The Ongoing and Collective Character of Digital Care for Older People: Moving Beyond Techno-Determinism in Government Policy

ABSTRACT

In this article, we contrast policy understandings of digital care with older people’s day-to-day digital care. In doing so, we discuss problems relating to deterministic approaches in government policy. Our policy analysis shows that digital care is articulated as an individual practice, and digital technologies as static actors. This bears clear marks of techno-deterministic reasoning. Our ethnographic study demonstrates the ongoing and collective character of older people’s digital care. When policy is not aligned with everyday practice, there is a risk of excluding groups of users. We argue that a socio-technical approach in government policy could contribute to achieving important societal goals.

KEYWORDS:

• Digital care
• eHealth
• techno-determinism
• socio-technical
• older people
• government policy

Introduction and aim

While there has been an upsurge in studies on both the policy and practice of digital health and social care for older people, there is still a lack of empirically informed investigations bringing these perspectives together. This article aims to contrast government policy understandings of digital care with digital care in practice, as experienced by older people in their day-to-day use of care technologies. In doing so, we discuss potential problems relating to deterministic approaches to digital care technologies, as found in government policy. Focusing specifically on digital care for older people, but aligning ourselves with an emergent strand of scholarship in the area of digital care (Hochwarter, 2021), we emphasize that a more socio-technical perspective should be employed in the development of policies on digital health and social care for older people. We argue that such a turn could contribute to making digital services more sustainable for older people and could also contribute to achieving important societal goals. The article provides a theoretical and empirical contextualization of how techno-determinism comes into expression in relation to digital care technologies at a policy level, and how such understandings of technology may compare and clash with the everyday conditions of use of digital services. Theoretically, we draw upon previous scholarship in the area of the social shaping of technology, both concerning digital care and more broadly. Empirically, we give examples from analyses of government policy addressing the introduction and use of digital care technologies in Sweden, as well as from an ethnographic investigation into older people’s everyday use of digital care in rural areas. These empirical sections of the article build upon findings from a European collaborative research project that focused specifically on the social aspects of digital care for older people in rural settings (see Lindberg et al., 2021; Lindberg & Carlsson, 2018; Lindberg & Lundgren, 2022; Rasi et al., 2021; Valokivi et al., 2021). As the authors of this article represent the Swedish part of the collaboration, the data drawn upon here reflects that particular national context, but we believe that the discussion around how certain ideas about technological solutions fail to align with older people’s experienced social realities also has broader validity.

While this article pulls together some of our most important empirical findings, it also highlights more broadly the importance of applying a socio-technical perspective to digital care and care technologies, complementing the medical and technological perspectives that still have a hegemonic standing in this field (Lehoux, 2014). There has long been a call for a more “holistic approach” to digital health and social care—“one that takes into account the complexity of healthcare and the rituals and habits of patients and other stakeholders” (van Gemert-Pijnen et al., 2011, p. 1). We find this to be particularly important in relation to older people since they are specifically targeted in policy relating to digital care (SOU 2020:14; SOU 2019:42).

Like many other western countries, Sweden has been affected by austerity policies over the last several decades. This has included a partial dismantling of social welfare, including health and social care (Dahlgren, 2008). In parallel with this, there has been a political move toward “active” or “successful” aging in government policies; older people are described as increasingly willing and able to manage themselves in terms of, for example, health and social care (Andersson & Kvist, 2015; Lindberg & Lundgren, 2021). The introduction of digital services has been repeatedly envisioned by the Swedish government as improving older people’s independence, promoting health and safety, and reducing the need for and costs of care (SOU 2020:14; SOU 2019:42).

This article is structured as follows. Firstly, we present a general conceptual discussion addressing how technologies and society are interlinked and the relevance of such theoretical ideas to the area of digital health and social care. Secondly, we present insights gained from our policy analysis and ethnographic study. Finally, by contrasting government policy understandings of digital care and digital care technology with actual practice, as experienced by older people in their day-to-day use of digital care and care technologies, we discuss the potential problems in applying perspectives that stem from techno-deterministic understandings of technology and care. In doing so, our intention is not to dismiss digital solutions in health and social care altogether. Rather, it is to approach digital care and care technology from a critical and socio-technical perspective in order to provide ways for policymakers to achieve the important goals articulated in government policy.

