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Original Paper
Intrinsic Capacity and Active and Healthy Aging Domains
Supported by Personalized Digital Coaching:Survey Study Among
Geriatricians in Europe and Japan on eHealth Opportunities for
Older Adults
Vera Stara1; Luca Soraci2; Eiko Takano3; Izumi Kondo3; Johanna Möller4; Elvira Maranesi1; Riccardo Luzi1; Giovanni
Renato Riccardi5; Ryan Browne6; Sébastien Dacunha7; Cecilia Palmier8; Rainer Wieching9; Toshimi Ogawa6; Roberta
Bevilacqua1
1Medical Direction, IRCCS, INRCA, Ancona, Italy
2Unit of Geriatric Medicine, IRCCS, INRCA, Cosenza, Italy
3National Center for Geriatrics and Gerontology, Obu City, Japan
4Diocesan Caritas Association for the Archdiocese of Cologne, Cologne, Germany
5Clinical Unit of Physical Rehabilitation, IRCCS, INRCA, Ancona, Italy
6Smart-Aging Research Center, Tohoku University, Sendai, Japan
7Maladie d’Alzheimer, Université de Paris, Paris, France
8Service de gériatrie 1&2, AP-HP, Hôpital Broca, Paris, France
9Institute for New Media & Information Systems, University of Siegen, Siegen, Germany
Corresponding Author:
Elvira Maranesi
Medical Direction
IRCCS, INRCA
Via Santa Margherita 5
Ancona, 60124
Italy
Phone: 39 0718004767
Email: e.maranesi@inrca.it
Abstract
Background: The worldwide aging trend requires conceptually new prevention, care, and innovative living solutions to support
human-based care using smart technology, and this concerns the whole world. Enabling access to active and healthy aging through
personalized digital coaching services like physical activity coaching, cognitive training, emotional well-being, and social
connection for older adults in real life could offer valuable advantages to both individuals and societies. A starting point might
be the analysis of the perspectives of different professionals (eg, geriatricians) on such technologies. The perspectives of experts
in the sector may allow the individualization of areas of improvement of clinical interventions, supporting the positive perspective
pointed out by the intrinsic capacity framework.
Objective: The overall aim of this study was to explore the cross-national perspectives and experiences of different professionals
in the field of intrinsic capacity, and how it can be supported by eHealth interventions. To our knowledge, this is the first study
to explore geriatric care providers’perspectives about technology-based interventions to support intrinsic capacity.
Methods: A survey involving 20 geriatricians or clinical experts in the fields of intrinsic capacity and active and healthy aging
was conducted in Italy, France, Germany, and Japan between August and September 2021.
Results: The qualitative findings pointed out relevant domains for eHealth interventions and provided examples for successful
practices that support subjective well-being under the intrinsic capacity framework (the benefits offered by personalized
interventions, especially by promoting health literacy but avoiding intrusiveness). Moreover, eHealth interventions could be used
as a bridge that facilitates and enables social engagement; an instrument that facilitates communication between doctors and
patients; and a tool to enrich the monitoring actions of medical staff.
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Conclusions: There is an unexplored and significant role for such geriatric perspectives to help the development process and
evaluate the evidence-based results on the effectiveness of technologies for older people. This is possible only when clinicians
collaborate with data scientists, engineers, and developers in order to match the complex daily needs of older adults.
(J Med Internet Res 2023;25:e41035) doi: 10.2196/41035
KEYWORDS
intrinsic capacity; functional ability, active and healthy aging; digital coaching; eHealth interventions; older adults
Introduction
Background
The challenge of supporting and promoting active and healthy
aging (AHA) as “the process of developing and maintaining
the functional ability that enables well-being in older age” [1]
concerns the whole world. Within this AHA framework,
“health” refers to physical, mental, and social well-being and
“active” refers to continuing participation in social, economic,
cultural, spiritual, and civic affairs. Functional ability is strictly
connected to intrinsic capacity, the environment, and their
interaction, and intrinsic capacity refers to the sum of an
individual’s physical and mental abilities. Scientific data
suggested that it is more valuable to focus on intrinsic capacity
rather than on specific chronic diseases in older adults [2-13].
The worldwide aging trend requires conceptually new
prevention, care, and innovative living solutions to support
human-based care using smart technology. Indeed, technological
progress is providing numerous hardware and software solutions
to enable affordable AHA support and eHealth interventions
for older adults in recent years [14-19]. Especially, digital
coaching interventions seem to be promising [20-22]. For
example, dialog systems and conversational user interfaces (also
called conversational artificial intelligence [AI], voice user
interface, and chatbot) allow natural interactions using dialog
modeling techniques, and they are becoming ubiquitous
nowadays [23-25]. Enabling access to AHA through
personalized digital coaching services like physical activity
coaching, cognitive training, emotional well-being, and social
connection for older adults in real life could offer valuable
advantages to both individuals and societies. The main challenge
of such technologies is to secure independent living and
prevention, helping older adults to live longer in their own
homes with the possibility to act independently and participate
actively in society. These functionalities are intended to support
the continued well-being of users in the context of their health
conditions, real-life situations, and needs. Moreover, smart
systems provide particularly useful support for users with
long-term therapy management challenges as it is required to
maintain integrated well-being information management. These
enable predictive analytics and thus alert services to minimize
incidences of exacerbations of chronic conditions and allow
their mitigation management so as to reduce the scale of
emergency hospital admissions. At the same time, they
contribute to providing guidance in everyday life for older users
and contribute to better management of their physical, cognitive,
social, or emotional frailty symptoms. Based on this, the
complex phases of design, development, evaluation, and
implementation of novel technologies, combining capabilities
for integration into daily life routines and fulfilling personal
and emotional needs, are all significant to elevate intelligent
technologies to a more appropriate and sustainable AHA support
for improving the overall well-being of older adults. This means
that collaboration among different stakeholders, including
designers, users, developers, etc, could form a “network of
excellence” [26], enabling long-term involvement and
co-creation of new concepts. Therefore, innovative approaches
can support older adults in managing their health and well-being
only if active collaborations are established between older adults,
their informal and professional health carers, community
members, and policy makers. Although a large amount of
literature is available on older adults’ and caregivers’
perspectives of innovative technology, few studies have reported
on clinicians’ views or their direct engagement in the design
and development of such technologies [27,28].
