Ethics and acceptance of smart homes for older adults

Figures & data

Figure 1. Conceptual design of characteristics of health related QoL.

Figure 2. Functionalities of a smart home.

Table 1. Criteria for work to be included in this review

Inclusion Criteria	Exclusion Criteria
Focused on older adults where certain studies also included younger age groups.	Studies conducted using robots as assistive technology.
Technologies related to smart homes	Smart homes not consisting of participants of advanced age.
Assistive technologies for self- management, easily integrable in daily life to promote independence.	Assistive technologies involved in hospitals or rehabilitation centers
Older adults living independently.	Research focusing on other aspects such as robots, sound, speech detection and security aspects of smart homes.
Studies were published in English	Articles that did not fit the inclusion criteria.
Studies about perception of smart home technology focusing on acceptance or adoption by older adults.

Table 2. Commercial products categorized

Categories	Description
Smart Objects^2	Objects connected via smart phones or laptops such as smart pillbox, door or smart locks. Also, for auto detecting presence such as for turning on lights.
Monitoring via Cameras^3	Home security for older adults and activity monitoring.
Smart HVAC^4	Smart heating, ventilation, and air conditioning for temperature control. Saving energy as well as providing control via smartphone.
Personal Emergency Response Systems^5	Personal health monitoring system which can be used to call help in case of an emergency such as wearable push button necklace, watch, belts.
Smart Watch,^6,^7^8	Monitoring multiple measurements such as movement, falls, heart rate and SpO2.
Smart Phone Applications,^9,^10^11	Reminders, step counts, data sharing with family members.
Sensors^12	Monitoring activities and monitoring environment such as humidity sen sor, smoke alarm etc. Monitoring activities such as placed on the fridge, shower, pillbox, or any object to monitor that activity.

Table 3. Current (smart home) assistive technology products and services

Commercial Products	Description	Country	Cost Model
Lively^13	Lively provides activity sensors which can be placed on common objects within a home for example pillbox, doors, fridge, keychain etc. It also provides a watch that includes a push but- ton for calling help in case of fall emergency. The watch can give reminders for medication, counts steps and shares this with family members.	US	Various upfront and subscription packages.
HomeCare^14	Develco provides home monitoring sensors un- der the HomeCare umbrella, e.g., Gateway, Window sensor, Smart Plug, Light bulb, Flood alarm, Smoke alarm, Humidity sensor, Motion sensor for fall detection and preventing fire or any emergency. This is built for developers to design the solution.	Denmark	Individually priced sensors.
Geeni^15	Geeni provides home monitoring sensors e.g., smart plug and switches, sensor alarms, smart humidifiers and various sensors.	US	Individually priced sensors.
Just checking^16	Just checking is a home monitoring system to monitor movement of older adults by sensors attached to walls and various objects in the house. It is also for door monitoring and activity monitoring.	UK	Deposit with subscription packages.
CanaryCare^17	Monitors movements, bathroom visits, tracks sleep, temperature and reminds medication.	UK	Various upfront and subscription packages
MariCare^18	Smart floor and activity sensing for monitoring activities and falls.	Finland (with deployments in other countries)	Individually priced sensors
Smart Life in Fife^19	Smart Life in Fife is a visual tool to aid people to manage their aging progress with expert advice.	UK	Free

