The perspectives of doing, being, belonging, becoming on older homecare recipients’ use and experiences with technologies in the Assisted Living Project in Norway

ABSTRACT

The Assisted Living project (2016-2019) aimed to investigate older adults’ needs for digital technology for daily support and to develop technology solutions in collaboration with the user group. This paper presents data extracted from three sub-studies: Sub-study 1 investigated older homecare recipients’ use of and attitudes towards digital technology, sub-study 2 explored assisted living residents’ needs and requirements for technology, and sub-study 3 explored their experiences with environmental sensor technology to support safety and daily living. The aim was to explore how the occupational science concepts of doing, being, belonging, and becoming can provide a deeper understanding of technology use among participants in the Assisted Living Project. This study demonstrates that for older adults in the Assisted Living project to become technology users required both personal motivation and cognitive capacity for learning to use the device and become familiar with the technology, and access to internet and digital tools. Digitalization in society leads to new challenges for all citizens, especially those who are less familiar with using digital technology. By applying an occupational science perspective to technology use, this paper contributes to creating awareness about digital exclusion and occupational injustice. It provides a deeper understanding of use and non-use and the digital divide, such as the consequences of not having access to digital healthcare services, that may lead to breaches of democratic human rights.

KEYWORDS:

• Occupational science
• digital divide
• home dwelling older adults
• digitalization

The Assisted Living Project (2015-2019) aimed to define older adults’ needs for technology to maintain independence at home and quality of life, to develop technology that could address these needs, and to try out the technology with the user group to evaluate its usefulness, utility, and acceptance (Thorstensen et al., 2020). The background for this project was the demographic changes resulting in higher proportions of older adults in the decades to come, and thus an increased prevalence of dementia. It is expected that the number of people with dementia in Norway will double in 2040 to 193,000 (Gjøra et al., 2020), putting pressure on healthcare services. Therefore, governmental policy encourages a more extensive use of technology to support home-dwelling older adults receiving homecare (Norwegian Department of Health and Care, 2023; Norwegian Health Directorate, 2021). Strong values in Norway are the right to live at home as long as possible or wanted, and that all citizens who need care are entitled to receive it.

The authors collaborated in the Assisted Living Project, and we wanted to revisit our findings using the concepts of doing, being, belonging, and becoming, which are core concepts in occupational science (Whiteford & Hocking, 2012; See Figure 1). We did an abductive analysis to explore whether the theoretical concepts could explain our empirical findings (Tjora, 2021).

Figure 1. The Concepts of Doing, Being, Becoming, and Belonging

Background to the Study

In Norway, as in most other Western countries, digitalization in society is now a reality, leading to new challenges for all citizens, especially those who are less familiar with using digital technologies. In this paper, we elaborate on how occupational science perspectives can broaden understanding of digital technology adoption or non-adoption from the perspective of how older people talk about and reflect on digital technology. The current governmental will to include digital technology in healthcare services implies an intention to improve the quality of the services and reduce costs (Norwegian Health Directorate, 2023). Moreover, it is assumed that access to digital services has potential to maintain the abilities and improve the health and well-being of older adults, and lessen worries for family members (World Health Organization [WHO], 2015). Accessible and usable technology is then required.

Technologies may be described differently in different countries and research fellowships, for example as assistive technologies, everyday technologies, and digital technologies. The World Federation of Occupational Therapists (WFOT) asserts that “assistive technology comprises products (both mainstream and customized), environmental modifications, services, and processes that enable the participation of people with disabilities in desired occupations, across multiple environments and without prejudice” (WFOT, 2019b). Everyday technologies include mobile phones, microwave ovens, computers, and DVD players, which are increasingly used in homes and communities (Nygård et al., 2015), while digital technology includes internet, computers, lap-tops, and smartphones (Fischl et al., 2017). The urge for digitalization of homecare services places new demands on health professionals’ knowledge and competence to address individual requirements.