Evidence on interventions designed to support the intrinsic
capacity framework is of paramount relevance for older people,
as they may allow personalized strategies to be put in place to
support the independence and resilience of older people.
However, numerous studies in the field have identified research
trends and gaps that need to be solved to effectively integrate
the intrinsic capacity framework with more traditional therapies
and treatments [29].
The perspectives of health professionals and stakeholders are
essential to understand not only how to design intrinsic
capacity–integrated and technology-integrated interventions,
but also how to assess the improvement in intrinsic capacity
domains after conducting those interventions, as an assessment
tool to identify improvements in intrinsic capacity as a whole
(not only as a sum of domains) is still missing [29,30].
A starting point in this sense might be the analysis of
perspectives from different professionals, like geriatricians, on
such technologies. The perspectives of experts in the sector may
allow the individualization of areas of improvement of clinical
interventions, supporting the positive perspective pointed out
by the intrinsic capacity framework, which is more in favor of
a person-oriented approach than a disease-oriented approach,
allowing the greater personalization of any clinical intervention.
Therefore, the relevance of this study involves the identification
of existing research trends and possible gaps with experts in the
field, which should be applied in the near future when designing
technology-based interventions.
Objectives
The overall aim of this study was to explore the cross-national
perspectives and experiences of different professionals in the
field of intrinsic capacity, and how it can be supported by
eHealth interventions (also named technology-based
interventions or digital coaching). The specific research goals
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falling under this aim are as follows: (1) to collect information
about which everyday practices can increase and sustain intrinsic
capacity in the older population; (2) to identify what kind of
technology could support the related practices; (3) to understand
which technologies were useful to support the functional ability
and quality of life of older people during the COVID-19 crisis;
(4) to analyze the gender differences in planning interventions
to support the intrinsic capacity and functional ability of older
people, even considering eHealth interventions; and (5) to map
the positive and negative aspects of the intrinsic capacity
framework, even considering the possible roles of technologies.
To our knowledge, this is the first study to explore the
perspectives of geriatric care providers regarding
technology-based interventions to support intrinsic capacity.
Therefore, it contributes to the literature by demonstrating that
there is an unexplored and significant role for such geriatric
perspectives to help the development process and evaluate the
evidence-based results on the effectiveness of technologies for
older people. However, only when clinicians join forces with
data scientists, engineers, and developers and when innovative
technologies match the complex daily needs of older adults will
we be able to exploit the full potential of these technologies
[27]. This study is based on data collected during the e-VITA
project that is aimed to improve well-being in older adults in
Europe and Japan, thereby promoting active and healthy aging,
contributing to independent living, and reducing the risks of
social exclusion of older adults. In the eHealth intervention
project, a European and Japanese Consortium collaborated to
gain maximum outcomes and impacts for both regions, and to
jointly develop and connect innovative smart living solutions
that address the individual as well as cultural aspects and factors
of the AHA framework and overall well-being through AI,
intelligent data analysis, and tailored interventions based on
information and communications technology (ICT) and real-life
coaching.
Cross-Sectional Approach in the e-VITA Project
Owing to demographic changes, decreasing numbers of care
professionals, and dissolving family structures, all arguments
are now turning toward digital solutions to support elderly care
and prevention. Innovative approaches can support older people
in managing their health and well-being; however, this is only
possible if all beneficiaries are consulted and if they have
sufficient ICT literacy and can access affordable and
interoperable solutions that facilitate collaboration among older
adults, their informal and professional health carers, community
members, and policy makers.
Thus, it was planned to adopt a user-centered and value-sensitive
participatory design approach in all phases of the e-VITA
project, in collaboration with different stakeholders in all
participating countries, considering their engagement as a crucial
means to ensure the sustainability, acceptance, and uptake of
e-VITA in European countries and Japan.
The exchange of good practices and the inclusion of stakeholders
in all the countries will support local governments to adopt and
adapt policies for AHA in Europe and Japan on a cross-national
basis to build a reasonable support system that is sustainable as
it fulfills the real needs of older adults, considering different
cultural perspectives.
In the first phase, the cross-national approach has been applied
to the analysis of the attitude toward virtual agents, such as
e-VITA, in Italy, France, Germany, and Japan. Italy has a strong
emphasis on family-based care for elderly people. Traditionally,
Italian families take on the responsibility of caring for their
aging relatives. However, with changing societal dynamics and
increased mobility, the demand for formal care services has
grown. The Italian government provides various support
measures, such as financial aid and home care services, to assist
families in caring for their elderly members. There are also
nursing homes and assisted living facilities available for those
who require more specialized care. In France, there is a
comprehensive social welfare system that provides assistance
to elderly people. The government operates a national health
care system that includes coverage for long-term care services.
Elderly individuals can receive home care services, such as help
with daily activities, nursing care, and domestic assistance.
Additionally, there are nursing homes and residential care
facilities available for those who need more intensive care. The
French government also provides financial aid and benefits to
low-income seniors to ensure their well-being. Germany has a
well-developed system of social protection for elderly people.