A socio-technical perspective on digital technology

In many areas—politics, government, health and social care, etc.—where digital technology is employed with the aim of resolving or alleviating various problems, there has historically been a tendency toward assuming that, by its mere implementation, the technology will generate certain desired results. As stated by Barry (2016), there are strong prevailing beliefs in “human technological abilities to solve problems of unsustainability while minimizing or denying the need for large-scale social, economic and political transformation” (p. 108). This tendency is still very much alive today, and the area of digital care is no exception. Simply putting tablets in the hands of patients, or just placing “smart” care devices in the homes of elderly people, it seems, is sometimes seen as equivalent to having achieved the desired changes. The collective and social aspects of everyday tinkering and digital housekeeping that are required are often backgrounded (Rode & Poole, 2018). The inclination to assume that the implementation of technology alone can be a driver of change, and that this change will be good and progressive, is commonly termed technological determinism (Lindgren, 2022).

In relation to digital health and social care, and to be able to move beyond techno-deterministic views of digital care, we find it useful to draw more generally on perspectives that have been developed within the theoretical tradition commonly labeled as “the social shaping of technology” (Williams & Edge, 1996). In order to avoid simplistic and techno-deterministic ways of reasoning, early historians and theorists of the socio-technical pointed out paths to take when approaching technology, including digital technology. Kranzberg (1986), for example, wrote about the ways in which technology is not neutral, pointing out that technology interacts with the social ecology in complex ways. This can generate consequences that extend far beyond the technical devices themselves or the intentions that they are designed to promote. Kranzberg (1986) underlined that “the same technology can have quite different results when introduced into different contexts or under different circumstances” (p. 546). Thus, the consequences of technologies and technology use are always different, for different people, in different situations (MacKenzie & Wajcman, 1999). Hence, the focus should not be directed toward the technologies themselves, but “the change of scale or pace or pattern” that they introduce into the lives of humans (McLuhan, 1964, p. 20).

Indeed, in recent years, a growing field of research has focused specifically on the socio-technical challenges related to digital care (Hochwarter, 2021). Building on those perspectives, we see the social and cultural study of digital care and care technology as necessarily having a strong discursive component, focusing on how social meaning, and the action around it, is structured formally (see e.g., Hellberg & Johansson, 2017). That is why, in this article, we focus on policy, as well as on the day-to-day experiences of the users of care technologies. Furthermore, scholars of the socio-technical have stressed that technologies are constantly evolving. As argued by Arthur (2009), technologies are very seldom fixed. Rather, they continually evolve. As the purposes of any given technology change, and while the technology itself may be improved or altered, its architecture and impact will also change. “Bodies of technology” can be said to have a “living quality” (Arthur, 2009, p. 151) in the sense that they are complex and organic ecologies that must function together, while at the same time they are constantly evolving through the addition of new elements and contexts. So, while technology—and its attached meanings—changes through the uses to which people put it, it also has the inherent property of changing in itself. It is thus a core tenet of the literature on the social shaping of technology that social life and technology are mutually constitutive and that this is an ongoing process (Lindgren & Holmström, 2020).

Scholars in the area of human–computer interaction have long emphasized the importance of taking socio-cultural contextual dimensions into account (Nardi, 1995; Suchman, 1987). Guzman and Lewis (2020) discussed that when in launching the research field of human–machine communication, early thinkers stressed that technologies, including digital care technologies, are not merely technologies. When technologies interact with social settings, they must also be seen as agents in their own right because they play dynamic and different roles in people’s everyday social lives and spaces. Such a line of reasoning also resonates with the social constructionist approach to technology and society advocated within Science and Technology Studies (STS). Within this line of scholarship, sociologists such as Latour, Callon, and Law developed Actor-Network theory (ANT) as an approach that allows for networks of social action within which the agency of human and non-human agents is seen as equal (Callon, 1986). According to ANT scholars, the implementation and design of technologies is always historically and socially contingent, and technologies are always used and developed within specific contexts that are shaped by a varying range of social considerations. Care technologies, however, also impose conditions to which subjects need to relate (Pols, 2015). More recently, Lupton (2019), a leading scholar in the area of digital health, has proposed a “more than human” approach to digital care that stresses the interconnection between human and technological actors, and how the agencies of different actors in care are distributed, relational, and situated.

In line with our approach in this article, this view directs the focus toward the entangled, contextual, emerging, and ongoing nature of both humans and technologically social actors, as well as the relationships between them—in this case, within the area of digital health and social care for older people. On the one hand, care technologies come into being through a process of discursive co-construction, whereby different interpretive frames are established and negotiated (see e.g., Weiss, 2019). Technologies, including digital care technologies, are always surrounded by socially shared and ideological structures of meaning; for example, in policy. On the other hand, these structures—the technologies—are always evolving and will determine the real-life impacts of the technologies in question.

Analytical strategy and research material

To be able to compare digital health and social care in policy and everyday practice, the methodological strategy for this article involves a policy analysis, an ethnographic investigation, and a critical juxtaposition of the two.