Table 4. Key findings from assistive technology studies

Author	Sample	Technology	Key Findings
Demiris et al. (2006)^Citation65,Citation75	Focus Groups: 3 Male: 5 Female: 9 Total: 14 aged 65 and above Session Duration: 1 hour	Tiger place (Intelligent Ambient Living/Smart Home) which provides activity recognition data	Concerns related to privacy of data, social isolation, and lack of control over the technology were raised by participants, but they confirmed that the system was an independent unobtrusive way of living.
Demiris et al. (2006)^Citation65	Focus Group: 1 Gerontology Nurses: 4 Social Worker: 1	Tiger place (Intelligent Ambient Living/Smart Home) which provides activity recognition data	Visualization of large activity recognition data sets such as summaries and overall trends were thought to be more useful. Suggestions for designing the application to have consistent interfaces, allow communication with health care providers and interoperability with other applications for record keeping.
Rahimpour et al. (2008)^Citation76	Focus Groups: 10 Interviews with patients (congestive heart failure and/or chronic obstructive pulmonary disease) Location: Sydney Background: 7 different ethnic groups	Video and prototype demonstration of the a Home Telecare Management System (HTMS) by MedCare Systems Pty. Ltd. (Sydney, NSW, Australia)	The participants agreed that the technology could benefit their health, but concerns were raised regarding cost, usability, clinical support, inability to self-operate and anxiety issues relating to operating the system.
Coughlin et al. (2007)^Citation64	Focus Groups: 30 leaders in aging advocacy and aging services from 10 north-eastern states. Location: United States and Washington, DC	Commercially available and still under development technologies ranging from telemedicine systems, smart scales, health kiosk systems, personal advice systems to guide diet, home monitoring	Concerns regarding usability, privacy, reliability, and cost were identified, although participants acknowledged benefits of the technologies.
Courtney (2008) ^Citation77 Courtney et al. (2008)^Citation25	Focus Groups: 4 with 11 participants and 3 additional interviews Adults aged 65 and above Location: Mid-western U.S. residential care facilities	Smart Home technologies containing various sensor technologies such as bed sensor, kitchen sensor, motion sensor and fall detection sensor	The study found that privacy was the major concern which caused low adoption. But the need for these technologies could potentially override their privacy concern.
Dhukaram et al. (2011)^Citation21	Focus Groups: 5 Participants: 34 Location: West Midlands and Cheshire areas in England	BRAVE HEALTH System combining a wearable vital signs measurement system with telemedicine	Participants showed a positive attitude toward the benefits of the technology but were not willing to adopt the system due to current privacy, trust, reliability and security issues
Chernbumroong et al. (2010)^Citation78	Participants: 14 participants aged 26 to over 80 years old Location: Local hospitals, nursing homes and general population	A survey conducted to understand the perception of smart home technologies for assisting older adults	The participants showed positive attitude toward the six smart home technologies under review (cooking hob and oven safety control, sleeping pattern monitoring, emergency alarm, automatic lighting system, video monitoring system and activity monitoring system). However, willingness to adopt these technologies was uncertain among the participants. This could be due to factors such as difficult User Interface design, learning difficulties, privacy concerns, cost and lack of human responders.
Ziefle et al. (2010)^Citation15	Participants = 82 aged between 40 and 92 years. 53% male and 47% female 39/82 participants stated to have a chronic disease.	Questionnaire for smart technologies including smart homes, smart phones and smart clothing.	The study found no interrelation between age, gender or health status and willingness to adopt technology. Therefore, diversity (age groups, gender, health states) do not impact the acceptance of technology. The study also shows that smart homes were most critically evaluated compared to mobile devices or smart clothing. Also, participants gave less importance to the design and esthetic of the technology and more toward its beneficence.
Wilkowska et al. (2011),^Citation79 Wilkowska et al. (2012)^Citation80	Questionnaire Participants: 104 Qualitative data evaluation Focus Groups: 1) n = 7 aged 24– 29 2) n = 6 aged 60– 68 3) n = 6 aged 67– 73 Quantitative data evaluation Focus Groups: 1) n = 25 aged 21– 29 2) n = 15 aged 30– 39 3) n = 21 aged 40– 49 4) n = 16 aged 50– 59 5) n = 16 aged 60– 69 6) n = 11 aged 70+	E-Health technologies e.g., blood pressure meter, blood sugar meter, insulin pump	The participants of all ages in this study perceive data protection and health and safety as highly important. Men tend to perceive greater advantages of health control using medical devices more than women. However, this is marginal difference only. Men also pay less attention to anonymous and intimate ways of using the technology, but other aspects of privacy seem to be similar in all gender groups. The study also shows that healthy people hold more importance for data protection, its storage and transfer for e-health usage than people with poor health. People with poor health tend to be less concerned about the permanent surveillance unlike healthy people.
Demiris et al. (2013)^Citation81	Focus groups: 2 Location: Seattle, Washington Participants: 12 older adults with average ages of 79.3 years 8 female and 4 males	Telehealth kiosk for assessing vitals such as blood pressure, weight, pulse oximetry and blood glucose	Participants perceived telehealth wellness kiosk as useful but many users said that staff assistance for using the system would be essential. Participants also liked the community aspect of the system and did not have privacy concerns using it. It was also discussed in the findings that peripheral devices need to be selected and designed with the user in mind. Ergonomics such as a mouse can be replaced by touch enabled devices and audio requirements can include headphones with adjustable volumes.
