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Original Paper
Acceptance of a Digital Assistant (Anne4Care) for Older Adult
Immigrants Living With Dementia: Qualitative Descriptive Study
Marloes Bults1, PhD; Catharina Margaretha van Leersum2,3, PhD; Theodorus Johannes Josef Olthuis4, MA; Egbert
Siebrand5, MSc; Zohrah Malik1, MSc; Lili Liu6, PhD; Antonio Miguel-Cruz6,7,8, DSC; Jan Seerp Jukema9, PhD;
Marjolein Elisabeth Maria den Ouden1,4, PhD
1Technology, Health & Care Research Group, Saxion University of Applied Sciences, Enschede, Netherlands
2Department of Technology, Policy, and Society, Faculty of Behavioural, Management and Social Sciences, University of Twente, Enschede, Netherlands
3Faculty of Humanities, Open University, Heerlen, Netherlands
4Care & Technology Research Group, Regional Community College of Twente, Hengelo, Netherlands
5Research Group Ethics and Technology, Saxion University of Applied Sciences, Enschede, Netherlands
6School of Public Health Sciences, Faculty of Health, University of Waterloo, Waterloo, ON, Canada
7Department of Occupational Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
8GRRIT Hub Glenrose Rehabilitation Research, Innovation & Technology, Glenrose Rehabilitation Hospital, Edmonton, AB, Canada
9Smart Health Research Group, Saxion University of Applied Sciences, Enschede, Netherlands
Corresponding Author:
Marloes Bults, PhD
Technology, Health & Care Research Group
Saxion University of Applied Sciences
M H Tromplaan 28 Enschede
Enschede, 7513 AB
Netherlands
Phone: 31 620946213
Email: m.bults@saxion.nl
Abstract
Background: There is a need to develop and coordinate dementia care plans that use assistive technology for vulnerable groups
such as immigrant populations. However, immigrant populations are seldom included in various stages of the development and
implementation of assistive technology, which does not optimize technology acceptance.
Objective: This study aims to gain an in-depth understanding of the acceptance of a digital personal assistant, called Anne4Care,
by older adult immigrants living with dementia in their own homes.
Methods: This study used a qualitative descriptive research design with naturalistic inquiry. A total of 13 older adults participated
in this study. The participants were invited for 2 interviews. After an introduction of Anne4Care, the first interview examined
the lives and needs of participants, their expectations, and previous experiences with assistive technology in daily life. Four
months later, the second interview sought to understand facilitators and barriers, suggestions for modifications, and the role of
health care professionals. Three semistructured interviews were conducted with health care professionals to examine the roles
and challenges they experienced in the use and implementation of Anne4Care. Content analysis, using NVivo11, was performed
on all transcripts.
Results: All 13 participants had an immigration background. There were 10 male and 3 female participants, with ages ranging
from 52 to 83 years. Participants were diagnosed with an early-stage form of dementia or acquired brain injury. None of the older
adult participants knew or used digital assistive technology at the beginning. They obtained assistance from health care professionals
and family caregivers who explained and set up the technology. Four themes were found to be critical aspects of the acceptance
of the digital personal assistant Anne4Care: (1) use of Anne4Care, (2) positive aspects of Anne4Care, (3) challenges with
Anne4Care, and (4) expectations. Assistance at first increased the burden on health care professionals and families. After the
initial effort, most health care professionals and families experienced that Anne4Care reduced their tasks and stress. Contributions
of Anne4Care included companionship, help with daily tasks, and opportunities to communicate in multiple languages. On the
other hand, some participants expressed anxiety toward the use of Anne4Care. Furthermore, the platform required an internet
connection at home and Anne4Care could not be used outside the home.
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Conclusions: Although older adult immigrants living with dementia had no previous experience with digital assistive technology
specifically, the acceptance of the digital personal assistant, called Anne4Care, by older adult immigrants living with dementia
was rather high. The digital assistant can be further developed to allow for interactive conversations and for use outside of one’s
home. Participation of end users during various stages of the development, refinement, and implementation of health technology
innovations is of utmost importance to maximize technology acceptance.
(JMIR Aging 2024;7:e50219) doi: 10.2196/50219
KEYWORDS
assistive technology; technology acceptance; immigrant; dementia; marginalized older adults
Introduction
Background
Dementia is a global health problem associated with emotional
and financial challenges for people living with dementia, their
relatives, health care professionals, and health organizations
[1,2]. Worldwide, approximately 47 million people are
diagnosed with dementia [3]. Around 280,000 persons are
presently living with dementia in the Netherlands among a
population of nearly 19 million [4]. The number of people living
with dementia is expected to increase in the coming years.