The country has a mandatory long-term care insurance program
that provides coverage for long-term care services. Elderly
individuals can receive assistance with personal care, nursing,
and household tasks through home care services. The German
government also supports the development of community-based
services and encourages independent living for seniors. Nursing
homes and assisted living facilities are available for those who
require round-the-clock care. In Japan, the care and support
provided to elderly people are characterized by a combination
of family involvement, community-based care, and formal care
services. Similar to Italy, Japan places a strong emphasis on
family-based care for elderly people. It is culturally expected
that children will take care of their aging parents. Many elderly
individuals live with their adult children or nearby, and families
often provide primary support and assistance. Moreover, Japan
has a well-developed system of community-based care services.
Local governments and community organizations provide a
range of services to support independent living for seniors.
These services include home help, meal delivery, transportation
assistance, social activities, and health monitoring.
Methods
Procedure
An essential phase of the e-VITA project is linked to the
mapping of indicators and practices that facilitate stable good
health conditions through consultation with relevant
international experts in intrinsic capacity and AHA. Therefore,
a survey involving 20 geriatricians or clinical experts in the
fields of intrinsic capacity and AHA was conducted in Italy,
France, Germany, and Japan between August and September
2021. The survey aimed to collect information on which
everyday practices increase the intrinsic capacity and subjective
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well-being of older adults and how digital coaching can offer
support in this process.
It was conducted using a semistandardized questionnaire
formulated in English and then adapted to the language of the
respective country (Italy, France, Germany, and Japan). The
survey consisted of the following 5 topic sections populated by
open questions (see Multimedia Appendix 1):
1. Topic 1. Clinical expert perspective: This section aimed to
collect information about which everyday practices can
increase and sustain intrinsic capacity in the older
population (ie, everyday activities that older people can
perform by themselves such as monitoring health vital signs,
taking appropriate medication, lifestyle activities, etc).
2. Topic 2. Technology enhancement: In this section, experts
can indicate what kind of technology they suggest for
supporting the intrinsic capacity practice.
3. Topic 3. Supporting intrinsic capacity during COVID-19:
This section focused on the identification of which
technologies were found useful to support the functional
ability and quality of life of older people by experts during
the COVID-19 crisis.
4. Topic 4. Gender considerations: This section was devoted
to analyze the gender differences in planning interventions
to support the intrinsic capacity and functional ability of
older people.
5. Topic 5. Aspects of intrinsic capacity: This closing open
question aimed to gather information on the positive and
negative aspects of the intrinsic capacity framework, and
the improvements and future areas of interventions to
support older people.
An invitation email was sent to invite the experts and to explain
the objectives of the project as well as the aim of the survey.
An informed letter was attached to the email, and the experts
were kindly invited to visit the project website [31] as a
repository of all the significant content, videos, podcasts, press
releases, and materials related to the project activities.
Ethical Considerations
The procedures and approaches adopted during all design
activities of the e-VITA project are in accordance with the
ethical standards and have been approved by the Ethics
Committee of Siegen University (ER_31/2021; June 21, 2021).
Sensitive and private data were covered by informed consent
in each participant’s own language, in accordance with the
ethical standards on human experimentation (institutional and
national), the GDPR (General Data Protection Regulation) 2018,
and the national legislations on privacy and data protection.
Recruitment
The experts recruited for the survey in Germany are network
partners of the Diocesan Caritas Association for the Archdiocese
of Cologne. They were contacted by email. The email explained
the aims of the survey and contained the questionnaire and an
informed consent form. The informed consent form was filled
out digitally by the study participants and returned together with
the questionnaire.
In France, the experts were recruited through the Broca Living
Lab network. An email invitation was sent to the experts. The
email explained the objectives of the project and the purpose
of the questionnaire, and contained the questionnaire. If they
agreed to participate, the experts returned the completed
questionnaire by email.
In Italy, the experts were recruited within the hospital units of
the National Institute of Health and Science on Aging (INRCA).
An invitation email was sent to invite the experts. The email
explained the objectives of the project and the aims of the
survey. If they agreed to participate, they signed the informed
consent form attached to the email and answered the questions
on the questionnaire. All participants returned the signed
informed consent form and the questionnaire by email.
In Japan, the experts were recruited within the National Center
for Geriatrics and Gerontology (NCGG) and through the
network of the eHealth intervention Japanese partner. An
invitation email was sent to invite the experts. The email
explained the objectives of the project and the aims of the
survey. If they agreed to participate, they signed the informed
consent form attached to the email and answered the questions
on the questionnaire. All participants returned the signed
informed consent form and the questionnaire by email. In total,
5 experts were recruited.
Individuals who took part in the study were provided with and
asked to sign a written informed consent form regarding data.
Statistical Analysis
Data were collected and analyzed in the native language of each
site, and then, the local results were translated into English and
combined cross-nationally. Local questionnaires and the national
findings were analyzed using the framework analysis method
[32,33]. The MAXQDA software package (VERBI Software
GmbH) for qualitative research was used. Researchers classified
and categorized text data segments into a set of codes that were
then combined under main themes. Specifically, different data
segments were associated with the same code, and codes were
gathered under the same theme. To ensure comparability among
the countries and their languages, the main categories were
created deductively based on the topics of the questionnaire
used (Topics 1-5) for gathering insights in the fields of intrinsic
capacity and AHA. The substantive differentiation of these
topics was carried out inductively in the further course of the
analysis on the basis of the raw data from the participants for
the open questions. To validate the data analysis, the lead author
(VS) performed the coding. Then, the list of codes was validated
by 2 other researchers from the team (JM and ET) in order to
minimize personal bias and interpretation errors, and to ensure
validity and reliability. Quotes were then sorted out, and
comparisons were made between them [34]. Following this
coding process, quotations referring to the same quotes were
grouped in a code, and the results have been reported using the
frequency of codes (see Multimedia Appendix 2) as the number
of times each code was found in the case of general agreement
(ie, n/20). Specific quotations have been reported to clarify the
meaning of the codes merged from the analysis.