In analyzing understandings of digital health and social care in government policy, we used a critical policy analytical approach. This approach builds on theories about the influence of shared discourses of meaning (Bacchi, 1999; Lombardo & Kantola, 2017). According to Bacchi (1999), government policy reports are key actors in the ongoing construction of the social. Policy reports “stabilize” and “materialize” specific discourses. By doing that, policy reports contribute to institutionalize dominant political representations of what is to be considered a societal “problem”, but also how such a problem needs to be resolved in the best possible way. From this point of view, policy reports can be seen as political actors that define, organize, and transform care and care practices (Timmermans & Berg, 2010) and “do not intervene from the outside”, since the reports are inherent parts of what is being governed (Shove et al., 2012, p. 145). Importantly, a critical policy analytical approach also includes the identification of competing issues that might not be articulated as “problems”, and are thus not recognized or prioritized in policy (Bacchi & Goodwin, 2016). Analyzing government policy from this perspective helps to identify the understandings, perceived problems, and solutions that are foregrounded, but also to highlight issues that are downplayed or disregarded in policy, and how such articulations can impede possible solutions to identified issues.

In this article, we develop our previous policy analytical findings (Lindberg & Carlsson, 2018; Valokivi et al., 2021), and contrast them with the everyday use of digital care by older people in order to both highlight and critique the technologically deterministic understandings that predominate in Swedish government policy about digital health and social care. The corpus of material for our earlier policy studies (Lindberg & Carlsson, 2018; Valokivi et al., 2021) consisted of official government reports and inquiries that mention and discuss “eldercare”, “ageing”, “welfare technology”, “digital care”, and “eHealth” between the years 2009 and 2020. Altogether, 16 Swedish policy reports that met these criteria were used in our earlier studies (see Lindberg & Carlsson, 2018; Valokivi et al., 2021). In order to develop our earlier analyses in this article, and to give examples of techno-deterministic understandings in policy about digital healthcare, we use two recent and on-point Swedish government reports: “Framtidens teknik i omsorgens tjänst” (Future technology in the services of care) (SOU 2020:14) and “Digifysiskt vårdval—Tillgänglig primärvård baserad på behov och kontinuitet” (Digi-physical care choice—Accessible primary care based on need and continuity) (SOU 2019:42). Quotes from the government reports that are used in the article have been translated from Swedish to English by the authors.

In order to study older people’s day-to-day use of digital care technologies, we employed an ethnographic approach. This included semi-structured interviews with 19 individuals aged 61–85—twelve women and seven men. Altogether approximately 29 hours of interviews were recorded and transcribed verbatim. Quotes from the interviews that are used in the article have been translated from Swedish to English by the authors. The research material also included short observations and visual documentation of participants’ uses of care technologies, as well as both formal and informal interviews with registered nurses and managers at two healthcare centers from which digital services were being operated. Combined with the in-depth interviews, this helped us to capture the roles of digital services in older people’s everyday care.

The study participants were selected on the basis of having used one or a number of different digital healthcare technologies in their participation in everyday healthcare. In our selection of participants for the study, we aimed for a distribution in terms of age. Participants who were “youngest-old”, “middle-old”, and “oldest-old” (Lee et al., 2018) were included in the study. To recruit participants for the study, registered nurses working at the two previously mentioned community healthcare centers described the research study in brief to patients aged 60 years or older. Afterwards, they asked potential participants for permission to pass on their contact information (name, age, and telephone number) to first author. First author then phoned selected individuals who had given approval to be contacted. During that contact, more information about the study was provided, and it was discussed what a potential participation might entail. At the end of the phone call, preliminary consent to take part in the study was obtained from potential participants. Also, a preliminary date, time, and place for an interview was set. The ethnographic part of the project was approved by the Regional Ethical Review Board at Umeå University (Review number 2017/364-31).

Both the gathering and analysis of the ethnographic material were inspired by theories about “saturation” (Aldiabat & Le Navenec, 2018). In the gathering of research material, this meant that we continued to collect ethnographic material until we assessed that we had a solid empirical base for analysis. During the analysis, it meant that we built our analyses on systematic identifications of both recurring and pivotal conditions or practices in the material (Morse, 2015). For this article, we have synthesized the results from previous articles in the ethnographic sub-study (Lindberg et al., 2021; Lindberg & Lundgren, 2022; Rasi et al., 2021). Building upon our earlier insights, we have re-analyzed our ethnographic material and, hence, identified central conditions and practices for older people that are imposed by the introduction and use of digital care services. By highlighting such conditions and practices in the article, and exemplifying them using quotes, we have described how these matters unfold in everyday care (Nicolini, 2017).