Reeder et al. (2013)^Citation82	Participants: 8 healthy adults aging 79 to 86 Location: Seattle, WA	A theory based monitoring study comprising of motion sensors, gateway (a hub or device which connects sensors to a server for data transmission) and data visualization.	Participants found the system to be unobtrusive, useful, with little to no privacy concerns and were interested in viewing their activity data. However, participants did not consider adopting the system as they considered themselves to be in good health.
Guo et al. (2016)^Citation74	Participants: 650 293 participants aged between 18 and 26 198 participants aged between 27 and 49 159 participants aged 50 and above Location: China	A survey of 650 participants with different age groups in China was conducted. This survey was conducted to study trust, privacy concerns and adoption intention for Mobile Health Services.	The study found that privacy concerns are associated with trust and intention of adopting the technology. While personalization is proportional to consumer trust and willingness to adopt. It also found that privacy is unlikely to be a problem for older adults which could be due to the lack of awareness about technology compared to young people.
Joe et al. (2016) ^Citation83	Participants: 14 older adults aging 62 Focus Groups: 3 6 male and 8 females participants	Focus groups with participants were conducted about a wellness tool where they expressed various features which were desirable and undesirable to them.	Participants had a positive attitude toward the wellness tool but expressed privacy concerns and preferred to use a portable device which would be reliable and easy to use.
Hoque, R. et al. (2017)^Citation84	Participants: 300 participants aged 60 years or above	The study conducted a face-to-face structured questionnaire survey to determine factors impacting intention to adopt and use mHealth service technologies among older adults.	The findings show that social influence, performance expectation, anxiety related to using technology, and resistance to change had a significant impact on the intention of the older adult to use and adopt mHealth services.
Chung et al. (2017)^Citation85	Participants: 6 Korean American older adults Location: Seattle, WA	Motion sensors placed in home environment for monitoring daily activities	Participants generally found the system to be useful but expressed that it would only be beneficial to them in later life or due to health decline. They also raised concerns regarding privacy and obtrusiveness.
Chung et al. (2017)^Citation86	Participants: 11 Korean American older adults 10 Korean American older adults	Focus group and interviews conducted with older adults to understand perception of a home monitoring system for health. The home monitoring system includes features such as monitoring activity using motion sensors, temperature and door contact sensors, sleep monitoring, detecting falls etc.	Study found that many participants initially were not aware of sensor technologies but showed a positive attitude once it was explained to them. They expressed privacy concerns and were not comfortable using image capturing technology. Cost was also found as a barrier to adopting technology. But the need to live alone due to immigration or being away from family motivated the participants to be more accepting of the home monitoring technology.
Etemad-Sajadi, R. et al. (2019) ^Citation87	Participants: 605 older adults who use health technologies.	The research focuses on older people’s acceptance of healthcare technologies within their home.	The findings show that the usefulness of the healthcare technologies impacts older adult intentions positively and hence they agree to use them. Along with that, the social presence from using health care technology positively influences one’s decision to use it.
Reeder et al. (2020)^Citation88	Participants: 10 female participants aged 60 or above.	The research studies perceptions of smart home and wearable technologies among older women. Technologies included fitness trackers, accelerator sensors, residential sensors such as bed sensors, activity sensors and video sensors.	Participants perceived sensors as acceptable for data collection of personal activities. Participants generally perceived wearable sensors more useful than smart home sensors as they mostly had activities outside their homes. While home sensors were considered most useful for those who spent their time mostly at home. Privacy concerns related to break-ins or unwanted disclosure of activity levels and overall had few concerns about data sharing.
Ashraf et al. (2020)^Citation89	Participants: Participants aged 55 year and above Location: Pakistan	Interviews covered perception of smart home technology among the Pakistani aged community.	About 91.5 percentage of the participants perceived smart technology as useful and convenient. However, it was found that excessive pressure from relatives and friends can easily hinder older adults from adopting technology. Issues with accuracy of technology can also negatively affect their adoption.
Shirani, F. et al. (2020)^Citation90	Participants: 24 residents aged between 20 to 70 years old Participants were interviewed once a year over a successive three year period Location: Caerau, South Wales Valleys	Interviews covered perception and experience of smart technology of low income house holders amongst vulnerable consumers.	Participants considered smart technology for vulnerable energy consumers to be beneficial for example remote controlled energy assistance for those with mobility impairments. Participants either showed interest in the new technology or found it wasteful. Participants under 40s considered it as ’cool’ technology and perceived benefits of increased control while many of the older participants were less interested in it. This could be due to participants finding smart technology to be complex and unusable.
Pal, D. et al. (2020)^Citation44	Participants: 315 and 1945 participants in two phases Age range varied from 20s to 50s and above. Location: Thailand	Two surveys were conducted to study the adoption intention of the voice based smart home system.	Findings state that the senior people with high income and smart home appliances were most likely to use voice based smart home systems within an year. Participants with low intention of adoption perceived the technology to be less useful.