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Results
Study Population
A total of 20 experts in the field were recruited (4 from France,
5 from Italy, 5 from Japan, and 6 from Germany). However, 1
questionnaire had to be excluded from the qualitative analysis
of the open-ended questions owing to missing answers. Table
1shows the main characteristics of the respondents.
The different topics are presented below. The most frequent
sets of codes and findings are discussed in each paragraph and
reported in Multimedia Appendix 2.
Table 1. Participant characteristics.
SpecializationGender
Participant IDa
Elderly care, nursing scienceMaleDE_EXP_01
Nursing administrator/nursing manager, Master of GerontomanagementMaleDE_EXP_02
Specialist adviser for elderly careFemaleDE_EXP_03
PhDFemaleDE_EXP_04
Health Care Research MSc, Doctorate in Health Science (degree pending)FemaleDE_EXP_05
Outpatient care and palliative careFemaleDE_EXP_06
GeriatricianFemaleFR_GER_01
GeriatricianFemaleFR_GER_02
PsychologistFemaleFR_EXP_03
PsychologistMaleFR_EXP_04
GeriatricianMaleIT_GER_01
GeriatricianMaleIT_GER_02
GeriatricianFemaleIT_GER_03
GeriatricianMaleIT_GER_04
GeriatricianMaleIT_GER_05
GeriatricianMaleJP_GER_01
GeriatricianMaleJP_GER_02
GeriatricianMaleJP_GER_03
Rehabilitation medicineMaleJP_EXP_04
GeriatricianMaleJP_GER_05
aRegarding the participant ID, DE refers to Germany, FR refers to France, IT refers to Italy, JP refers to Japan, EXP refers to clinical expert, and GER
refers to geriatrician.
Topic 1: Clinical Expert Perspective
Across all countries, the experts agreed on the value of physical
(18/20, 90%) and social activities (14/20, 70%) as the main
everyday practices that can increase and sustain the intrinsic
capacity of older people. Indeed, all physical activities like any
kind of sports (walking, jogging, swimming, cycling, yoga, etc)
as well as the independent performance of household chores
and the active pursuit of hobbies can prevent frailty symptoms
and preserve physical functioning. Some responses were as
follows:
In ageing research, the relevance of physical activity
is very often pointed out. The empirical studies to
date show that regular exercise, for example, reduces
the risk of developing frailty symptoms (e.g. weight
loss, fatigue), which in my view greatly influences a
person's intrinsic capacity. [Participant ID:
DE_EXP_04]
The promotion of lifestyle activities is mandatory to
avoid physical decompensation and to sustain
physical and mental health. [Participant ID:
IT_GER_04]
Moreover, nutrition as well as a healthy and balanced diet (7/20,
35%) was a significant determinant to have enough energy and
strength to participate in physical activities. One participant
commented as follows:
All the physical activities empower social activities
such as going to the cinema, the theatre, the
interactions among individuals, family members, and
health care professionals. [Participant ID:
IT_GER_05]
…having dinner with friends or family, looking after
grandchildren, being an active member of an
association. [Participant ID: IT_GER_05]
Other ranked activities cited by half of the European experts
were cognitive activities (9/20, 45%) related to intellectual and
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affective-relational stimuli and self-care (5/20, 25%). European
and Japanese geriatricians (9/20, 45%) underlined how regular
health status monitoring is important to identify any deficits or
medical problems at an early stage and thus perform appropriate
interventions. In this specific case, health literacy was seen as
basic knowledge for self-management.
Topic 2: Technology Enhancement
According to the respondents, physical (13/20, 65%), cognitive
(10/20, 50%), and social (9/20, 45%) interventions based on
technology could improve physical activities and social
connections, as well as self-esteem and well-being. This
improvement could lead to a general overcoming of the anxiety
in performing daily activities that may contribute to the sensation
of mental fatigue. For example, the respondents imagined that
technology-based interventions could track adequate nutrition
and hydration using a daily diary (9/20, 45%) and physical
activities using geolocalization tools (5/20, 25%) and reminders.
These tracking measures could also be shared with other older
adults to exchange experiences and support each other as in a
virtual community. This could lead to approaching the need for
social connections at the same time. Indeed, integrating eHealth
interventions into everyday life or using programs to create
interactions between humans and virtual coaches could help
people fulfill their wishes and enjoy their hobbies. Based on
their clinical experience, the experts underlined that individuals
often do not know exactly what they like, so it is essential to
implement a function that proposes a list of enjoyable activities
and assists them in performing the activities. Indeed, the
importance of offering support, motivational tips, and
suggestions was underlined (5/20, 25%) as a key to fostering
positive engagement. Moreover, the service should be
personalized (5/20, 25%) considering that due to the
heterogeneity of the target, some older adults prefer to be
“active” users who maintain control and want the feeling of
power, while others require more direction.
Moreover, the use of virtual coaches, smartphones, and
computers would facilitate these activities. Indeed, these devices
would make it possible to centralize different applications
covering broad areas, for example, by offering gymnastic
applications to strengthen muscular capacities and encouraging
outdoor activities (5/20, 25%), which can then improve social
links. These tools also help to promote cognitive abilities by
proposing personalized activities that can be close to home or
remote, such as visiting virtual museums. Additionally, user
autonomy can be encouraged through calendars, lists, and
banking applications.