In this paper we focus on digital technology use by older homecare recipients. People live longer and the risk of chronic diseases increases with chronological age, which implies changes of health, everyday life, and independence (Norwegian Health Directorate, 2022). Due to demographics, more people become recipients of homecare services, especially people in the oldest age groups. Subsequently, since homecare services are increasingly being delivered digitally (Tid for Handling, 2023), people who are digitally illiterate may be at risk of being subject to unintentional injustice and ill-health. In addition, poor health, low income, and loss of social networks are often reinforced in the oldest old and increase the risk of being excluded from a digital society (Norwegian Health Directorate, 2022). Older adults not being able to receive digital healthcare services at home is a serious concern. Such consequences, often referred to as “digital divides” (van Dijk, 2005), may lead to social injustice and breach people’s lawful rights.

The European Commission’s (2022) recent strategy for digitalization to include all citizens emphasizes that “digital technologies should protect people’s rights, support democracy, and ensure that all digital players act responsibly and safely”. Social inclusion is one of the aims that should unite, rather than divide people. A strategy for digital inclusion and competence was launched in Norway 2021, with five objectives; access to internet and digital tools, basic digital skills, user friendly digital services (clear meaning and easy to use), and digital judgement (to possess sufficient digital skills to use digital tools and services in a responsible way and ability for reflection and critical thinking) (Ministry of Local Government and Modernisation, 2021).

This paper contributes to occupational science by exploring use of digital technology with older adults in the Assisted Living Project in the light of the concepts of doing, being, becoming, and belonging. Since many older adults seem to be at risk of digital exclusion and occupational injustice, we sought to create awareness about this.

Occupational Science

Occupational science, a pluralistic epistemological science, anticipates that humans are active beings and that taking part in and creating meaningful occupations has consequences for health, well-being, and quality of life (Whiteford & Hocking, 2012). Occupational science encompasses concern with how people use technology and how they are influenced by technology, regardless of the type of technology (Meyer-Larsen et al., 2022). When using a technological device to engage in an occupation, the device interweaves in the person’s context to create meaning for the person, and to enable social interaction and participation in society. Such a transactional view offers a way to see how humans and situations relate from an occupational perspective (Dickie et al., 2006). However, certain health conditions hinder occupational performance, such that some people are dependent on others to engage in meaningful occupation and participate in society. Technology has the potential to facilitate occupation and participation in society, enabling the inclusion of citizens who otherwise would have been excluded (Meyer-Larsen et al., 2022).

Occupational Justice

Occupational science sees social inclusion, human rights, and democracy as core values. Social inclusion concerns “people and populations having opportunities to participate in society and to enact their rights of citizenship in everyday life” (Whiteford & Pereira, 2012, p. 188); in other words, that all humans are entitled to just possibilities and to be part of society (Whiteford & Townsend, 2011). Access to technologies may have the potential to enable older adults, regardless of illness or living in a remote location, to participate in society and achieve democratic and human rights. The term occupational justice implies that all humans have a right to take part in occupations that are considered to be wanted, preferred, and necessary occupations of members of that society (Christiansen & Townsend, 2014; Whiteford & Hocking, 2012). If some classes of people are deprived of this, we can talk about occupational injustice (Whiteford & Townsend, 2011).

Aim of the Study

In this paper we consider findings from three sub-studies in the Assistive Living Project with the dual aim of exploring how the concepts of doing, being, becoming, and belonging can account for these findings, and to increase our knowledge of digital technology use in older adults receiving homecare services, as seen from an occupational science perspective. Our research question is: How can the occupational science concepts of doing, being, belonging, and becoming provide a deeper understanding of technology use among participants in the Assisted Living Project?

Method

Data collection

The data were derived from three sub-studies in the Assisted Living Project (2015-2019) (Thorstensen, 2020). The first author of each of the sub-studies extracted data from the findings that related to the concepts of doing, being, belonging, and becoming.

Data extraction from the three sub-studies

Sub-study 1: Perspectives on digital assistive technology among older Norwegian adults receiving community health services

Citation: Halvorsrud et al. (2021)

Aim: To explore perspectives on digital technology among home-dwelling older adults with or without cognitive impairment who receive community health services. The following research questions were explored:

• How do home-dwelling older adults express their perspectives on using digital assistive technology as part of their everyday lives?

• What types of technology do they talk about/use?

