Solutions to master the Demographic Change: Ambient Assisted Living for the Elderly

Table of contents

1 Introduction
1.1 Background
1.2 Central research question and research objectives
1.3 Methodological approach and structure of the study

2 Theoretical framework
2.1 Diffusion of Innovations Theory
2.2 The application of the Diffusion of Innovations Theory

3 Methodology
3.1 Nature of the research
3.2 Steps in the research procedure
3.3 Review of EU policies, projects, and initiatives
3.4 Review of studies on AAL
3.5 Reliability and validity

4 Results
4.1 EU actions towards AAL (results of document analysis)
4.2 Ambient Assisted Living at a glance (results of systematic literature review)
4.3 Main results

5 Discussion
5.1 Discussion of AAL on grounds of the Diffusion of Innovations Theory
5.2 Discussion of methods
5.3 Answer to the research question
5.4 Recommendations and conclusion

List of abbreviations

List of figures, boxes and tables

Figure 1: Population structure by major age groups, EU-27, 1990-2060

Figure 2: Research framework

Box 1: Background and potential of ICT-enabled solutions for the elderly

Table 1: Categorization scheme of AAL domains

Table 2: Categorization of challenges of AAL

Table 3: EU actions towards AAL

Table 4: AAL at a glance

Table 5: Challenges of AAL

1 Introduction

1.1. Background

Today’s modern society is characterized by its vast and rapid changes in most facets of human and environmental life. Through globalization, challenges that where faced by single countries in the past, today concern groups of countries as a whole as for instance the demographic changes that will reinvent our future. On the one hand, improvements in public health such as sanitation and food hygiene, as well as new medical technologies and solutions have altered and expanded the lifespan that humans are expected to live. On the other hand, through the industrial revolution, the trend to urbanization, and improvement in levels of education, the priorities of people have changed throughout the last generations and so have values and norms that shape contemporary societies (Lee & Reher, 2011). Today, people place more value on their careers and life attainment than ever before and delay family planning decisions through means of contraception, resulting in very low fertility rates. Reasons for this decline have been researched tremendously, but a single reason could not be identified. Rather, the decline is the consequence of changes in social life and economic circumstances throughout the past generations (Lutz, 2006).

After the baby boom in the 1960s, fertility rates have been declining for decades (Eurostat, 2012a). Simultaneously, the gaps between European countries concerning fertility rates have been converging and the latest 2009 Eurostat data for the whole European Union (EU) identifies only one single country (Ireland) that still meets the replacement level, which is considered to be 2.1 children per woman (2012). While in 2002 fertility rates of only 1.45 births have been observed in the EU-27, this has slightly improved to an average of 1.59 in 2009, although some countries still face extremely low rates, such as Germany (1.36), Portugal (1.32) or Latvia (1.31) (Eurostat, 2012b). The trend of decreasing fertility rates has been accompanied by a declining mortality, due to investments in health care and improvements in health awareness among people in developed countries (Grundy, Tomassini, & Festy, 2006). According to Eurostat statistics, the proportion of elderly people in Europe is increasing immensely. While the proportion of the European population aged 65 and older was 17.4 in 2010, it is projected to be 20.6 in 2020 and even 23.6 in 2030 (see Figure 1), implying that almost a quarter of European citizens will be 65 and older in 2030 (Eurostat, 2011). Hence, while fewer children are born, death is prolonged and people become older. This scenario of demographic changes in the western world raises questions to which answers are rather unclear, as for instance: Who will care for the elderly and how will this look like?

illustration not visible in this excerpt

Figure 1: Population structure by major age groups, EU-27, 1990-2060. From: Population structure and ageing, by Eurostat, 2011. Adapted with permission.

Although in some European countries family networks still act as care-giving networks for elderly relatives, this constellation is vanishing slowly and is being replaced by more narrow families with children living far away from their parents. This is reflected by a significant decline in multigenerational households over the past 30 years, although regional differences remain (Grundy, et al., 2006). Hence, through weakening family bonds, access to family care for elderly persons declines while at the same time the demand is on the rise. Other options for elderly persons who are in need of care or assistance are available, too, as for instance nursing homes.

