely under certain circumstances. But you need to teach people how to use it.’ (Mr. D: 157)

In terms of health, technology is predominantly perceived as a positive advance, provided it does not replace interpersonal contact, e.g., in a care setting.

‘It may be beneficial, but it is also impersonal. The human interaction is irreplaceable. (…) when they say a few good words.’ (Mrs. E: 195)

‘In nursing, it is essential that people talk to each other and always stay on the ball (...). That is extremely important. (...) the robot is not terrible when putting the patient to bed, but that’s about it. Okay, it can also hand out coffee (...). With technology, people must be careful that they don’t fall behind.’ (Mr. C: 123)

‘There shouldn’t be too much technology in care because it’s all about humans. And communication with the human being. Due to time restrictions, we already have difficulties going even a little beyond the usual. That means being in touch with the patient or listening to what other problems they have. They may be sad. Maybe because the husband has been dead for so long. (…). Today you have almost no time and must be careful that the use of technology doesn’t get out of hand. Technology is simply inhuman. Technology is not human. It’s not evil. I don’t mean that. But it’s not warm.’ (Mrs. A: 134)

How we experience and construct technology influences our social life. Flick refers to it as a social representation of technological change in everyday life [12]. The results show that there are older adults who are fluent in their use of technology, while others are not engaged with the digital world at all. However, not all older adults who are outside of the digital world are the same. There are older adults who explicitly reject the opportunity to participate in the digital world, reasoning that they simply have no interest or use for technology. Accordingly, the dimension ‘subjective experience’ is an expression of the different attitudes toward technology. The short descriptions of the participants show a range of social representations of technology. For example, the computer is experienced as an ‘elixir of life’ (Mr. B) and the Internet as ‘my world’ (Mrs. K). This experience goes beyond a mere expansion of the scope of action. Rather, technology control [17] can be constitutive for one’s own self-conception. For example, Mr. J describes that he wouldn’t ‘feel comfortable’ without technology. Other interviewees take on specific roles when dealing with technology, such as ‘contact person’. It becomes evident that the individual usage of technology can be a fundamental need of older adults. For the approach and access to (health) technologies, it is, therefore, significant to consider the personal life conditions and personal benefit. In addition, the diversity of perceptions, attitudes, and use of technology also demonstrates the need to use biographical research and learning approaches to prevent age-related stereotypes in technology development. To make the relational conditions between biographical narratives and (digital) artifacts visible, educational researcher Bettinger also advocates a research strategy based on media-sensitive biographical research, which is based on newly forming or dissolving ‘relations between people and things’ [18]. Consequently, impulses from biographical research [19] can be of interest for techno-sociological approaches.

In a comparable interview study, Wangler and Jansky outline the beneficial potentials in the context of the appropriation and use of new media among older adults: Hobby extension, support network, compensatory tools, opportunity to connect and escape from everyday life [20]. These phenomena are also reflected in the results of the technology stories presented. These categories can be extended by the potential’s emancipatory experiences and identity-forming spaces (e.g., ‘English humor is just more interesting. I only read e-books because of that. I have them all in English.’ Mrs. F: 33). Furthermore, we add the potential gains in autonomy. The use of technology thus promotes, at least in some places, far-reaching processes of participation that lead to a greater sense of well-being on the part of the interviewees (e.g., ‘It fulfills me, it gives me ground.’ Mrs. K: 221).

Social construction processes and the perception of technology influence learning paths and are thus requirements for successful learning. The literature shows that especially smaller (qualitative) studies and projects must be advanced to develop effective (everyday) technologies tailored to the needs of older adults [21]. For the development of new support services and structures empowering older adults in appropriating new technologies, it is necessary to consider the inclusion of their biography, and social environment, in addition to the existing regional IT infrastructure [22]. As a result, the presented technology stories lead to a better understanding of the different mechanisms underlying technology use in a regional context.

An earlier survey in the project region already showed that citizens have a pragmatic approach to everyday technology, perceive it as supportive, and want to use technology to the extent of their individual needs [8]. For example, the use of a smartphone was only considered sensible after the function of a navigation app was discovered, which meant more safety in everyday life for that person.

The interviewees are confronted with technology in different ways. Within the acquisition of technology, the learning prerequisites, and learning dispositions are also highly individual (e.g. ‘I think it’s great to learn digitally at the age of 87. So, I can participate in life.’ (Mrs. G: 83) vs. ‘I don’t care to learn anything else.’ (Mrs. H: 181)). The results further show that as soon as the individual benefit of technology is recognized, it will be used, or at least the willingness to come to grips with its handling increases.

Some of the interviewees experienced learning situations as cognitively demanding and, in some cases, stressful. All interviewees who described themselves in this way have developed individual strategies for use and appropriation. The most frequently mentioned strategy was to ‘always ask’. Usually the ‘contact person’ then was a specific person with whom there was a basis of trust. Whenever the interviewees had access to specific educational offers for older adults, they would tend to make the use of them. Concentrating on a few specific functions and ignoring other possible uses, for the time being, makes it easier for the interviewees to use technology [20].