• Do they express any concerns regarding the use of digital technology?

Methods: Findings from a cross-sectional study were combined with a questionnaire package (n = 83) and qualitative individual interviews (n = 7).

Participants: Older home-dwelling adults, mean age 85 (63–97) years.

Findings: The participants already used digital technologies like TV remote controls, social alarms, mobile phones, stove timers, electronic medicine dispensers, PCs, and tablet computers (See Table 1). They were both optimistic and sceptical of technologies, and expressed different perspectives on usability, privacy, and fear of losing face-to-face care (See Table 2). This study revealed that older adults’ perspectives on technologies are multifaceted and complex and can partly be explained by the interaction between person, technology, environment, and context.

Table 1. Overview of Technology Used by Participants in Sub-Study 1 (n = 83)

Types of technology (n = 83)	%
TV remote control	95
Cell phone	75
Social alarm	81
Stove timer	41
PC / computer	24
Tablet	39
Digital calendar	4
Digital medicine dispenser	5

Table 2. The Survey Participants’ Perspectives on Own Technology Use

Questions	Agree %	Neither/Nor	Disagree
1. I am accustomed to using computers, mobile phone, and other technical equipment (n = 82)	49	10	41
2. I like to learn to use new technology (n = 83)	39	11	50
3. Technology is helpful in everyday life (n = 82)	77	13	10
4. I am too old to use technology (n = 82)	60	10	30
5. Technology is useful for others, but not for me (n = 82)	55	10	35
6. When I am using technology, I am worried about others receiving information about me (n = 82)	17	13	70
7. Technology may lead to less personal assistance (n = 82)	18	27	55

Occupational science perspective: The findings from this sub-study can be related to the International Council of Nurses (ICN) statement that the unique function of nurses is to assist individuals “in the performance of those activities contributing to health or recovery or to dignified death that they would perform unaided if they had the necessary strength, will, or knowledge to do this” (ICN, 2022). This includes enabling people, sick or well, to engage in occupations of importance to them to experience good quality of life. This can be seen as a right to support and care, and the right to take occupational choices in line with occupational justice (Galvaan, 2012).

Sub-study 2: Involving assisted living residents in technology research and development discussions through dialogue cafés

Citation: Lund et al. (2021)

Aim: To involve residents of assisted living facilities in technology discussions, with the following research question:

• In what ways are dialogue cafés useful for directing research and development and for engaging residents in assisted living facilities in discussions about their technology-related experiences, needs, and preferences?

Method: Six dialogue cafés were carried out over a period of 3 years (2016–19) with assisted living residents. Reports written by the group leaders after each café were analysed. An overview of the six dialogue cafés is presented in Table 3.

Participants: Assisted living residents aged between 65 and 92 years.

Table 3. Overview of the Topics Discussed in Dialogue Cafés, Sub-Study 2

Dialogue café	Topic	Number of participants
1	Explore the participants’ needs	13
2	Dissemination of the potential of future solutions via examples on how automation and smart-home technology can be useful in daily life Examples of technologies were discussed to get feedback on the usefulness and acceptability of the solutions	13
3	The participants tested and discussed prototypes of low-tech existing solutions to support everyday living	14
4	To get feedback from the participants on the usability and applicability of a fall detection module and service based on Microsoft Kinect Invitation to try out sensor technology in their own flat	11
5	Recruitment of participants for a field trial to provide data for Machine Learning studies	12
6	Closing the project	12

Findings: Dialogue cafés enabled older assisted living residents to contribute with opinions about their needs, preferences, and perspectives on technologies in general. This negates the view of older adults as too frail or illiterate to participate and demonstrates the importance of including and collaborating with older adults in technology research. The participants found the dialogue café groups interesting and engaging. The dialogue cafés also succeeded in directing the research and technology development in the project. This indicates that dialogue cafés may facilitate adoption of technology, particularly because this discussion format offered information and learning.