The starting point for this article was to compare understandings of digital care and care technologies in government policy (the policy analysis) with how digital care was experienced and performed by older people in day-to-day care (the ethnographic study). In recent years, there has been a growing number of empirical studies investigating digital care for older people from either a policy (e.g., Naumann et al., 2021) or a user (e.g., Airola, 2021; Wilson et al., 2021) perspective. Still, there are very few empirically informed investigations that bring these perspectives together and compare them. The juxtaposition of government policy and everyday care in this article helps to identify critical discrepancies between digital care in policy and practice. The results form an empirical basis for our discussion of potential problems with techno-deterministic approaches, but could also highlight how a socio-technical perspective on digital care could help policymakers to achieve goals that are articulated in government reports.

Results: Policy analysis

Our previous analysis of government policy reports revealed important findings connected to the introduction and use of digital technologies in health and social care for older people (see Lindberg & Carlsson, 2018; Valokivi et al., 2021). Similarly to other western countries (e.g., European Commission, 2018), in Sweden digital technologies are said to contribute to achieving important goals in society. It is stated, for example, that “the digitalization of primary care provides great potential benefits for patients” (SOU 2019:42, p. 302) and digital technology is labeled as the “future” (SOU 2019:42, p. 296) and an “inevitable” (SOU 2019:42, p. 307) progression in health and social care. Generally, policy reports are grounded in an organizational perspective on digital care, and it is claimed that the further introduction of digital technologies will help in tackling the demographic challenges faced by Swedish welfare systems—including increasing costs and higher demand—while also contributing to improving the general quality of eldercare and the lives of older people (SOU 2020:14, p. 520). According to policy, digital technologies will also help to resolve future problems, and impending technologies—Artificial Intelligence, for example—will offer even greater possibilities (SOU 2020:14, p. 231).

Generally, the social aspects of digital care for older people are not processed in policy documents. They seem instead to be relying on specific articulations of technologies and older people in the context of digital health and social care. Throughout our analysis, we have identified two specific understandings that are used in the construction of digital care as a “solution” to identified problems. In Swedish policy reports, digital care is articulated as an individual practice and digital care technologies as static actors.

Digital care as an individual practice

An understanding that pervades Swedish government policy is that of digital care as an individual practice. This specific understanding is visible partly through an increased emphasis on “self-care” by older people in digital health and social care. While it is clearly stated that “digital care can never fully replace physical care” (SOU 2019:42, p. 307), it also seems to be an implicit assumption that digital care includes a move toward self-care by individual elders. Generally, the motivations for this move are articulated from organizational or staff perspectives: cost savings, increased efficiency, etc. It is, however, also supported by older people’s supposed desire for more self-care. It is claimed, for example, that there are “increased demands [by patients] on the [administrative] regions [in Sweden] to take advantage of and use the opportunities of digitalization. For example, more self-care and home monitoring” (SOU 2020:14, p. 520). Yet, examples of digital care that are provided in the reports are generally articulated in ways such that digital services seem to also include more (digital) self-care. Digital services are described in such a way that individuals’ everyday management of care—self-care—is already an integrated part of digital health and social care (e.g., SOU 2020:14, p. 163), or such that self-care does at least play a major role in individual users’ digital care (e.g., SOU 2019:42, p. 203). In this context, older people are described as willing to engage in digital self-care as long as the digital services provided are tailored according to their needs (e.g., SOU 2020:14, p. 435).

The articulation of digital care as an individual practice is most clearly evident, however, in the way in which the roles of two groups of actors are backgrounded in the policy texts: formal and informal carers. The reports identify both formal and informal carers as important actors in older people’s digital care. Still, there is a striking absence of in-depth discussion or concrete suggestions about how formal care staff (registered nurses, assistant nurses, technical support staff, etc.) could or should support older people in their everyday digital care. Even more so, the day-to-day involvement of informal carers (spouses, relatives, close friends, etc.) in older people’s care is disregarded (SOU 2020:14, pp. 49, 568). Altogether, the strong emphasis on older people’s self-efficiency in digital care, combined with a subsequent lack of acknowledgement of the different roles of either formal or informal carers, contributes to articulating older people’s digital care as an individual practice.

Digital technologies as static actors

Connected to the understanding of digital care as an individual practice are understandings of digital technologies as static actors. When digital care was discussed at a strategic level, digital technologies were often presented as vibrant entities, capable of resolving both present and future problems. At an applied level, however, when digital technologies were discussed in the context of everyday use, these technologies seemed to be understood as actors that neither changed nor evolved. Again, such understandings were not explicitly articulated. Rather, they became visible through a pervasive lack of discussion about social aspects of digital care and, more specifically, the absence of any suggestions for strategies or practices intended to assist older people in their long-term use of digital care services.