People with an immigration background are at an increased risk
of developing dementia and are more likely to experience
barriers in accessing dementia services and care, which may
lead to health inequities and a reduction of quality of life [5-7].
Hence, there is a need to develop and coordinate dementia care
plans, including the use of technology, for marginalized older
adults living with dementia, such as those with an immigration
background and low literacy levels [8].
Health Literacy and Health Technology
Health literacy has been defined as “the degree to which
individuals have the capacity to obtain, process, and understand
basic health information and services needed to make
appropriate health decisions” [9]. Adequate health literacy and
access to services among immigrant populations are important
to empower, support or facilitate these persons to become active
participants in their health [10]. Persons with limited health
literacy have difficulty finding, understanding, and applying
information about health and health care. Health
technology–based solutions that support health promotion, for
example, mental and physical health, offer opportunities to
increase health literacy in vulnerable populations [11,12].
The World Health Organization reports that innovative health
technologies are promising tools to enhance knowledge, skills,
and coping mechanisms to improve the daily lives of people
with dementia and their caregivers [13]. In recent years, a variety
of technologies to support self-management have been
developed for people with dementia and their caregivers. Studies
have focused on the effect of these technologies on the physical,
mental, and social well-being of people with dementia and their
relatives and families [14,15]. Technology seems to stimulate
cognitive function and communication skills and reduce
loneliness among people with dementia, but these results are
personal and context-dependent [14,15]. Acceptance of
technology is a major challenge and prerequisite for the
implementation of technology in practice. For successful
technology implementation in the daily lives of people, it is
important to have insight into the acceptance of technology
among end users. Although studies have examined the
acceptance of technology among people living with dementia
and their caregivers [16-18], the number of studies that focus
specifically on older adult immigrants living with dementia is
minimal.
Citizen Science
Co-design and the involvement of people with dementia and
their professional and family caregivers are crucial elements
for the acceptance of technology [17]. However, immigrant
populations are seldom included in stages of development,
refinement, and implementation of assistive technology
innovations [19]. This can be associated with low levels of
acceptance of health technology innovations, which can
contribute to health inequities among populations. One
opportunity to increase the involvement of end users is through
citizen science, which is an approach that engages end users to
be partners in research so that their experiences and needs are
considered [20]. Citizen science is a powerful approach to
include public participation in research as well as optimize
acceptance of technologies [20,21]. In citizen science, scientific
principles and methods are used by nonprofessional “scientists”
in close collaboration with scientific researchers [22]. The
involvement of older adults in the development, refinement,
and implementation of technology, acknowledging their
expertise and needs, and working together in short iterations to
adapt the technology for their specific needs are reported to be
valuable elements by scientific researchers, older adults, and
health care professionals [23].
Aim
This qualitative descriptive study aimed to provide an in-depth
understanding of the acceptance of a digital personal assistant,
called Anne4Care, among older adult immigrants living with
dementia by using a citizen science approach.
Methods
Research Design
This study used a qualitative descriptive research design with
a naturalistic inquiry [24] and citizen science principles [20].
In this study, Anne4Care was extended with the development
of a Turkish version. All the involved older adults had the task
of testing the device as well as communicating with each other,
their care professionals, and the Anne4Care help desk. For
example, there were workshop-like meetings in which all shared
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experiences, assisted each other with difficulties, and expressed
the need to further develop the Turkish version of Anne4Care.
Furthermore, participants actively collaborated with scientific
researchers, for example, in discussing the topics for the
interview guide and analyzing the data from the interviews.
Aligning with citizen science principles there was a close
collaboration between older adults participating as
co-researchers, health care professionals, and scientific
researchers. A detailed description of how older adults with an
immigration background were engaged in this study is described
in a separate paper [23]. The team of researchers closely
collaborated with a group of citizens representing the target
group and health care professionals in their role as co-researcher,
during all phases of this study: recruitment, obtaining informed
consent, data collection, and analysis.
Setting
This research was part of the TOPFIT Citizenlab program, a
research and innovation program in which citizens, health care
professionals, and companies join forces with scientific
researchers to develop and implement technology for health.