Influenced by negative experiences or merely a negative image of technology, some interviewees proactively avoid technology. Thus, we interpret the deliberate (non-)use of technology as a strategy to preventively counteract ‘stress’ and negatively perceived notions of technology.

The interviewees resort to different strategies of technology appropriation. In particular, the openness and interest of the respondents should be used to explain the individual benefits. Hänninen et al. [23] describe a continuum of older adults’ digital technology use, ranging from active, independent to limited. It becomes apparent that non-technical incentives are significant to the individual use of digital technology. These are: attitudes/perceptions, life transitions, and personal health status [23]. Thus, digital literacy includes a constellation of life skills necessary for full participation in our information-rich and media-saturated society [24]. Digital literacy among older adults is thus closely related to physical and mental well-being [25]. For example, older adults can profit from ICTs through tracking health parameters [21], [26], [27]. Lee & Kim find that socially isolated older adults who are experiencing health problems particularly benefit from using internet technology (to complete tasks, or manage their health, when, for example, health and service providers are lacking) [28]. The interviewees use health-related technologies (e.g. digital blood glucose meters) and express openness towards using digital health data. However, one fear mentioned several times is that technology could eventually minimize or even replace care, touch, or social exchange. This fear underlines the assumption of Heitmann-Möller & Remmers that the contingency of human existence and the associated vulnerability in (care) relationships cannot be made obsolete by technology [29].

In the context of e-Health, health literacy plays a critical role alongside health-related technology use. However, in healthcare, education, policy, and research in Europe, the concept of health literacy is not comprehensively integrated [30], [31]. In addition, the e-Health literature shows that age is generally associated with low e-Health literacy. Older adults are lagging younger adults in the use of e-Health resources with health limitations being but one aspect that prevents them from using technology in everyday life [23]. Currently, the integration of educational strategies, particularly for older adults, has not been established. Nevertheless, there is a steadily growing number of older adults accustomed to technology.

In their socio-spatial-tech positioning, Oswald and Wahl [32] attribute great importance to (new) technologies for participation processes regarding the subjective well-being of older adults. Accordingly, technology use represents a participation aspect and can enable new (digital) exchange processes. As a current research task, both the subjective experience and the increasingly overlapping spatial boundaries (analog and digital worlds) are thus gaining relevance in terms of an expanded concept of living [32].

We recommend considering the points given in Table 3 [Tab. 3] in terms of barriers and solutions to the implementation of e-Health practices.

In this qualitative interview study, we used the interviewees’ statements to create short descriptions that illustrate how older adults in rural areas shape their support arrangements regarding technology. We outline what they experience as helpful or obstructive. This study meets the demand for qualitative studies, which include life circumstances in the research field of older adults and their experience of technology. The presented technology stories serve as a basis for the development of specifically tailored educational offers that take biographical aspects and individual perceptions of technology into account and to be able to reduce inhibitions in a targeted manner. The results show that it is necessary to take a closer look at the accompanying potentials for the support of technology use in the context of age and aging. The generalizability of this study is limited due to the small sample size and the open-ended, flexible interview guide. Another significant limitation of this study is the lack of a clear definition of technology to compare interviewees’ experiences. For future qualitative studies, an assessment of what older adults rate as learning gains or whether a specific intervention increased their use of, for example, computers and the Internet over time would be desirable. Therefore, further longitudinal studies/longitudinal research is needed to allow follow-up of detailed technology adoption strategies.

Technological development is fast-moving and rarely geared to the needs of older adults. There is a lack of research regarding the lifeworld and everyday significance of technology for older adults. In this context, qualitative study designs often take a back seat. However, these aspects are of immense importance to counteract stereotype images of age and address the needs of older adults in an increasingly digital and complex health care system. Empirical technology stories reveal highly individual potentials, which are especially significant for the acquisition of digital sovereignty and indispensable for the development of tailor-made educational offers. Consequently, future research and its methodological designs will also need to take up suggestions from biographical research methods to map older adults’ actual (autonomous) technology use.

AH identified the research question, developed the study design, prepared the documentation for ethics approval, conducted interviews, analyzed the related data, and wrote the manuscript. SS assisted to analyze the data. AH handled the revisions and re-submission. All authors critically reviewed the manuscript and approved the final version submitted for publication.

Ethical approval was obtained from Osnabrück University of Applied Sciences Research Ethics Committee (HSOS/2019/2/4), and informed written consent was obtained from all participants.

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This paper is published as part of a project (Grant Number: 16SV7453) funded by the German Federal Ministry of Education and Research. The project’s (duration 11/2015–04/2021) aim was to identify, develop and test human-technology best practice solutions that enable older adults to live independently in their familiar homes for as long as possible. Further information at: https://www.dorfgemeinschaft20.de/

The authors declare that they have no competing interests.