Occupational science perspective: The findings can be related to the WFOT (2019a) position statement on occupational therapy and human rights which asserts that occupational therapists are obliged to promote occupational rights as the actualization of human rights. This includes the right to have a voice in all matters that are of concern to the person or group. For example, if technologies are to be installed in an assisted living facility, the residents are entitled to have information, demonstration of the technology, and training for using it. These actions are to avoid alienation and unforeseen disadvantages for the residents, which is in line with the term “environmental justice”, meaning that a change in the environment may contribute or not to a potential benefit (i.e., internet access, accessibility to digital technology and basic digital skills, user-friendliness) (Ministry of Local Government and Modernisation, 2021).

Sub-study 3: User engagement in a technology research and development project

Citation: Holthe, Halvorsrud, & Lund (2020)

Aim: To involve assistive living residents to try out sensor technology in their apartments.

• How may assistive living older adults experience trying out environmental sensors in their apartments?

Method: Residents taking part in the dialogue cafés were invited to try out sensor technology at home. The technology solutions were developed together with the residents, through a series of dialogue cafés. The result was a home-monitoring-safety-system, consisting of environmental sensors to detect if the coffee-machine or stove was on or off, detect open or closed windows and doors (e.g., on the refrigerator), and to detect movements that activated lights on and off. The residents were invited to try out the sensor system for 12 months in their apartment, with 3-month measure-points.

Participants: Eight older residents aged between 82 and 91 years. See Table 4 for participant demographics.

Table 4. Overview of Participants in Sub-Study 3 and Self-Reported Health Measures

Participant	Age (years)	RAND-12	MCFSI	HADS Anxiety	HADS Depression
A	85	3	3.5	0	6
B	84	2	4.5	2	3
C	92	2	4	1	0
D	82	4	2	1	0
E	86	3	1	0	0
F	88	5	3.5	3	0
G	81	3	3.5	1	6
H	88	4	6	3	0

Notes: RAND-12 The 12-Item Short Form Health Survey (SF-12) (RAND cooperation 2019): 1 = excellent, 2 = very good, 3 = good, 4 = fairly good, 5 = poor. (Use of the SF-12 is governed by Quality Metric).

MCFSI – The Mail-In Cognitive Function Screening Instrument (Walsh et al 2006): 1 = yes, 0,5 = maybe, 0 = no. According to a Norwegian validation study, the limit for recommending an assessment of cognitive functioning was 5 for self-scored responses and 7 for scores given by next-of-kin.

HADS – Hospital Anxiety and Depression Scale (Zigmond & Snaith 1983): Number of scores between 0 and 7 = normal (no anxiety/depression), 8-10 = borderline cases, 11-21 = abnormal cases.

Findings: The eight participants wanted strongly to be perceived as autonomous citizens, deciding what is best for themselves and overseeing their own life. They wanted to learn about technological possibilities, in case they became frailer in the future, and to be assured they would get help and support when needed. Moreover, they participated in the project to help others in the same situation, rather than gaining personal benefits. Regarding the technology, it turned out that the sensors did not function as intended. Immediately after the installation, some fell off the wall, or their batteries were flat, or more seriously, signals were not transferred as intended due to gateway errors.

Occupational science perspective: Being a citizen with rights and duties does not have age restrictions. It may be problematic when the term ‘older adults’ is conflated with frailty. More people above 65 years of age are still at work, compared to the number of residents in nursing homes and care homes. Thus, using the term ‘older adults’ as synonymous with being frail may reinforce the stereotype that all older adults are frail and dependent upon others (Centre for Seniors’ Policy, 2022). The risk for discriminating against citizens due to age, referred to as ageism, may lead to exclusion of citizenship and occupational injustice (Laliberte Rudman, 2007, 2012). Technologies are seen as one way of supporting safe living at home, however, when technology fails or is not reliable, it might cause false security and put people at risk of not getting help in a timely manner.

Analysis

We did an abductive analysis, revisiting the findings from three sub-studies in the Assisted Living Project (2016-2020) to explore if the concepts of doing, being, belonging, and becoming were relevant and sensible and could provide a deeper understanding of the findings (Tjora, 2021). One of the advantages of such analyses is the distance from the interviewees and the opportunity to have a second review of the findings (Szabo & Strang, 1997). We constructed new tables to present an overview of the findings from the sub-studies to explore and compare how the four domains in occupational science demonstrate the use of and experiences with digital technology of older care recipients and adults in assistive living facilities.