The Technology
Anne4Care is a digital personal assistant that includes
video-calling, a personal agenda, medication reminders, reading
the news, and games that can be used in one’s home. Anne4Care
is a technological platform created to help people with dementia
to continue living independently in their own homes and
supporting caregivers in their tasks [25]. Anne4Care included
hardware as well as a software platform. Anne4Care is available
in Dutch, German, Italian, and English. The company was
developing a Turkish version of Anne4Care and saw the
embedding of Anne4Care in homes of older adults with an
immigration background as an opportunity to test, improve, and
implement the latest version.
Recruitment Strategy
The recruitment of participants was performed by 3 health care
professionals from 2 health care organizations. These
organizations provide care for clients with an immigration
background with cognitive impairments.
Inclusion criteria were as follows:
•Diagnosed with an early-stage form of dementia or acquired
brain injury;
•Having an immigrant background;
•Visiting the activity program of 1 of the 2 participating
health care organizations
Exclusion criteria were as follows:
•Diagnosed with a severe stage form of dementia limiting
their ability to participate
All clients of the 2 health care organizations (IMEAN
Consultancy & Care and Alifa Wellbeing Older Adults) were
invited by their health care professionals to participate in this
study. All older adult participants had an immigration
background, that is, 1 came from Britain and the other 12 came
from Turkey (Table 1). They visited the activity program of 1
of the 2 health care organizations, which are situated in the
Twente region of the Netherlands. In addition to an immigration
background, all 13 older adult participants, or co-researchers,
had an early-stage form of dementia or acquired brain injury.
The sample included 10 male and 3 female participants, and
their ages ranged from 52 to 83 years. There were no exclusion
criteria based on digital literacy, that is, participants did not
need any experience with technology. Internet access was
provided to participants who did not have an internet connection
at home.
Table 1. Demographic characteristics of the participants (N=13).
ValuesVariables
Age (years)
71 (9.8)Mean (SD)
52-83Range
Age group (years), n (%)
1 (7.7)45-54
1 (7.7)55-64
6 (46.2)65-74
5 (38.5)75-84
Sex at birth, n (%)
3 (23.1)Female
10 (76.9)Male
Nationality, n (%)
12 (92.3)Turkish
1 (7.7)British
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All 3 health care professionals involved in this study were
female. They introduced Anne4Care to the older adults, assisted
them, and were in close contact with the participants during all
phases of this study. The health care professionals took care of
the clients and spoke their native language, which created a safe
and trustful environment. The health care professionals also
served as a voice for the participants who could not
communicate in the Dutch language.
Data Collection
Anne4Care was introduced to allow health care professionals
to communicate with and monitor older adults. Data were
collected between September 2020 and November 2021.
Semistructured in-depth interviews took place at the care
organization or at the home of the older adult immigrants. The
location was chosen based on a participant’s preference. During
the interviews, a care professional was present and served as
an interpreter. Participants were invited for 2 interviews. The
first interview was planned shortly after the introduction of
Anne4Care in their home, and a second interview 4 months
later. Participants had the opportunity to continue using
Anne4Care after the data collection period, funded through a
stimulation subsidy for eHealth at home during the COVID-19
pandemic. Five researchers with mixed credentials, training,
occupation, location, and gender conducted the interviews (MB,
CMvL, TJJO, ES, and ZM). To secure interrater reliability, the
researchers had biweekly meetings to discuss the procedure and
previous interviews. Two researchers were present during each
interview; the teams of 2 were different for each interview. One
was the main interviewer and the other took notes and asked
additional questions. The follow-up interviews were conducted
by the same researchers to ensure the established relationship
between researchers and older adults.
The topic guide was developed in collaboration with 1
participant from the daycare facility and 3 health care
professionals. Thirteen first interviews were conducted focusing
on understanding the lives and care needs of the participants,
learning about their expectations regarding Anne4Care, and
sharing previous experiences with care and technologies, what
facilitators and barriers they encountered while using technology
(Multimedia Appendix 1). The first interviews lasted between
30 and 60 minutes. A total of 8-second interviews were
conducted with the same participants who participated in the
first interview (5 of the participants were not able to participate
in the second interview due to COVID-19 illness). The second
interview focused on the facilitators and barriers participants
experienced when using Anne4Care, suggestions for
modifications of Anne4Care, and the role of health care
professionals in using technology (Multimedia Appendix 1).
The second interview lasted between 20 and 45 minutes.