Regarding e-coach interventions, some experts (4/20, 20%)
underlined the importance of having the easiest interface as a
significant component of any kind of technology designed for
older adults. This includes the use of clearly understandable
icons and control through voice interaction as the most natural
way of communication. In addition, suggestions were made to
combine technical and human support.
For example, 1 participant proposed that supermarkets should
be geared to the needs of older people and that shopping should
be planned using apps:
Supermarkets for older people with products at eye
level and large numbers, checkouts with friendly staff
who take their time. Apps that suggest products to
order through pictures.[Participant ID: DE_EXP_05]
Moreover, physical training should be promoted by supporting
technologies where appropriate. One participant commented as
follows:
…exercises to strengthen the muscles, possibly guided
by artificial intelligence (AI) and measurement of the
muscle tissue to monitor success. [Participant ID:
DE_EXP_06]
To maintain mobility, the experts also suggested using
technology to make trips more predictable. This includes the
identification of possible barriers that the user might encounter
on the way, the use of public transport, and the knowledge of
public toilets.
To promote social participation in the community, the experts
advised social networks to connect users (possibly with similar
interests) and mention where people can offer their help in
specific areas (9/20, 45%). One participant stressed the concept
of technologies that cooperate with clinicians:
I cannot imagine a future in which any electronic
device or e-coach will replace humans in supporting
older patients. I think that an extremely useful action
would be to implement technology‐based services
delivered and managed by healthcare and other
professionals. To note, I am not saying that
technology is not important but some “human
functions” cannot be replaced. [Participant ID:
IT_GER_03]
Topic 3: Supporting Intrinsic Capacity During
COVID-19
During the COVID-19 emergency, the surveyed participants
made extensive use of video communication and social apps to
establish contact and opportunities with their patients (20/20,
100%). In Germany, such platforms were used even for online
education to support the functioning and quality of life of older
people during the lockdown. Indeed, these tools allowed older
adults to maintain social links and even promoted physical
activities. All the experts reported that the use of such remote
modalities was very important to decrease the sense of social
isolation, uncertainty, and powerlessness during the period of
social distancing. This represented a very important tool to
increase mental well-being and social engagement.
Topic 4: Gender Considerations
The surveyed participants underlined that a virtual coach should
account first for individual differences and then, in some cases,
for gender (12/20, 60%). The experts usually planned their
interventions by accounting for individual differences
(characteristics and preferences of the person). Nine of them
suggested that empathetic communication, discussions or
reactions involving the user, and the different physical abilities
between men and women should be definitely accounted for,
considering gender differences. Moreover, the user could choose
the gender of the coach. The participants commented as follows:
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I'm not sure if there are really gender differences or
if they don't break down more and more in the next
years and one should pay much more attention to the
individuality of the person and generalized
approaches based on gender characteristics don't
lead to achieving the outcome. Technological support
for crochet can also be interesting for men.
[Participant ID: DE_EXP_01]
…make sure to personalize the intervention according
to the patient's wishes and interests, their previous
lifestyle. [Participant ID: FR_GER_01]
Make a fair assessment. No gender difference but
depends on the person's abilities/personalities/
understanding interests. [Participant ID: FR_EXP_03]
One participant described that gender-specific differences should
be considered especially against the background of age, culture,
and religion:
A distinction must be made here depending on age
and also in relation to culture. A gender-specific
consideration is necessary around age, as
gender-related attributions still play a major role
here. e.g. for women, domestic activities and
handicrafts, and for men, e.g. playing Skat,
handicraft-related tasks, early morning hopping. The
younger the people are, the more the activities are
similar. In general, however, there is always a
cultural and religious distinction. [Participant ID:
DE_EXP_06]
Another participant commented as follows:
Even though women were considered at risk of
increased functional capacity with aging, today we
are seeing how such differences are becoming less
evident, thanks to improvement of lifestyles and social
engagement of women. [Participant ID: IT_GER_04]
The following specific suggestions regarding the virtual coach
were shared: the language and choice of words could be
individually adapted by the user, the gender of the coach could
be individually selected, and the difference in physical abilities
between men and women should be taken into account.
The importance of communicating the information differently
was mentioned:
Women are often more receptive to prevention advice.
For men it seems more important that they understand
the direct individual benefit of interventions. When
men are in a couple, it is sometimes interesting to go
through his wife to get the messages across.
[Participant ID: FR_GER_02]
Participant FR_EXP_04 explained that people are addressed
and interventions are planned according to the
“bio-psycho-social level. From a cultural and developmental
point of view,” which explains why sometimes the interventions
are not the same according to gender.
Other geriatricians commented as follows:
Preservation of intrinsic capacity needs to be
particularly targeted in women, since they are more
prone to develop functional disability over time
compared to men of the same age. [Participant ID:
IT_GER_05]
Women are more prone to locomotion and cognitive
decline, and prefer group activities, while men have
general characteristics such as a preference for solo
activities, and it is necessary to understand these
characteristics while giving consideration to
individuality. [Participant ID: JP_GER_01]
Regarding physical activities probably men and
women should practice more different domains (eg,
balance vs strength). Women are more prone to
socialization and less close to accept a device like
that (I suppose). When trying to implement empathetic
discussions or reactions to the user, gender should
be definitely accounted for. [Participant ID:
IT_GER_03]
Topic 5: Aspects of Intrinsic Capacity
The participants commented as follows:
The intrinsic capacity framework is full of positive
aspects. Indeed, it may improve self-wellbeing through
enhancement and preservation of baseline capacities.