Table 5. Comparison of Design and Concepts over the Three Sub-Studies

Case	Design of case	Doing	Being	Becoming	Belonging
1	Questionnaire on attitudes towards digital technology and personal experiences	The participants used by average eight types of technologies, both everyday technology and technology to support functional health decline	Most of the participants were neither worried about privacy nor receiving less personal assistance when using technology	Half of the participants wanted to learn more about technology use Almost two thirds considered themselves to be too old to use technology, however, they expected it to be useful to others	Technologies support the participants in everyday life and society. They were divided in their views on how accustomed they were to use technical equipment, which was seen as a requirement for belonging
2	Technology research and development discussions through dialogue cafés	Dialogue cafés enabled older assisted living residents to contribute with opinions about their needs and perspectives on assistive digital technologies. “I enjoyed this café … [we had] very good discussions”	The participants felt useful by contributing to research and discussions on assistive digital technology	The participants did indeed discuss the topics outlined for each café, which informed further research and technology development in the project related to the choice of solutions to develop and test in practice The participants were becoming skilled dialogue partners	Dialogue cafés seemed to demonstrate a two-way learning process for the researchers and the participants. “I felt included”
3	User participation in a complex technology trial with environmental sensors Evaluation of usability and acceptability of sensor technology	Eight residents were motivated to participate in the project to learn about technology for needs that might occur at a later stage, and to help other peers in the same situation, as well as the researchers	They claimed to be autonomous citizens, deciding for themselves, wanting to be visible and competent	They wanted to become skilled regarding technological possibilities, to prepare for perhaps becoming frail or forgetful	They saw themselves as citizens on equal terms with others and it was important to them to keep their position as a member of society

Table 6. Summary of Factors Connected to the Concept of Doing

	Factors that may influence technology use	Factors that may influence technology non-use
Person	Motivation to use technology Skills – digital literacy Information about technology	Age Cognitive impairments Lack of motivation Lack of digital skills Low income /economic reasons
Technical and infra-structure	Access to technology and infrastructure Training to use technology Support from next-of-kin and health professionals	Lack of access to Internet
Healthcare services	Successful needs assessment Follow-up of technology use	Lack of needs assessment Lack of support and follow-up

Table 7. Summary of Factors Connected to the Concept of Being

	Factors that may influence technology use	Factors that may influence technology non-use
Person	Wanting to be a citizen and fulfill societal obligations The personal responsibility for being independent /autonomous	Not being interested in technology Attitudes and prejudices: Technology is not for me, but for younger people. Technology is complicated and difficult to use
Technical and infra-structure	Having access to information, devices, training and support	Lack of access to information, devices, training and support
Healthcare services	Support technology use of healthcare receivers	Lack of routines to assess needs for technology and implementation of technology Ageism

Table 8. Summary of Factors Connected to the Concept of Becoming

	Factors that may influence technology use	Factors that may influence technology non-use
Person	Interested in potential advantages of technology to stay independent	Lack of interest Fear of technology as alien and complicated
Technical and infra-structure	Having access to technology and Internet	Not having access to technology or Internet
Healthcare services	Supportive attitudes	Taken-for-granted assumptions that older adults are not interested or competent to use technology

Table 9. Summary of Factors Connected to the Concept of Belonging

	Factors that may influence technology use	Factors that may influence technology non-use
Person	The need to feel included	Withdrawal Cognitive deterioration
Technical and infra-structure	Available devices and infrastructure	Lack of user-friendly devices /interfaces
Healthcare services	Supportive services	Taken-for-granted assumptions of older adults as non-users of technology

Findings

The findings related to the four concepts were extracted to get an overview of the data and to compare and reflect on these findings related to digital technology use (Table 5).

Identification of concepts

The last step of the abductive analysis was to explore and compare how the four concepts in occupational science may shed light over use and experiences of technology in older care recipients and adults in assistive living facilities. We summarized each of the four concepts, and Tables 6-9 present factors related to technology use on three contextual levels: person level (micro), technology level (meso), and healthcare staff level (meso).