However, according to the Eurobarometer 283, the vast majority (78%) of the European elderly population aged 55 and older prefers to be cared for at home, either by a relative or by a professional. Moreover, nursing homes are rated as being not affordable or hardly affordable by the majority (45%) of persons with an elderly parent living in such an institution (European Commission, 2007). Hence, the question arises, how future care for the elderly will look like in times when children drop out of the care-giving chain. The answer to this question may be ambient assisted living (AAL), a branch of information and communication technologies (ICT) aiming at keeping elderly persons as independent as possible in their familiar surroundings in order to postpone hospitalization. AAL can be defined as: ‘aiming to prolong the time people can live in a decent way in their own home by increasing their autonomy and self-confidence, the discharge of activities of daily living, to monitor and care for the elderly or ill person, to enhance the security and to save resources’ (Jara, Zamora, & Skarmeta, 2009). Moreover, AAL solutions have the potential to improve quality of life (physical, mental, social) of elder persons (Belbachir, Drobics, & Marschitz, 2010). Examples of AAL solutions are for instance sensors that detect a person falling, immediately submitting an emergency signal according to the intensity of the fall (Srp & Vajda, 2010), or computerized screen technologies directly giving suggestions for meals according to the individual diet or even ordering food (Ruyter, Zwartkruis-Pelgrim, & Aarts, 2010). Hence, with AAL solutions, people can remain independent for a longer period of time by postponing the need for human interaction (Belbachir, et al., 2010). Another social aspect is that AAL solutions can contribute to social interaction of the users, since they are kept in the familiar surroundings (Belbachir, et al., 2010; Moumtzi, Wills, & Koumpis, 2010; O'Grady, Muldoon, Dragone, Tynan, & O'Hare, 2010).

The EU plays a major role in developing AAL solutions and enhancing research in the area of ICT, as depicted by the 6th framework programme 2002-2006 or the EU’s e-inclusion policy featuring the Digital Agenda 2010, just to name examples (European Commission, 2002; 2007; 2010). However, it remains questionable which challenges AAL – seen as an innovation – faces.

1.2 Central research question and research objectives

The aim of the research in this study is to present the field of AAL with relation to home care. Furthermore, the work of the European Union (EU) in the field of AAL is presented, as the EU is a major key player in enhancing research on AAL solutions that help meeting the demands of the future. Moreover, a categorization scheme of AAL solutions is developed through research evidence. Eventually, knowledge and evidence from the research conducted is used to give recommendations for the future concerning the diffusion of AAL and research directions.

Central research question the research seeks to answer:

- What is the EU-added value of AAL to elderly care and what are the challenges for diffusion of these innovative technologies?

Research objectives:

- A short elaboration about the demographic transition, with facts and figures and projections for the future with a focus on the elderly generation (introductory section)

- Data collection and analysis of relevant EU actions

- Data collection of relevant articles on AAL; discussion of those based on the Diffusion of Innovations theory in order to identify challenges

- Framing of recommendations on how to deal with AAL in order to meet the challenges of the future

1.3 Methodological approach and structure of the study

In order to answer the research question and the objectives, the study first presents the theoretical framework that is used for the research, i.e. the Diffusion of Innovations Theory. Thereafter, a chapter on the methodology follows, which is characterized by a dual nature, as it involves a document analysis and a systematic literature review. Subsequently, the paper presents the results of the research, divided into EU actions and initiatives and ambient assisted living at a glance with categorizations of its types and related challenges. Finally, the last chapter discusses the findings, answers the research question and gives recommendations on how the diffusion of AAL can be enhanced.

2 Theoretical framework

2.1. Diffusion of Innovations Theory

The theory that is used for the analysis is the ‘Diffusion of Innovations theory’ (DoI). Although it has been discussed by French sociologists in the early 20th century already, the American Everett M. Rogers further developed the theory to what it is today. In very general terms, it describes the process by which an innovation, which can be a product, a way of thinking, or the like, comes into the social system, hence into use. In 1962, Rogers published the first edition of this book ‘Diffusion of Innovations’ in which he elaborates on the theory. The most current version of his theory is presented in the fifth edition of ‘Diffusion of Innovation’ (2003). For the development of the theory, he gathered research evidence from over 500 studies dealing with the diffusion and adoption of innovations. According to Robinson (2009), the insights that Rogers’ theory provides are verified by over 6000 field tests and studies and are therefore considered as highly reliable. The central issues of the theory focus on the process of social change and seek to present how an innovation is taken up among members of a specific population. In his book, Rogers concentrates on four main elements with regard to the diffusion of an innovation. These are the innovation itself, communication channels, time, and social system. The next paragraphs review the different dimensions of the theory, based on the works of Clarke, Kaminski, Orr, Robinson, Rogers, and Rogers and Scott (1999; 2011; 2003; 2009; 2003, 1997).