One obvious example of how social aspects were omitted from discussions and how this seemed to relate to understandings of digital technologies can be taken from how barriers to engagement with digital care were identified. In the reports, such barriers are almost exclusively positioned in the realm of the technical, while conditions for day-to-day care are not identified as concerns. Lack of connectivity to the Internet or lack of up-to-date digital technology could serve as examples of barriers that are deemed structural and in need of resolution if older people are to be able to engage in digital care and gain its benefits (e.g., SOU 2020:14, p. 478). Social aspects, such as the complexity of digital technologies and technology use, are consistently under-communicated. As an example, the inability to operate digital technologies or difficulties with them—the lack of so-called “digital literacy”—tend to be identified as marginal issues among a small group of older users, not as structural outcomes deriving from the introduction of inherently evolving technologies:

A common objection regarding older patients with complex needs, is that they to a large extent suffer from so-called digital exclusion, i.e., they cannot operate computers and other digital tools. (…) At the same time, it is important to emphasize that the ability of older people to handle digital tools should not be underestimated, not least because modern tablets and other digital tools tend to be relatively easy to operate. (SOU 2019:42, p. 306).

Another illustration of how discussions about social aspects were absent could be taken from statements about the ways in which digital technologies can help to make more time available in care. In the reports, the move from “traditional” and physical modes of care to digital services was described as a way to enable time and energy to be freed up for “real” care and social interactions:

[N]ew technical solutions can meet the needs of the ageing in new ways while more time can be freed up, for example for daily activities for a meaningful life and for the meeting between the ageing and care staff. (SOU 2020:14, p. 337)

In statements like the above, there are explicit assumptions being made that digital technologies would decrease the time and effort that older people put into self-care. The policy texts did not, however, include any discussions about how digital services could work also to redistribute the expenditure of time—that technology use requires ongoing efforts and time to be put into the management of digital devices.

A third example could be taken from the lack of consideration about how older people engage with digital services and learn how to use them. In the reports, continued learning was a pivotal theme and support with digital self-care was stressed as a key aspect for success (SOU 2019:42, p. 437). Yet, in line with the organizational perspectives that pervaded the reports, strategic discussions related almost entirely to staff, not users. It was stated, for example, that:

Skills development among staff is a success factor. Introduction of digital technology often leads to new ways of working, which places demands on competence development (…) Future elderly care must be characterized by a collegial learning [and] continuous competence development. (SOU 2020:14, p. 21)

The explicit focus on staff, combined with a general lack of any such strategies for users, contributes to an articulation in policy in which older people do not seem to require any ongoing development of skills. Engagement with digital services, and the learning that accompanies it, appears in policy as a singular event restricted in time. It seems that, once older persons have learnt how to operate their devices, they will also be able to manage future versions and services. Embedded in the above articulations of digital health and social care is a distinct understanding of digital care technologies. The three examples given above could stand as illustrations of the ways in which digital technologies are presented as static actors in policy. This, in turn, seems to support a belief that the social aspects of digital care do not need to be addressed at a policy level.

Results: Ethnographic study

Our ethnographic investigations (Lindberg et al., 2021; Lindberg & Lundgren, 2022; Rasi et al., 2021) demonstrated important social aspects relating to digital health and social care and showed that digital technologies give rise to new practices within the context of everyday care. Two conditions that stood out were how the day-to-day use of digital care had an ongoing and collective character. It also seemed that technology-centred and individualized forms of digital care, like the ones articulated in policy reports, could contribute to preventing older people from using digital care services.

The ongoing character of digital care

An important finding in our study was that older people’s adoption of digital care was not a singular event. Rather, using digital care was experienced as an ongoing process during which older people had to learn how to manage constant change across a broad range of areas and over extended periods of time.

An example of this from the interviews was how day-to-day digital care included continuing efforts related to the handling of digital technologies like smartphones, tablets, or mobile applications. In such cases, it was apparent that digital care required constant learning by participants. In many cases, learning how to maintain their devices was framed as a parallel process to the actual care, where efforts had to be put into making the preconditions for digital care—digital technologies—work. One participant described this continuous work during an interview and used the mobile application that was installed on his smartphone as an example. He then continued to describe the frustration he felt when issues with updates and changes piled up:

You should download some [new] app. (…) No, I can’t do it. And I’ve lost it [the app]. That’s the truth. (…) But I knew I was going to get a new one, a better one. But then my smartphone died, it had a minor stroke, so everything in my phone – SNAP – gone! He [the smartphone] quit!