Doing

Under the DOING concept, using technology, giving interviews, and sharing opinions, reflecting on conversations, discussing technological solutions, and testing technology at home, were typical examples of doing in the three sub-studies (see Figure 1).

Being

Under the BEING concept, the older adults mentioned the importance of being autonomous citizens, deciding for themselves. They wanted to be visible and competent citizens, being citizens on equal terms with other citizens. The sense of still being useful and able to contribute to society, as societal citizens, while being residents in an assisted living facility, was identified as an important value. Thus, participating in the project and having access to a mutual learning arena between participants and researchers were apppreciated.

Becoming

The participants wanted to learn more about technology and how to benefit from it. They were interested in learning how technology could support them with future potential consequences of ageing and diseases. BECOMING more literate concerning technology and even a technology user, was perceived to support independent living, and eliminate fearing technology as something alien and difficult.

Belonging

Expressions related to the concept of BELONGING concerned the potentials of technology to keep the residents connected to society, family and friends, as a citizen with full rights. Although not using many types of technologies, the main impression was that they found technology helpful in everyday living. Non-adoption of technology may thus lead to exclusion and occupational injustice.

Discussion

The discussion addresses how the occupational science concepts of doing, being, belonging, and becoming may account for the findings from three Assisted Living Project sub-studies. It is organized in the following topics: occupational inclusion or exclusion, use or non-use of technology, methodological considerations, and implications for practice.

Occupational inclusion or exclusion

The three sub-studies refer to using technology as ‘doing’, which necessitates having access to technology. There may be several factors that foster or hinder technology use; van Dijk (2005) stated that the first requirement for using technology is access. In Norway, in 2020, approximately 3% of the inhabitants used neither the internet nor digital tools. The majority of these people were seniors, unemployed, or had little education (Ministry of Local Government and Modernisation, 2021). The Norwegian strategy for digitalization emphasizes the importance of including all citizens in a digital society to safeguard human rights, democracy, and citizenship (Ministry of Local Government and Modernisation, 2021). The broader society needs to prepare for digitalization in healthcare services and make them sustainable, based on ethical, legal, and professional frameworks (WHO & UNICEF, 2022).

Introducing technologies into homecare services has several implications. The purpose of digitalizing homecare services is to save costs and increase its quality. Furthermore, the current policy in Norway, as in other countries, encourages older adults to live at home as long as possible and receive homecare services if needed (Norwegian Department of Health and Care, 2023; WHO & UNICEF, 2022). This will require a sustainable digital infrastructure, as well as technological support. Access to technology is important to improve or maintain health and well-being, which imply both user-friendly devices, robust connections, and digital competence. Healthcare staff are of utmost importance, as they often must implement, adapt, facilitate, and follow-up the homecare receivers’ technologies. In the future, healthcare professionals must prepare for digital technology being pointed out as one of the solutions to ensure sufficient homecare for the inhabitants (Tid for Handling, 2023). Health professionals thus have an obligation to update their skills on digital technologies used in the healthcare to mediate the governmental strategies (Holthe, Halvorsrud, Thorstensen, et al., 2020).

One major concern is the potential users’ motivation to adopt, acquire, learn, and then to use these technologies for purposes like information, communication, transaction, or entertainment (van Dijk, 2005). The process of adopting and using technology requires both cognitive capacity (knowledge) and an emotional desire or interest to use the technology. Thus, ‘doing’ requires access to technology, motivation for using it, and cognitive capacity to do so. Lack of cognitive capacity may lead to occupational deprivation, resulting in passivity and non-use of technology. However, cultural and/or social pre-conceptions may hinder participation and social involvement. Healthcare staff and family carers must strive to adapt everyday occupations so that people with dementia can engage in meaningful occupations.

Occupational inclusion regarding digital technology requires user-friendly interfaces. One way to gain insights into older adults’ user requirements is to include them in projects or processes that aim to tailor technologies for the specific user group (Lund et al., 2021). User involvement in the sub-studies was about giving interviews, sharing opinions, discussing technology experiences and preferences, and trying out environmental sensors designed to monitor events and movements in their apartments.