With regard to the innovation, Rogers identified certain characteristics that determine whether an innovation will be successful in its adoption. The ultimate end of a diffusion process is called saturation point, i.e. the moment when the innovation is fully integrated. The first characteristic is relative advantage and describes in which way it is better than current practice. However, there are no specific attributes that constitute ‘relative advantage’. Therefore it is depending on wishes, needs, and perceptions of the users. The greater the perception of this characteristic, the faster is the innovation likely to be adopted. The second characteristic is compatibility concerning the consistency with socio-cultural values, specific needs, and practices. If an innovation is not compatible with norms and values of the target group, its adoption process is considerably slowed down. The third characteristic, complexity, refers to the nature of the innovation and the question whether it is simple to use or not. Simple ideas that are easy to understand have a more rapid adoption process than ideas that are more difficult. In the latter case, users that are to adopt the innovation may have to build up new ways of thinking or skills in order to understand the innovation, which slows down the adoption process, too. Trialability presents the fourth characteristic discussed by Rogers and concerns the possibility whether it is possible to try the innovation or not. Given the case that it is not possible to try out the innovation, high levels of uncertainty may arise. As uncertainty presents a severe obstacle in the adoption process, an innovation should ideally be trialable. The last characteristic identified by Rogers is observability and refers to whether positive results are visible. The more positive results are easily visible to people, the lower is the rate of uncertainty associated with the innovation. Moreover, visibility of positive results also encourages people to talk about it. Another key principle that can be linked to the successfulness of an innovation is the consideration of re-invention, yet it is not specifically included as a characteristic for a successful innovation. Accordingly, an innovation is even more likely to reach the saturation point, if it is possible to alter and amend the innovation during the implementation phase, according to changing needs or as challenges emerge. The notion of re-invention is essential because it refers to continuous improvements of the innovation, which are important for its successful diffusion.

With regard to communication channels, Roger identified two types of channels through which an innovation is communicated, i.e. the mass media and interpersonal channels. Mass media has the advantage that it spreads information rapidly and to many people at once. Hence, the mass media channel is essential for raising awareness about the innovation itself. However, the effect of interpersonal channels is immense, too, as strong attitudes are formed when people communicate with each other (Orr, 2003). Therefore, this channel is essential for the influence on decisions of people whether to adopt or reject the innovation. These two channels ultimately influence the pace and the quality of the adoption process.

The dimension of time in the theory focuses on three ways of time involvement. The first way is the innovation-decision process, which can be looked upon in five steps. These steps encompass: knowledge, referring to knowing what it is about and recognizing the function of the innovation; persuasion, in terms of realizing that it is beneficial; decision, referring to deciding about its introduction; implementation; and confirmation, in terms of whether it yields beneficial results. As already noted, the ultimate end of an innovation is when it reached its saturation point. The second way of time involvement is the degree of innovativeness of people of the social system and refers to the specific types of people that are involved in the adoption process as time passes by. The theory categorizes and characterizes these groups of people. These include: innovators, early adopters, early majority, late majority, and laggards. However, a detailed characterization of each of the groups is not necessarily relevant, yet it has to be stressed that the first two groups are especially necessary. The innovators present a small group of idealistic people, which put great creativity and energy into the development of new ideas and innovations and without those people, there would not be any innovation. Soon after the innovators made the benefits of the idea or innovation visible, early adopters become aware of it and start involving in the process either in a purely private way or in seeking business opportunities. Whereas innovators and early adopters present the smallest segments of a social system, the other three groups present the bigger segments and adopt the idea or innovation one after another. The third way of time involvement refers to the rate of adoption. This rate is influenced by the successfulness of the innovation, characterized through the characteristics presented earlier and presents the pace of diffusion, usually measured in how many people of the social system adopt it in a specific period of time.

The fourth element that Rogers describes in his theory is the social system. Accordingly, a social system is defined as ‘a set of interrelated units that are engaged in joint problem solving to accomplish a common goal’ (Rogers, 2003). Members of a system are not necessarily specified, therefore units of a social system can be comprised of organizations, individuals, or other groups of people that have something in common or share common views.