While many of the study participants described similar experiences, the ongoing character of daily care appeared to be particularly difficult to manage for participants who were “oldest old” or other participants who had problems operating digital services, for example those living with chronic disease. A participant who had suffered a cerebral hemorrhage described how changes and updates would pose major difficulties for her:

I don’t have the energy to fiddle. [For] a week and a half I was struggling almost all day to phrase the most important stuff in a [direct] message [to healthcare staff through her digital device]. I was sitting with a magnifying glass. (…) So I had to go back to see what I’d written and why. Cos I couldn’t see it and I didn’t understand!

The above example also makes it evident that day-to-day digital care often extends beyond the maintenance of digital technologies, and into less expected arenas, such as how to communicate digitally with care staff.

The ways in which individual technologies raised matters in need of resolution were seldom articulated as major issues in interviews. However, as these accumulated and became part of everyday care, they seemed to generate negative, sometimes dismissive, attitudes among study participants. This, in turn, seemed to affect both their short- and long-term engagement with digital services. Some of the study participants talked about having stopped or restricted their use of specific services because they were sick of learning to use new technologies, or update old ones. A number of participants had even abandoned local digital initiatives and turned instead to “traditional” and physical modes of care in other parts of their region, even though this had restricted their access to specific care interventions.

The collective character of digital care

Another finding in our ethnographic study was the collective character of digital care for older people. Many, but not all, services involved barriers to use. While some of these barriers seemed easy to resolve, others required more effort. These barriers were often related to changes or updates to technologies, as described above. For digital solutions to be feasible for the participants to use, different forms of support networks were required and formed. From the accounts of the study participants, it was apparent that the gradual withdrawal of “traditional” and physical care, and the emergence of digital solutions aimed at self-care, was a strong agent for the emergence of such networks.

Older people’s support networks would often include healthcare staff, both in their formal role as professionals and in more semiprofessional roles. Several participants said that they would approach staff at their local healthcare center, even though they “knew” that they were supposed to manage their digital care themselves. Their networks would also include informal carers. Participants’ spouses, children, grandchildren, friends, and neighbors were regularly approached for help and support. But, while these networks tended to build on already existing relationships, they would also require new social connections to be made, for example with support staff for individual devices. A finding that illustrates the broad and fragmented character of support was how difficult it was for study participants to properly pinpoint support. In interviews, participants would sometimes struggle to coherently articulate how their support within digital care was organized and enacted. There seemed to be multiple reasons for this. Usually, the support networks that participants used ran in parallel, and movement between them was needed for the participants to manage the digital services in day-to-day life.

Some networks, however, would be more “theoretical”, in the sense that participants felt that they could approach, for example, staff, friends, or support professionals. Still, many had not done so—the sense that they could if they really needed to seemed to be enough for them to feel that they could pursue their use of the digital services. One participant said that he felt confident in using his digital device because he could contact both medical and support professionals for help if necessary, although he had never done so:

I can call [registered nurse at local healthcare centre] or there’s a number to support services that you can call. (…) I’ve never talked to them.

Often, participants’ support networks appeared to be both porous and inconsistent. They might have received help or advice from a friend, neighbor, acquaintance or professional once, or on a few occasions, over an extended period of time, but still felt that they could rely on that connection. One participant who claimed that he “knew nothing” about digital technology said that he had been in contact with official support once. Because of that one contact, he seemed to feel that the support person would be able to help him again. Another participant described how she had received help from a friend early in her use, and it was obvious throughout the interview that she felt that this friend would help her again:

[The friend] has helped me actually. She’s smart. She used to work with that [computers], you know!

Altogether, older people’s day-to-day use of digital care appeared to be an ongoing and collective effort, where the combined properties of different support networks were important for older people’s use of digital services, both in the short-term and more long-term. Thus, digital care included a significant social aspect whereby older people needed to interact with a variety of actors at professional, family, community, and individual levels.

Digital care in policy and everyday practice

In sum then: it was an explicit objective in the policy reports to set out the directions for “future” health and social care in Sweden. The government policy reports that we analyzed tended to describe digital health and social care as a wide-ranging solution to a variety of perceived problems. The structural introduction of digital care technologies, along with a subsequent move by older people to digital self-care services, was presented as a solution to issues such as demographic changes and a way to increase the quality of both care and life for older people. While technical barriers to use were identified in the policy reports (e.g., lack of connectivity to the Internet, lack of up-to-date technology, etc.), the social aspects of digital care were not thoroughly addressed.

Following Bacchi (1999), the specific understandings of digital care that were found in the policy reports: that care technology use is an individual practice and that digital technologies are static actors, contributed to the downplaying of potential concerns about social aspects of older people’s digital care. Older people’s need for support in digital care was constructed as a non-problem and, subsequently, as a non-barrier for older people in their use of digital services. These articulations together appeared to have resulted in the absence of any strategic suggestions or concrete practices aimed at accommodating ongoing support as part of older people’s everyday digital care. Older people’s engagement with digital services seemed to be understood as a singular event that was restricted to one point in time; a one-way transfer from one mode of care—“traditional” and physical—to another—digital. From this perspective, the problems that were identified in policy reports could be overcome by the structural introduction of digital services and a subsequent move by older people to digital modes of care.