Three semistructured interviews were conducted with the 3
health care professionals. These interviews took place at the
care organization and lasted for 60 minutes. The aim of these
interviews was to talk about their role and the challenges they
experienced as professionals in the use and implementation of
Anne4Care (Multimedia Appendix 2). Furthermore, the findings
of the interviews with the older adults were shared with the care
professionals.
Data Analysis
All interviews were audio recorded and transcribed verbatim.
The transcripts were made in English and Dutch. All Turkish
spoken words were translated by an interpreter during the
interviews. Only these translations were part of the transcripts.
Content analysis of transcripts used an inductive approach
[26,27]. We used the software package NVivo11 to support data
coding. Open coding was used to identify relevant themes, there
were no themes in advance of the data analysis. Several steps
were taken to develop a code book. First, 3 researchers (MB,
CMvL, and TJJO) performed the analysis of 2 transcripts and
compared codes. A preliminary codebook was developed
comprising these themes. Second, the coding of one transcript
was discussed together with one older adult. This participant
was motivated and had some previous experience with research
and data analysis. Together with the co-researcher, additional
themes were added to the code book. Last, the other transcripts
were analyzed by 1 researcher (CMvL). The data analysis and
application of codes were discussed during biweekly meetings
with the research team. Data saturation was reached after
analyzing the data obtained with all involved older adults and
care professionals. During the data analysis, similar and
confirmation of all findings appeared when analyzing and coding
the transcripts. In preparation for the paper, the quotes in the
raw data were translated into English.
Ethical Considerations
Ethics approval was obtained from the ethical advice committee
of the University of Applied Sciences Saxion (reference number
SEAC-2020-005). The participants were informed about the
study before the start of the research period with Anne4Care.
Thirteen participants gave written consent and were informed
about their right to withdraw at any time. Data were
anonymized, confidentiality was maintained, and the data will
be retained for a period of 10 years after which they will be
destroyed.
Results
Overview
The analysis of data revealed that the personal situation and
perceptions of participants regarding access to dementia services
and care (in short: care) were 2 underlying themes that described
the adopter system from the older adult immigrants living with
dementia. The code tree is presented in Multimedia Appendix
3.
Personal Situation
Personal situation considers the perceptions of older adult
immigrants regarding their health status (physically and
mentally), level of spirituality, quality of life, social and societal
participation, and daily functioning. The personal lives of
participants were diverse, with their immigration background
as a main commonality. They were all born in another country
and moved to the Netherlands for their work. Most of the
participants worked in the textile or metal industry. The
participants were all retired and visited the facility for daytime
activities once or twice a week. On other days, their daily
activities consisted of grocery shopping, housekeeping, or just
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doing nothing. Spirituality (eg, religion) was an important part
of the lives of most participants. The physical and mental health
of all participants is deteriorating, with illnesses that range in
severity. In addition to dementia or acquired brain injury, some
have health conditions such as diabetes, high blood pressure,
and cataracts. These deteriorating health conditions had a major
impact on their daily functioning as well as their quality of life.
In the earlier years of their lives, some participants experienced
challenges in participating in Dutch society, but this became
even more difficult during the COVID-19 pandemic. Social
relations were mainly with family members, and some had close
contact with their neighbors.
Since I came here in the Netherlands, in the year
1977, I bought a house and since then until now I live
in the same street, the same neighborhood with the
same neighbors and this was always a very good
network. It is a community with the Turkish and Dutch
neighbors, in which I am a beloved man, I go to the
mosque a lot and had several board positions for a
while, such as a board member of the mosque.
[Participant H]
Care
Care refers to the perceptions of participants regarding access
to dementia services and care in including all assistive and care
needs of the participants. All participants acknowledged the
fact that they became older and had increasing trouble taking
care of themselves. Some participants had troublesome
experiences with care in the past or could not find suitable and
personalized care. In most cases, family members, partners,
children, or neighbors assisted and provided support and care.
However, most participants perceived this as a burden for their
relatives and, therefore, was not a desirable situation.