It would be important to provide patients with
appropriate tools and technologies to support choices
and to speed up the recognition of individuals at risk
of decline. [Participant ID: IT_GER_04]
The intrinsic capacity Framework pushed the
importance of prevention compared to treatment and
of the preservation of physiological reserve compared
to the disease-based approach. [Participant ID:
IT_GER_05]
The advantages of the concept were recognized as follows:
It considers the person as a whole, ie, psychological
as well as physical aspects are included. [Participant
ID: DE_EXP_04]
However, the same expert also stated the following:
The concept of intrinsic capacity is based on the
assumption that all persons have the same (financial,
social) resources to maintain or improve their own
intrinsic capacity and mentions that it is often
described in the literature as having been developed
for the “privileged group” of older persons.
[Participant ID: DE_EXP_04]
This is particularly significant in light of the fact that research
shows that social and environmental contexts lead to negative
health outcomes. Therefore, the development of the e-coach
should also take into account people who, for example, have
limited financial resources or few digital or health-related skills.
For participant FR_GER_02, intrinsic capacities are important
to take into account because their decline leads to a loss of
autonomy. However, for this expert, these intrinsic capacities
are sometimes complicated to understand for elderly people:
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Intrinsic capacity's definition and evaluation are
complicated for the elderly. [Participant ID:
FR_GER_02]
Another participant commented as follows:
However, this concept is often difficult to understand
by the elderly because the decline in intrinsic
capacities sometimes goes unnoticed and is only little
taken into account by carers. It is also little sought
after by carers who are often focused on the loss of
autonomy: It would be appropriate to better
communicate and raise awareness of the concept of
intrinsic capacities among older people and carers.
[Participant ID: JP_GER_01]
The promotion could be valuable since “the positive aspects of
intrinsic capacity are related to health and longevity and are
useful for self-management” [Participant ID: JP_GER_01] and
“many elderly people recognize that maintaining their intrinsic
abilities is in itself a positive aspect” [Participant ID:
JP_GER_03].
Another participant commented as follows:
In terms of improvements and future areas of
intervention to support older people, the
implementation of the intrinsic capacity framework
should ensure to sensitize both health care
professionals and individuals on the importance of
intrinsic capacity and functional capacity. [Participant
ID: IT_GER_05]
This comment indicates that the promotion of intrinsic capacity
is intended for not only older adults and their caregivers but
also all clinical staff.
Moreover, 1 participant stated:
A fair assessment of the functional capacities and the
impact on the person's life should refer to the
functional abilities and the impact of their loss on the
older person, as some people will accept and regulate
their living conditions, while others will suffer and
may increase this loss. [Participant ID: FR_EXP_03]
If there is a negative aspect to intrinsic capacity, “it is spiritual
distress over the fact that actual physical functions are declining
compared to the ideal or desired physical functions” [Participant
ID: JP_GER_03].
On the other hand, another participant commented as follows:
Intrinsic capacity is the capacity or ability of an
individual person, and a person's sense of value. We
had better think of it as a positive or negative aspect,
but rather as a way to capture individual abilities.
[Participant ID: JP_GER_05]
Furthermore, how intrinsic capacity could be supported by a
virtual coaching system is seen in the fact that it could improve
the general well-being of users, potentially support people to
live independently at home for as long as possible, and support
their health safety. The participants commented as follows:
It could offer a multitude of activities concerning
cognitive stimulation (watching reports/films, learning
a foreign language), physical activity (learning to
dance, relaxation) and promoting social contacts
(web conferencing, teleconsultation). And, the virtual
coaching system should take into account ethical
considerations, in particular the fact of not
infantilizing, of respecting the user's free will, the
user's capacity to make choices and of proposing
personalized interventions since a human is by
definition not a machine, he does not behave in a
uniform manner. This system is disturbing in its
reduction of humanity to a norm. [Participant ID:
FR_EXP_04]
It is questionable whether every person can afford
this technology. In addition, isolation in a
technology-infused home could occur and social
contacts could be pushed into the background.
[Participant ID: DE_EXP_03]
The interest of the users could decrease and that
suggestions from the coach are not accepted or are
perceived as annoying.[Participant ID: DE_EXP_05]
Discussion
Principal Findings
This study aimed at identifying and analyzing (1) which
everyday practices can increase and sustain intrinsic capacity
in the older population; (2) what kind of technology could
support the related practices; (3) which technologies were found
useful to support the functional ability and quality of life of
older people during the COVID-19 crisis; (4) the gender
differences in planning interventions to support the intrinsic
capacity and functional ability of older people, even considering
eHealth interventions; and (5) which are the positive and
negative aspects of the intrinsic capacity framework, even
considering the possible roles of technologies.
The qualitative findings point out relevant domains for eHealth
interventions and provide examples for successful practices that
support subjective well-being under the intrinsic capacity
framework. From Topic 1 (clinical expert perspective),
participants agreed on the value of physical and social activities
as the main everyday practices that can increase and sustain the
intrinsic capacity of older people. The relevance of supporting
physical activities and social connectedness, especially through
technology, is in line with the literature in the field of
multicomponent interventions to support older people’s
well-being, as demonstrated by large clinical studies, such as
MyAHA [7], FINGER (Finnish Geriatric Intervention Study to
Prevent Cognitive Impairment and Disability) [12,13], and
MAPT (Multidomain Alzheimer Preventive Trial) [10,11]. All
those studies, in fact, have provided promising insights on the
benefits offered by personalized interventions aimed at targeting
multiple domains of intrinsic capacity, such as physical activity,
cognitive stimulation, and participation in social life, in terms
of improvement of the overall health status and specific health
domains.