Marikyan, D. et al. (2020)^Citation54	Participants: 387 smart home technology users Age range varied from 18 to 65 and above.	A survey conducted to gather input about negative emotions and difficulties faced, from 387 smart technology users (for example smart security system, smart kitchen, visual assistant and many other technologies)	The findings state that people who experience negative emotions caused by a technology performance might cope by giving up the use of smart home technology.
Mashal, I. et al. (2020)^Citation39	Participants: 258 household Location: Jordan	This study investigates the reasons that influence people in Jordan regarding acceptance and usage of smart home services.	The findings show that trust, perceived usefulness, ease of use, enjoyment and personalization influence intention to use and technology adoption. Also, cost was found to be an insignificant factor to influence intention to use.
Nikou, S., Agahari et al. (2020)^Citation53	Participants: Interviews (N = 59) and Focus group (N = 12) sessions Electronic survey collected from older adults in Netherlands Follow up interviews (N = 7)	This research develops and tests a theoretical model to explain intention to use health technologies by older adults by considering how the digital health technologies enhance their ability to live independently.	Findings state older adults were positive about independent living and were against living in care settings. Participants mentioned difficulties faced by them to find the correct health care technology and service for them-self to live independently. Older adults base their intentions to use health care technology by assessing the capability of the products and service which enhances independent living.
Robinson, E. L. et al. (2020)^Citation66	Participants: Four Focus Groups of 23 participants aged 60 and above One Focus Groups of 5 participants with family members Five 90 Minutes Focus Groups	Focus groups were conducted to gather input from older adults and family members about adapting and using the home sensor technology	The findings state that family members were more eager to adopt the technology then older adults. Family members also expressed that they would want to have access to their older relatives health information despite them not wanting to obsess about their health. Participants of both groups did prefer using their cell phones to receives messages and health alerts. Older participants expressed concerns about privacy related to video monitoring.
Schlomann, A. et al. (2020) ^Citation91	Participants: 1863 participants aged 80 to 103 years old Location: North Rhine-Westphalia, Germany.	The research studies about the adoption of assistive technologies among older adults in private homes and care facilities and analyses the environment and characteristics in both settings.	Mobile phones were most common among older adults living in private homes who did not receive any care. Assistive technology was found to be less common in private homes than in long term care. Information communication technology users were found to be younger, have higher level of functional health and were more interested in technology while users of assistive technology were older and had poor health comparatively.
Kadylak, T. et al. (2020)^Citation92	Participants: 1148 respondents aged 65 years and above Location: United States, America.	An online survey conducted through Qualtrics to assess willingness to adopt various emerging technologies including smart home technologies.	The findings show that older adults were most willing to use digital home assistants, smart technologies and Internet-connected cameras.
Guhr, N. et al. (2020)^Citation43	Participants: 187 respondents 100 males and 79 females and 8 unknown gender	The study explores and addresses information privacy concerns that affect usage intention of smart homes	The research found that privacy negatively impacts intention of use for smart home technology.
Weck, M. et al. (2020)^Citation93	Participants: Participants aged 55 years and above Location: 3 Finnish cities, Finland	Focus groups interviews were conducted to understand use of digital technology among aging people. The research presents findings on the basis of trust toward technology functionality, institution such as healthcare authorities in Finland and costs related to technology.	Findings suggest that generally, participants trusted digital assistive technology to work well but the healthcare service providers or authorities integrity and competence needs to be taken into account. Cost issues were also raised and that technology should be available for everyone equally.
Zou, P. et al. (2020)^Citation94	Participants: Participants aged 65 and above Chinese Immigrant Community in Canada Two groups-controlled trail with a sample size of 60 participants with high blood pressure Location: Ontario, Canada	A pilot study to design and test smart phone based dietary app for Chinese Canadian seniors to help with a healthy diet and hypertension control.	The research is in progress and aims to test the usability and feasibility of the dietary application to support Chinese Canadian seniors with a healthy diet and hypertension control. The research hypothesizes that this app will help decrease blood pressure and improve quality of life of seniors with elevated blood pressure.
Lin, T. et al. (2020)^Citation95	Participants:35 Participants aged between 58 and 82 years old. Majority of participants were diagnosed with hypercholesterolemia and hypertension Location: Singapore.	Semi structured Interviews were conducted regarding ownership of mobile phones and its usage for healthcare to understand the willingness of adoption. Videos of mHealth applications were also shown to participants.	Participants considered mobile. phones as a personal device and a way to access healthcare via calls and messages. It was identified that older adults face technology anxiety causing resistance toward adoption of mHealth applications. It was suggested that training can help reduce this anxiety and increase adoption of mHealth services and applications.

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