Co-creation of user interfaces on digital technologies may support older adults’ social participation through doing occupations they find important in their lives (Fischl et al., 2020). However, when it comes to technology preferences, it is expected that many will consciously prioritize technology that enables meaningful occupations. Many want simple solutions that do not require learning new operations or training courses, but rather based on well-integrated habits and routines (Kottorp et al., 2016).

Several elements may contribute to the successful incorporation of the technologies into occupations, and to adoption of technology (Kottl et al., 2021). The first essential is to learn to use technology and incorporate it in everyday living. Next is to learn the different steps and functions of the device, and finally to use the technology independently when engaging in valued occupations. These learning-steps were shown to have a positive impact on the participants’ minds and inner selves; that is, it influenced their ‘being’ and enabled a connection to people and places, thereby enhancing the feeling of ‘belonging’ (Kottl et al., 2021). Becoming acquainted with technology through regular use and by relating it to previous experiences was essential (Meyer-Larsen et al., 2018). Learning how to use technology is a process of learning-by-doing, which may stimulate adoption of technology and hinder occupational alienation. One study involving older adults in assisted living facilities trying out tablets reported that the participants learnt to perform familiar occupations in new ways. In addition, the participants developed strategies to meet barriers for technology use in everyday life (Sølvsberg & Lund, 2021). This demonstrates that the participants managed to adopt the technology by becoming users of it. Having learnt to use a device implies that you have become competent to master the technology to address your own needs and preferences.

Occupational exclusion may be due to non-use of technology, which may be associated with lack of access to the internet or lack of technological equipment, due to limited financial resources, interest, or motivation (van Dijk, 2005). Moreover, technology use is impacted by lack of digital literacy or competence, and personal values and beliefs that technology is unnecessary or of little relevance (Bjønness et al., 2021). Lack of motivation, passivity, and withdrawal from instrumental, social, and lifestyle occupations are significant factors regarding how the person engages in technology use and collaborates in using technology (Fabricatore et al., 2020).

Use and non-use of technology

Research has found that older adults use fewer technological devices than younger people (Bjønness et al., 2021; Kottorp et al., 2016) and this may be explained by the co-morbid ageing processes that lead to reduced individual capacity. Withdrawal from daily tasks increases risk for occupational deprivation and marginalization (Kottorp et al., 2016). When body and brain are deprived of stimulation and daily life behavior, fulfilment of doing may be restricted, and become a threat to health, survival, and well-being (Wilcock & Hocking, 2015). Moreover, withdrawal from technologies can also be seen as a response to perceiving technology as too challenging due to health-related conditions or lack of skills, and it is anticipated that older adults’ technology skills will deteriorate in line with other ageing deterioration.

According to a Finnish study, older adults’ lived experiences determined how they perceived technology, based on their attitudes, life transitions, and personal health status (Hänninen et al., 2021). Their life path defined the person’s participation in novel everyday living with technology (Bülow & Söderqvist, 2014) as well as their life experiences (Erikson et al., 1986). A Norwegian study on older assisted-living adults and their use of tablets found that it was acknowledged as a tool for maintaining social relationships, and to keep themselves updated on what is going on, both of which were regarded as meaningful to the participants (Fjeldberg & Lund, 2019). Moreover, it was also a way for the housekeeper in the assisted living to announce organised occupations or the daily menu etc., which was a strategy to include residents in becoming active and making choices for themselves.

Non-use of technology by homecare recipients may be due to lack of information about suitable technology, or rather, lack of a relevant needs assessment which may deprive a person of opportunities to achieve independence and/or social contact (Holthe, Halvorsrud, Thorstensen, et al., 2020). Moreover, assumptions about older adults not being capable of using technology may conceal social processes and mechanisms through which occupational injustices are created and kept alive (Laliberte Rudman, 2012), and subsequently exclude older people. This is a real concern, given that the most frequent non-users of digital services such as websites, online forms, and digital IDs are above 80 years of age, who also are the largest proportion of homecare recipients (Bjønness et al., 2021). Being digitally illiterate may create the risk of exclusion from information, communication, occupations, and services and lead to occupational injustice (Kottorp et al., 2016).