Moreover, in the results of Topic 1, it emerged that the eHealth
intervention could promote health literacy. Since low health
literacy is associated with worse health outcomes [35-37], the
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eHealth intervention could also promote knowledge and skills
to improve the health literacy of older people. For example, the
experts cited healthy lifestyle and nutrition knowledge or skills
for managing possible diseases. From Topic 2 (technology
enhancement), it emerged that the eHealth intervention must
be personalized and matched with the users’ needs since the
“one-size-fits-all” approach is not suited to a diverse set of users.
The challenge is to adapt content and functionalities to the aims,
behaviors, preferences, context, and lifestyle of the intended
user. This means changing the system’s functionalities, interface,
content, or distinctiveness to increase its personal relevance. It
is indeed one of the most critical issues that emerged in other
studies [38-40]. Another implication related to the concept of
personalization is that the eHealth intervention must promote
independence and personal control. Any services or
functionalities should be controlled by the users who, at every
point in time, can decide if they are able or unable to manage
them. Older adults are not a homogeneous group, and
interindividual variability (between individuals) and
intraindividual variability (within individuals) need to be taken
into account. For example, the eHealth intervention could
support seniors in maintaining their abilities and could make
them feel as active and determined as possible, increasing their
control over the world [41-44]. For sustainable interventions,
digital coaching should propose and encourage activities in
accordance with one’s own values. Even if some experts
underlined that often individuals do not know what they like or
need to be pushed to do some activities, technology-based
coaching should not impose but rather propose interventions
for older adults and should always avoid intrusiveness by
respecting the privacy and will of the person concerned. Another
important vision that emerged from Topic 2 and was reinforced
by Topic 3, supporting intrinsic capacity during COVID-19,
was that the eHealth intervention could also be intended and
used as a bridge that facilitates and enables social engagement
and relationships. Digital coaching could have the ability to
enhance and enrich the lives of older adults by facilitating (not
substituting) better interpersonal relationships, thus making it
easier to connect with loved ones, friends, and the community,
as well as mitigating loneliness and isolation. For example, as
proposed by the majority of experts, the eHealth intervention
should encourage sharing experiences on emotional well-being
and connectedness among older adults. Definitely, the level of
social engagement and the sense of belonging as a social
member of the community have significant impacts on active
and healthy aging in place [45-50]. Despite this important role
of enabling social connections, within Topic 5 (aspects of
intrinsic capacity), it was mentioned that digital interventions
should avoid the risk of isolation in a technology-infused home.
This recommendation points out the importance of not
substituting human companionship and real-life relationships
with AI. On the contrary, technology-based interventions could
provide a link with medical staff as reported in the findings of
Topic 2. The system could be seen as an instrument that
facilitates communication between doctors and patients, as well
as a tool to enrich the monitoring of actions by medical staff,
for example, in the case of regular health status checking to
identify any deficits or medical problems at an early stage and
perform appropriate interventions. The experts underlined the
necessity to develop a system that guarantees a higher level of
usability and learnability since older adults are not technology
native and they could sometimes have difficulties in approaching
new devices. For instance, in Topic 2, they suggested the
enrollment of caregivers or relatives as facilitators of acceptance
and engagement with the system. For people living alone, an
additional “human” support may be beneficial. Moreover,
guaranteeing equal access to all individuals must be a
precondition.
From the main results of Topic 4 (gender considerations), the
experts enrolled in this study explained how they usually plan
their interventions by accounting for individual differences
(characteristics and preferences of the person). They suggested
that empathetic communication, discussions or reactions
involving the user, and the different physical abilities between
men and women should be definitely accounted for, considering
gender differences.
Various practices were analyzed from a gender perspective
through the literature. For example, the high frequency of social
participation activities is an important driver of well-being and
better health for older women and men, and should be a focus
of any technology-based intervention. Even if older men are
less involved in social activities, they are more sensitive to
loneliness and tend to need a closer social circle [51]. Another
issue to consider is that women have a higher life expectancy
than men with related consequences. They are living alone
longer with less incomes and more health needs. This is one of
the drivers for women to live with family members. Physical
activities and good nutrition are necessary to maintain a healthy
life and high well-being among older people. When designing
an eHealth coaching system for older adults who want to age
in place following an active and healthy aging life, these specific
needs of women and men need to be recommended.
The positive effect of physical activities on the health and
well-being of older people, regardless of gender, is a known
factor, and technologies should therefore be a support in the
practice of the activities, offering different formulas and regular
monitoring of the completion of the activities. For women, the
e-coach system could look at the internal motivations
(completion of a psychological need), and for men, it could
focus on external motivations such as the competitive aspect
and playing sports in a group [52,53]. Finally, the educational
level is also a motivating factor for performing sports. eHealth
interventions should take this into consideration to make future
generations and public institutions aware of the importance of
a long-term vision of sports education for the well-being of
older people, especially older women [54]. Moreover, users
could choose the gender and the characteristics of the coach as
reported in previous studies mentioning the importance of design
features, including the agent’s age, gender, and role [55,56].
Intrinsic capacity can be supported by digital interventions to
improve the general well-being of users, but a great effort is
needed to promote the concept among clinicians, caregivers,
and patients. The goal of supporting the intrinsic capacity of
individuals through eHealth interventions is an important one,
as it enables people to maintain and enhance their physical and
mental abilities, promoting healthy aging and overall well-being.
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eHealth interventions refer to the use of electronic means, such
as digital platforms, mobile apps, and remote monitoring
devices, to deliver health care services, information, and support.