The results emerging from our policy analysis correspond to similar studies about digital health and social care (e.g., Greenhalgh et al., 2011). Digital services are framed in very a techno-positive manner in government policy. Furthermore, government reports are dominated by strategic and organizational perspectives, while lacking any focus on the conditions for end-users. The disproportionate articulation of the positive effects of digital care technology seems to mirror a lack of awareness among policymakers about the everyday practice of care (Fine & Glendinning, 2005). Overall, the policy reports that we analyzed for our project lacked a deeper conceptual approach to matters of technology and humans in interaction. On the one hand, policymakers seemed heavily invested in the belief that care technologies could work as actors in their own right. The introduction of digital services was pinpointed as a way to introduce new patterns and behaviors in health and social care, such as digital self-care among older people. On the other hand, there was a lack of any deeper understanding of how interactions between technologies and humans are constantly changing these patterns, such as how formal and informal networks for support are formed and utilized in order for older people to be able to manage their everyday digital care. Overall, digital care was articulated in line with its intended, not its actual, use, as the complex interactions between technologies and humans that emerge as part of digital care were not discussed or accounted for. We argue that this way of understanding and promoting digital technology in health and social care bears clear marks of techno-deterministic reasoning.

The results emerging from our ethnographic investigation are also supported by earlier studies. First and foremost, digital care requires recurring “digi-housekeeping” and everyday tinkering (Mol et al., 2015; Nymberg et al., 2019; Urban, 2017; Whiting & Symon, 2020). It was apparent in our investigation that the introduction of digital care required older people to put considerable effort into learning how to use digital services at an early stage. In many ways, the introduction of digital care services did promote healthcare behaviors by older people similar to the ones described—and desired—in government policy. An important empirical result, however, was that the adoption and everyday use of digital care is not a singular event restricted in time. Rather, it was experienced and practised as an ongoing task over extended periods of time. For the study participants, long-term use involved having to continually manage a range of new practices. Due to recurring changes and updates in digital care technologies, users were forced to try to learn how to resolve issues in order to be able to proceed with their care. As described, this will have implications in terms of older people’s attitudes toward, and use of, services. Due to the ongoing character of everyday care, there was a growth and proliferation in older people’s social connections; social networks that included formal and informal support actors who to different extents could help older people to manage their digital services. While many of these networks were not concrete or formalized, they were still vital to the participants (Szebehely & Ulmanen, 2012). In our ethnographic investigation, older people’s digital care appeared to be a collective, not an individual, practice. A worrying factor was that older people’s willingness and ability to pursue digital care was significantly reduced if they felt that they could not access the necessary support. They tended to withdraw from digital services or migrate elsewhere for “traditional” and physical modes of care when they felt themselves to be too alone in handling their digital services. Even more troubling is that some settled for digital services even when they could not operate them properly or did not find them adequate. This was particularly clear among some groups of participants, for example the “oldest-old” or people living with chronic disease. Notably, these are groups who are specifically emphasized in government policy and are said to benefit from a move to digital solutions (SOU 2019:42; SOU 2020:14).

Toward a socio-technical understanding of digital care in government policy

In scholarly areas where the entangled relationships between the social and the technological are studied, it is generally agreed that deterministic views of technology will hamper our understanding of what happens with humans and technology in context. Such beliefs tend to obscure the fact that society and technology are mutually shaped (Šabanović, 2010) and they work as driving forces to resolve identified problems, not by rethinking current approaches, but instead by developing “better” versions, or using more of the same technologies (Alexander & Rutherford, 2019). According to Morozov (2013), such techno-deterministic forms of reasoning involve the ideological belief that various technologies—digital devices, communication media, machines—can function as catch-all remedies to make society better. Such beliefs can often inform a kind of digital solutionism whereby issues that are socio-political are approached as “puzzles” to be solved, rather than as complex issues that must be responded to in a multitude of potential ways. We are moving down a dangerous path, Morozov (2013) adds, if we see technology as something that can “fix the bugs of humanity” (p. 14).

Such prospects do not mean, of course, that policymakers should not take action or should not use digital technologies to try to resolve important societal issues. There is a growing body of research supporting the claims in government policy that digital health and social care includes important opportunities for older people (e.g., Ahmed et al., 2019; Airola, 2021). It does make it even more important, however, that efforts to introduce digital care are addressed adequately, so that services aimed at older people do not introduce or reinforce inequalities, rather than counteracting them (Mariën & Prodnik, 2014).