Now there is someone who assists in housekeeping,
and our children assist with the more administrative
tasks. Next-door there are some younger neighbors
who offered to help for example with the garden. I
have a lot of help from all of them. However, in the
past I had a lot of frustrations with health care
professionals. When we arranged a time, they did not
show up and none made any record of my needs. Then
the agency went bankrupt and the clients were left in
the dark. [Participant G]
Acceptance of Anne4Care
In addition to the 2 underlying themes, the analysis of the
acceptance of Anne4Care by older adult immigrants revealed
four themes: (1) use of Anne4Care, (2) positive aspects of
Anne4Care, (3) challenges with Anne4Care, and (4)
expectations. In this section, results are presented for each
theme. The code tree is presented in Multimedia Appendix 3.
Multimedia Appendix 4 provides visual information about
Anne4Care.
Use of Anne4Care
This theme refers to the acceptance and actual use of the digital
personal assistant Anne4Care by older adult immigrants living
with dementia in their own homes. The use of Anne4Care
applies to how someone uses Anne4Care, what someone does
with Anne4Care, and how health care professionals or families
are involved. None of the participants knew or used an assistive
technology similar to Anne4Care. All were unfamiliar with the
existence of these types of digital assistive technologies. One
participant acknowledged that technology like Anne4Care could
assist health care professionals. In addition, the health care
professionals underlined the potential of Anne4Care for
supporting clients at a distance. Although the participants were
unfamiliar with technologies like Anne4Care, they were familiar
with technologies such as a doorbell with a flashlight or a talking
clock, and 1 participant owned a robot vacuum cleaner.
I was so pleased when I saw the result, this robot
really cleans everything. You can just leave your home
and it will clean everywhere. [Participant L]
Anne4Care was mainly used as a memory assistive tool, for
appointments and medication.
It is very useful. Anne4Care tells me when I must take
my medication. She helps me to remembers, she is
tough and fun. I am very happy with it. [Participant
M]
In addition to the agenda function and medication reminders,
the game, radio, and newspaper functions of Anne4Care were
used or requested by some participants. A health care
professional would need to be aware of participants’ requests
in order to activate the radio or newspaper functions.
He would like to receive more radio channels. He has
a Turkish music channel, but would like to receive
Dutch channels as well. We can add these channels
easily to the list, I will ask him at a later moment
which he would prefer. [Health care professional B]
Thus, the health care professionals and sometimes family were
responsible for adding new functions as well as appointments
in the agenda, and changes in the medication list. In the
beginning, this costed time and was a source of burden. Some
assistance to understand Anne4Care was needed at the start.
However, after this initial adjustment, most health care
professionals and families experienced the tablet as a task
relieving as well as stress relieving. Anne4Care gave the
reminders so that care partners did not have to keep track of
everything during the day. Some participants admitted that
continuous reminders from their partners made them angry, but
reminders from Anne4Care were received more positively,
causing fewer troubling situations at home. Furthermore, some
participants preferred to update the agenda themselves if they
could learn to work with Anne4Care. This feature is currently
not possible with the platform.
I just need a keyboard to add appointments in my
agenda. It is important for me to do this myself
without any assistance, just some explanation and
exercises in the beginning. It would be great if that
would work! [Participant E]
After a few months, 3 participants decided to stop using
Anne4Care. Two participants did not see the additional value,
Anne4Care did not give them any new tools, and 1 participant
stopped using them due to illness.
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Positive Aspects of Anne4Care
This theme refers to participant experiences regarding the
advantages and benefits of Anne4Care. During the interviews,
participants were asked to share the positive aspects of
Anne4Care. The avatar of Anne4Care was received positively
by the participants. Coincidentally, “Anne” is also the Turkish
word for mother. Although Anne does not look like a Turkish
mom, she gave a feeling that there was someone in their homes
because she talks, makes movements, and looks like a nurturing
health care professional. Another positive aspect was the choice
of language. Most participants chose their native language
because Dutch was progressively more difficult to use with age
and since the onset of dementia. However, some participants
chose the Dutch language intentionally in order to develop and
maintain their Dutch language skills.
With regard to positive aspects, the participants commented on
the functionalities of Anne4Care: video calling, agenda,
medication reminders, games, radio, and newspaper. The most
positive aspect of the video calling was the quality and the size
of the screen (respectively 10-12.3 inch diagonal). They could
see the other person more clearly on the tablet than, for example,
on their smartphone. The most positive aspect about Anne4Care
was the agenda function with the reminders of appointments
and the medication reminder function. These reminders were
very essential for the participants’personal life and health. One
health care professional explained that any event or task could
be added.
Take for example the timing for their regular prayers.