It is crucial to ensure that eHealth interventions are accessible,
user friendly, and tailored to the specific needs and capabilities
of the target population. Regular evaluation and feedback from
users and health care professionals can help refine and improve
these interventions over time. By leveraging the power of
technology, eHealth interventions have the potential to
effectively support and enhance the intrinsic capacity of
individuals, empowering them to lead healthier and more
independent lives [29]. Nowadays, in fact, there is a lot of
evidence highlighting the positive role of eHealth sociotechnical
interventions in providing support to intrinsic capacity domains,
such as cognitive status, locomotion, energy consumption and
nutrition management, attention to reduced vision and hearing
capacity, and psychological support. Despite this, standardized
training on eHealth literacy [57] and a comprehensive
assessment tool to evaluate the impact on intrinsic capacity are
still lacking [20,29]
Limitations
While this study benefitted from including a survey for
professionals across Europe and Japan, linguistic barriers may
have limited the quality of the survey. The data collection was
conducted in the national language, and then, the data were
translated from the native language to English. Thus, the results
could have been impacted by this language switch. The use of
software programs for qualitative analyses counteracted this
issue. Despite this, the survey captured the main reflections and
experiences of the participants from cross-national and
multi-language perspectives. On the contrary, the specific
national centrality of Italy, France, Germany, and Japan, as well
as gender disparities in sample size could have introduced biases
and could be seen as significant limitations that do not allow
for the generalization of the results. Furthermore, the use of
qualitative analysis in combination with a semistandardized
questionnaire instead of a mixed-methods approach, which
could have guaranteed a broad understanding of thoughts and
emotions toward the use of eHealth interventions, could be
considered another limitation of this study. The open-ended
questions in the questionnaire provided only limited scope for
answers, and in-depth enquiries with the experts were not
possible owing to the design. Moreover, the data collection was
performed during the pandemic period across all countries, and
this situation could have impacted the thoughts and emotions
of the respondents. Another limitation is related to the sample
size. Although there is no commonly accepted sample size in
qualitative studies, in this research, purposive sampling [58-60]
was used since the researchers were interested in informants
having the best knowledge of the intrinsic capacity field, which
is a research topic still in its infancy. Furthermore, the data
analysis demonstrated saturation of the findings for the linked
items and their categorization [61,62] after applying the
investigator triangulation method [63] with 3 members of the
research team studying and evaluating the data from the source.
All these methodological steps meet the trustworthiness criteria
[64,65].
Conclusions
This research study explored the opportunities of eHealth
interventions designed for older adults according to the
perspectives of a sample of professionals in the fields of AHA
and intrinsic capacity from Europe and Japan. Indeed, digital
coaching seems to be very promising and able to sustain physical
activity coaching, cognitive training, emotional well-being,
social connection, etc, for older adults in real life. These
multicomponent interventions could offer valuable advantages
to both individuals and societies, and therefore help in mitigating
the need for new prevention, care, and innovative living
solutions, as already highlighted by the results collected with
older people in a similar study [66].
Through the qualitative analysis discussed in this study, the
importance of the perspective of experts was underlined to
demonstrate that there is an unexplored and significant role for
such a geriatric perspective to help the development process
and to evaluate the evidence-based results on the effectiveness
of technologies for older people. This is possible only when
clinicians collaborate with data scientists, engineers, and
developers in order to match the complex daily needs of older
adults. This synergy needs to be driven, and there is an urgent
need to strengthen data, research, and innovation to accelerate
the implementation of eHealth interventions in order to meet
the interests and needs of the aging society, especially with the
hindsight of the COVID-19 pandemic, which revealed the need
for improvement in all health services.
Future developments should include the involvement of all
stakeholders in the service, such as older adults as potential
users and technical or digital health experts in geriatric care.
Moreover, implementation approaches and recommendations
to specifically translate the conclusions of the study should be
planned.
Acknowledgments
This research received financial support from the European Union H2020 Program (grant agreement number: 101016453) and
from the Japanese Ministry of Internal Affairs and Communication (MIC) (grant number: JPJ000595). The e-VITA project
website is available at [31].
Conflicts of Interest
None declared.
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Multimedia Appendix 1
Semistandardized questionnaire.
[DOCX File , 15 KB-Multimedia Appendix 1]
Multimedia Appendix 2
Feedback from experts across countries.
[DOCX File , 20 KB-Multimedia Appendix 2]
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Abbreviations
AHA: active and healthy aging
AI: artificial intelligence
ICT: information and communications technology
Edited by T Leung; submitted 14.07.22; peer-reviewed by Z Nimmanterdwong, C Seah; comments to author 15.09.22; revised version
received 03.10.22; accepted 14.07.23; published 12.10.23
Please cite as:
Stara V, Soraci L, Takano E, Kondo I, Möller J, Maranesi E, Luzi R, Riccardi GR, Browne R, Dacunha S, Palmier C, Wieching R,
Ogawa T, Bevilacqua R
Intrinsic Capacity and Active and Healthy Aging Domains Supported by Personalized Digital Coaching: Survey Study Among
Geriatricians in Europe and Japan on eHealth Opportunities for Older Adults
J Med Internet Res 2023;25:e41035
URL: https://www.jmir.org/2023/1/e41035
doi: 10.2196/41035
PMID: 37824183
©Vera Stara, Luca Soraci, Eiko Takano, Izumi Kondo, Johanna Möller, Elvira Maranesi, Riccardo Luzi, Giovanni Renato Riccardi,
Ryan Browne, Sébastien Dacunha, Cecilia Palmier, Rainer Wieching, Toshimi Ogawa, Roberta Bevilacqua. Originally published
in the Journal of Medical Internet Research (https://www.jmir.org), 12.10.2023. This is an open-access article distributed under
the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted
use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet
Research, is properly cited. The complete bibliographic information, a link to the original publication on https://www.jmir.org/,
as well as this copyright and license information must be included.
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