Having information about technology and learning how technology can support daily living in old age was of interest of the participants in all the sub-studies. This can be seen as a moral right when ‘being’ a citizen. However, we interpreted this interest as preparation for a future with possible health decline, and the wish to be autonomous and in charge of their own everyday living. This reflects both the motivation for learning about technological possibilities and for taking personal responsibility for their life situation, in order to ‘become’ a technology user and sustain ‘being’ a citizen and ‘belonging’ to society.

Greenhalgh et al. (2017) asserted that “perceived usefulness, perceived ease of use and attitudes towards technology is important for using technologies” (p. 8). Implementation of technology as part of healthcare services was found to be challenging due to contextual requirements including architecture of the home, wall materials, stairs, mobility spaces, lighting, access to the Internet, support from family members, and so on.

Occupational injustice

Older adults are heterogenous citizens, with diverse health status. Some are more privileged than others, and thus may have easier access to technology, training, and support. Feeling out-of-date regarding digital technology can be a threat to inclusion and belonging (Lund et al., 2021). Being able to use technologies to engage in occupations that have a positive impact on people’s minds and inner selves influences their being and enables a connection to people and places, thereby enhancing the feeling of belonging (Meyer-Larsen et al., 2019). Subsequently, this necessitates being offered information about technology and having the opportunity to have hands-on experiences with various types of technologies and learn about advantages and disadvantages.

In other words, doing, being, becoming, and belonging seemed to be important values for the participants. They concluded that adoption of technology required using it. Consequently, homecare recipients may benefit from user needs analysis and individualization of technologies that may support them to cope with preferred occupations that sustain their quality of life.

Methodological considerations

An abductive analysis of the findings of our three sub-studies enabled exploration of the content related to occupational science. Comparing findings through theoretical concepts was fruitful to extend understandings of the consequences of digital technology use in older homecare recipients. The three sub-studies had different research designs. However, this study allowed investigation into how the concepts of doing, being, belonging, and becoming are useful to explain and understand the empirical findings.

Regarding ethical considerations, all three studies had described ethical issues. However, when it comes to digital technology to support homecare recipients, we must be aware of the “technological imperative”, meaning that we all must use technology because it is there for us to use. This perspective may force older adults to install technology they might not fully understand, or care to use. It may also blind our understanding of those who dissociate from technology. On the other hand, a prevailing assumption of older adults as technology illiterates may also prevent homecare recipients from having information about and access to digital technology, which may result in social exclusion and occupational injustice. Therefore, the issue needs to be navigated with consciousness and sensitivity to address the individuals’ needs and requirements.

Limitations and strengths

This is a theory-driven paper, based on empirical findings from three sub-studies from a larger study of technology with older adults. The samples in the three sub-studies were relatively small and that can be seen as a limitation. However, analysing them together revealed how the concepts doing, being, becoming and belonging can be interpreted. The abductive analyses were performed by experienced researchers from both occupational therapy and nursing which is a strength.

There is a need for future research to explore how homecare services may take advantage of digital technology as a sustainable and reliable resource, and to investigate what theoretical and practical knowledge about using digital technologies is needed with homecare recipients. This is an area which needs further research since there will be new generations and new technologies. As far as we know, occupational science research on older homecare recipients and digital technology is scarce but necessary to inform older adults in assisted living facilities, next-of-kin, and all those involved in design and running of the facilities and delivery of assistance.

Conclusion

This study demonstrates that for older adults in the Assisted Living project, to become a user of technology required personal motivation and cognitive capacity for learning to use and become familiar with the technology, as well as having access to the internet and digital tools. Digitalization in society leads to new challenges for all citizens, especially those who are less familiar with using digital technology. By applying occupational science perspectives on doing, being, becoming, and belonging related to technology use, this paper may contribute to raising awareness about digital exclusion and occupational injustice. The study provides a deeper understanding of use and non-use technologies and the digital divide, including possible breaches of people’s human rights as a consequence of not having access to digital healthcare services.

Disclosure Statement

No potential conflict of interest was reported by the author(s).