These are essential for someone’s life, and we can
easily add these into the agenda. [Health care
professional]
Another participant talked about the assistance of Anne4Care
in the daily cooking routine.
There are reminders when I need to start cooking,
but also already before which groceries I have to
purchase. After a while Anne4Care asks: ‘did you
turn off the stove?’That is very helpful and important
for me. [Participant K]
The game function was experienced as a fun activity to do
during the day. Furthermore, the radio and newspapers provided
by Anne4Care were perceived to be valuable. For example,
some radio channels with music from their past gave the
participants an opportunity to escape from their current time
and place. The newspapers were seen as essential to keep up to
date with current events; the read-aloud option was an asset.
It is wonderful that the radio and newspapers can
provide the news into my home. The news keeps me
up to date, and I also know what happens in Turkey
where my family is. [Participant H]
Challenges With Anne4Care
After using Anne4Care, the participants were asked about any
challenges they experienced. As mentioned, the agenda and
medication reminder functions were experienced as positive.
However, the video calling option presented challenges. The
main challenge was in making a connection with others. A video
call required both the caller and receiver to activate Anne4Care.
Therefore, all participants had to first send an SMS text message
with their mobile phone to request the recipient to activate
Anne4Care in order to receive a video call. With this extra step,
most participants decided to simply use their mobile device
instead of Anne4Care to make a video call. In addition, the
newspaper and radio functions do not allow participants to
search for radio stations, other than the ones preprogrammed.
I cannot find that newspaper, also the radio channel
is absent. When I try to search, I get the massage ‘no
stations available’, so there is nothing programmed
I think. [Participant B]
Another challenge was real interactions with Anne4Care. The
participants expected the possibility to have a conversation, but
that was not possible. Furthermore, part of this interaction was
the commands to which Anne4Care often does not react. For
example, when a participant asked Anne4Care for the time, or
to call someone, Anne4Care may not respond. This could have
been caused by the fact that Anne4Care did not recognize all
the verbal commands in the Turkish language.
We cannot talk together, because she does not
respond. Every morning I hear ‘good morning’, but
that is it. [Participant B]
The Anne4Care device itself presented some challenges. One
challenge was the anxiety among participants for the devices
to overheat, which caused the participants to turn off Anne4Care.
Another challenge was the requirement for an internet
connection at home. Some of the participants did not have
internet at the start of the study. Internet access was provided
to participants who did not have an internet connection at home
during the study period. However, internet access is not free.
Some of the participants are strapped for cash. This makes it
difficult for them to pay for Anne4Care and an internet
connection when the study ends. They have to make difficult
trade-offs.
Now we are using Anne4Care for free, but in a couple
of weeks there are probably some costs involved. We
do not have Internet connection. I only have a mobile
phone subscription with which I am happy. But I am
also happy with Anne4Care, so the costs make it quite
difficult to make a trade-off. [Participant N]
Because Anne4Care is now only available with an internet
connection at home, another challenge is to receive messages
from Anne4Care when someone is outside. It would be great,
for example, to transfer this with the Anne4Care message app
on their mobile phone in case they are not at home. According
to some participants, Anne4Care is currently a device only for
people who are at home most of the day.
Expectations
This theme represents the ideas, wishes, and future plans of the
participants for Anne4Care. In the beginning, some of the
participants expressed anxiety toward Anne. They turned the
tablet off at night because they thought someone could see or
listen to them through the device. One of the new plans most
of the participants came up with during the use of Anne4Care
was the addition of an option to connect quickly to emergency
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care services. This connection could be activated by the user,
but it should also be activated automatically when older adult
immigrants living with dementia do not respond to a call within
a period of time. Although all participants expected that
Anne4Care would improve the health care of people with
deteriorating health or dementia, their expectations were higher
at the start.
Anne4Care needs to be improved. At the moment, it
is too basic and does not meet the needs of some
people. We can do more by ourselves, it is a bit of a
disappointment. [Participant D]
As mentioned, it is a challenge to use Anne4Care outside the
home because the platform requires the internet. Outside the
home, it would be helpful if people could receive medication
reminders, therefore, this platform should also be compatible
with their mobile devices.
It would be great if I could just take Anne4Care
outside. Then I have my medication reminders when
I am outside, she will tell me to take the medication
and I could take them at the right moment. [Participant
M]
There were different ideas for new functions on the current
Anne4Care tablet. For example, the addition of short movies
or documentaries would allow it to be used for entertainment.