In the areas of scholarship to which we are relating here, it is generally agreed that technology use is an inherently “ongoing” phenomenon. Technologies and their everyday uses are constantly evolving, they are dependent on numerous actors and involve complex interactions between the technologies and human subjects (Lindgren & Holmström, 2020). But, while many of the perspectives that we have drawn upon in this article are not new as such, much policy on digital health and social care is not fully attuned to them. Ten years ago, Greenhalgh et al. (2011) were already emphasizing that digital care policymakers in the UK were reluctant to learn from history, and that they were “steeped in the logic of technological determinism (i.e., that technology X will have impact Y and that Y can be measured)” (p. 538). This problem does seem to persist within digital care more generally, as scholars, including recently, have called for more sensitivity to the fact that digital care must be seen as a “sociotechnical activity system” (Okkonen, 2020, p. 321). This is also evident in relation to older people. In a study on Swedish eldercare, Frennert (2021) argues that the current policy vision of digital health and social care “evokes technological determinism” (p.104), and that greater attention must be focused on “the needs and goals of the (…) end-users instead of on the continuing evolution of technology” (p. 109).

Building on such insights, along with the discrepancies between policy and everyday care practices that we found in our empirical investigations, we are adding to this call. More specifically, we argue that the techno-deterministic approach to digital care, as found in government policy, can pose major challenges to policymakers’ endeavors to achieve their goals concerning better quality in care and life for older people. In the context of digital health and social care, older people have to manage the inherent “ongoingness” of digital technologies and technology use as part of their day-to-day care. Looking forward, it is likely that future users of digital care will also have to manage similar states of “ongoingness” and, as a part of becoming older, relate to a continuum of digital services that are new or seem alien to them. Our point here is that the instrumental introduction of digital care technologies does not automatically resolve identified problems. We believe that there is a need for theoretical approaches in government policy that can accommodate social aspects, such as the need for both formal and informal support, which emerge out of the day-to-day use of digital care services, in order to really address issues relating to quality of care and life for older people. In line with Pettersson (2021), we argue that such understandings must be manifested in long-term strategies and concrete practices and fitted into the normative documents that govern welfare organizations: i.e., policy.

If government policy is not aligned with how digital care services are experienced and used by older people, there is a clear risk of excluding or distancing groups of potential users. It is a key argument of this article that techno-determinist understandings of digital health and social care can lead older people to abstain from using digital services. We find this to be particularly worrying since older people constitute a group in society that is steadily growing, but among whom there are already reported barriers to the use of digital services (Airola, 2021; Wildenbos et al., 2018; Wilson et al., 2021). We believe that a socio-technical approach which acknowledges the ongoing and collective character of digital care, and is manifested in concrete suggestions and practices, could help to reach the goals set out in government policy and make digital technologies into more sustainable solutions for future health and social care.

Acknowledgements

The authors would like to thank Päivi Heikkinen-Rasi, Ella Airola, Anna Sofia Lundgren, Robert Bhatt, Anton Ferm, Eric Carlsson, Heli Valokivi, Simone Carlo, and Marjo Outila for their involvement in the research that made this article possible.

Disclosure statement

The authors report there are no competing interests to declare.

Data availability statement

The data supporting the findings of the policy study is available on the Swedish Official Government Report website at https://www.sou.gov.se. This data was derived from the following resources available in the public domain: https://www.regeringen.se/4ad5e9/contentassets/6e378658462844798630946d5bf12fc3/digifysiskt-vardval-_-tillganglig-primarvard-baserad-pa-behov-och-kontinuitet.pdf. and http://www.sou.gov.se/wp-content/uploads/2020/03/SOU-2020_14_webb.pdf.

Due to the sensitive nature of the ethnographic research, participants in this study did not agree for their data to be shared publicly, so supporting data is not available.

Additional information

Funding

This work was supported by the Swedish Research Council for Health, Working Life, and Welfare (FORTE) under grant number 2017-00666; and Horizon 2020, JPI: More Years, Better Lives under grant number 643850.

Notes on contributors

Jens Lindberg

Jens Lindberg has a PhD in Ethnology and is a Senior Lecturer at the Department of Social Work, Umeå University, Sweden. His research is about human service organizations and digital health.

Elin Kvist

Elin Kvist is Associate Professor in Sociology at the Department of Sociology, Umeå University, Sweden. Her background is in Gender Studies and her research focuses on labour-market and welfare-state transformations, changing social organizations of care, and social reproduction.

Simon Lindgren

Simon Lindgren is Professor of Sociology, and director of the Center for Digital Social Research (DIGSUM), at Umeå University, Sweden. His research is about social interaction, participation, power, and resistance in networked online media.