2.2 The application of the Diffusion of Innovations theory

In the context of this study, the Diffusion of Innovations theory serves as a framework to discuss AAL solutions and technologies in light of care for the elderly (see Figure 2). The five characteristics that have been identified to constitute a successful intervention are the main focus when the theory is applied on AAL. Moreover, the consideration of re-invention is considered a characteristic of a successful innovation, too, and is therefore included in the analysis as a characteristic. Hence, the discussion of AAL will follow the characteristics of observability, relative advantage, compatability, trialability, complexity, and re-invention, which have already been depicted in the previous section. An elaboration on each of these characteristics emphasizes the potential challenges of AAL solutions while also revealing challenges and barriers for diffusion. The analysis only focuses on these characteristics and does not go beyond them or considers other dimensions of the theory, as the scope of this study is not be exceeded.

Figure 2: Research framework

illustration not visible in this excerpt

3 Methodology

3.1. Nature of the research

The research focuses on a review of secondary sources, including a review of EU actions towards AAL and a review of research evidence on AAL published in peer-reviewed journals; hence it is a secondary research (desk research) on already existing publications. The character of the study is both explorative and explanatory as it dives into the topic of AAL solutions for the elderly while also revealing related challenges. The part on EU actions is based on a document analysis, while the part on research evidence on AAL is based on a systematic literature review.

3.2 Steps in the research procedure

In general terms, the secondary research encompasses the following steps.

Step I – gathering information on relevant EU policies, projects, and initiatives

Step II – gathering information on AAL

II.1- Identifying sources of information

II.2- Gathering existing data

II.3- Normalizing data (in terms of identifying aspects that can be compared in a qualitative or even quantitative way)

II.4- Analyzing the data

These steps are based on a workbook on secondary research, provided by Market Street Research (MSR), which is a marketing research company also in the field of healthcare market research (MSR, n.d.).

3.3 Review of EU policies, projects, and initiatives

Sources of information for the EU related aspects are official websites of the EU, such as https://ec.europa.eu. This part only focuses on official EU publications (strategy documents, communications, decisions, etc.) directly obtained via websites of the EU, such as the official website of the European Commission (ec.europa.eu) or the official website of the European Statistical Office (https://epp.eurostat.ec.europa.eu) in order to ensure coherence and scientific validity. This aims to ensure the identification of the pure EU added value. Furthermore, only information and data available in English language is used with a focus on documents issued between 2005 and 2012. Search terms that were used are: ‘ambient assisted living’ and ‘AAL’ with amendments to ‘European Union’ and ‘EU’. As the step of normalizing data does not apply to a document analysis, it is excluded. The presentation of the results focuses on the research question in order to ensure that the scope of the study is not exceeded. Hence, the presentation of the results of EU-related matters aims to determine whether there is an EU-added value of AAL to the field of elderly care, which is discussed in the discussion section.

3.4 Review of studies on AAL

Sources of information for the systematic literature review on AAL are the following online databases:

- Oxford Journals,
- PubMed,
- ScienceDirect (Elsevier),
- SpringerLink and
- Web of Science.

Keywords for the data gathering are: ‘ambient assisted living’, ‘ambient assisted living challenges’, as well as amendments to ‘AAL’ instead of ‘ambient assisted living’. In order to limit the scope of the systematic literature review, certain limitation criteria are applied. The part on AAL solutions and technologies is limited to European publications. Additionally, it only includes publications from 2005 onwards and only those in English language. Moreover, book sections are excluded; therefore the focus lies on journal articles. An article is considered relevant when it not only focuses on technological issues but also discusses AAL solutions from other perspectives, as for instance the user perspective or a public health perspective. In the case of this qualitative research, normalizing data is a process within data analysis and deals with categorizing and coding of data that has been gathered. The analysis of the received documents deals with categorizing the discussed solutions in different domains in a mutually exclusive way and stating the frequencies of its emergence. Furthermore, challenges mentioned in the articles are written down, grouped, and mentioned together with the respective frequencies.

In detail, the analysis of the data gathered involves specific steps based on Pope, Ziebland & Mays (2000). Firstly, all literature needs to be read by the researcher in order to identify common themes and obtain a rough overview. Moreover, literature that came up during the data gathering process which is absolutely not related to the research objectives can already be excluded. Secondly, themes within the literature that are related to the different research objectives need to be identified. This process usually involves coding of text-phrases. For the sake of accuracy, each research objective obtains an overall category. Thereafter, all text phrases, themes, common concepts and the like are ordered in order to obtain information for each category separately. The next step involves looking at the data for each category (i.e. constant comparison) and coding common themes, concepts and the like. Through this process, the frequency of each coded item (how many times it emerged in the literature) can be recorded in order to judge its importance and validity. Usually it is desired that the categories as well as the coded items are mutually exclusive. The analytical writing process focuses on the coded items, their frequency and importance for each category.

[...]