Additions to the game function and more options, such as
multiplayer games allow an older adult to play with a partner.
A range of memory or language-related games, and more
challenging puzzles would help meet user preferences. The
memory and language games were specifically mentioned by
several participants and health care professionals, because of
the perceived benefits of cognitive engagement for older adult
immigrants living with dementia.
Discussion
Summary of Findings
This study aimed to understand the acceptance of Anne4Care
as perceived by older adult immigrants living with dementia
using a citizen science approach. This study showed that
although older adult immigrants living with dementia had no
previous experiences with digital assistive technology
specifically, the acceptance of the digital personal assistant,
called Anne4Care, by these participants was rather high.
Anne4Care was mainly used as a memory assistive tool, for
appointments and medication. The use of Anne4Care at first
increased the burden of health care professionals and families
because health care professionals and sometimes families were
responsible for adding new functions as well as appointments
in the agenda and changes in the medication list. After the initial
effort, most health care professionals and families experienced
that Anne4Care reduced their tasks and stress. Contributions of
Anne4Care included companionship, help with daily tasks, and
opportunities to communicate in multiple languages. On the
other hand, some participants expressed anxiety toward the use
of Anne4Care and experienced challenges in the use of
functionalities, for example, video calling and having real
interaction with the avatar. Furthermore, the platform required
an internet connection at home and Anne4Care could not be
used outside the home.
Reflection on the Literature
The personal digital assistant, Anne4Care, offered
companionship for older adult immigrants living with dementia
and helped them perform daily activities. Participants mentioned
that Anne4Care was very useful as a remember assistive tool,
especially for appointments and medications. This finding is
consistent with the results of previous studies about technology
acceptance in rehabilitation and assistive technologies, and in
health care technologies in general [28-30]. Technology
acceptance models, for example, the Unified Theory of
Acceptance and Use of Technology suggest that if performance
expectancy is high, that is, people believe that technologies can
help them to achieve their therapeutic goals or achieve their
health expectations, this increases the acceptability and actual
use of health technologies [31].
A key finding in this study was that participants believed that
they did not have all the conditions to use and adopt Anne4Care
for a longer period. These conditions are also known as
facilitating conditions in technology acceptance theories, for
example, the Unified Theory of Acceptance and Use of
Technology [31]. Facilitating conditions include, for example,
internet connection, technical infrastructure, as well as other
internal support such as health care professional involvement
and supporting staff (eg, availability of engineers to support the
system) [32,33]. In our study, participants reported a lack of
internet connection as a main limitation for the acceptance of
Anne4Care. There is an extensive body of literature in the field
of technology acceptance and use that points toward facilitating
conditions as an important determinant factor in technology use
[34]. Our result shows that to take full advantage of the potential
of digital technologies like Anne4Care, these digital
technologies should be accessible also to people of lower
socioeconomic status which may have an influence on a person’s
autonomy and independence [35].
In our study, health care professionals were involved in using
Anne4Care. These health care professionals had close contact
and a trustful and respectful relationship with the participants.
They played an important role in giving participants information
and instruction regarding Anne4Care, in which they can be
supportive of the acceptance of technology. Some participants
were concerned about their privacy when using Anne4Care.
They turned the tablet off at night because they thought someone
could see or listen to them through the device. The important
role of the health care professionals in this study warrants
discussion. The health care professionals, all with a Turkish
background, had the expertise to provide access and involve
the participants. They were an important frame of reference and
guided the participants whenever they received questions, or
observed discomfort or doubts. Furthermore, they were key
users of health care technology and had a positive attitude
toward implementing the new technology. Research suggests
that creating a positive, supportive atmosphere is instrumental
to the sustainability of technology use [36]. Other studies
describe that caregiver engagement is important for the everyday
use of technology among people with dementia [33,37].
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Although in recent years several technologies have been
developed for people with dementia and their caregivers to
support self-management, in our study none of the participants
knew or used an assistive technology comparable to Anne4Care.
All were unfamiliar with the existence of these types of
technologies. Globally, there is an increasing aging population
and more people staying longer in their own homes which has
an impact on society and health care [38]. Although evidence
shows that technology for people with dementia seems to
stimulate cognitive function and communication skills and
reduce loneliness [14,15,39], the implementation of technology
can also contribute to the burden of health care professionals
and informal caregivers. In our study, participants needed the
assistance of health care professionals or families, which
increased the demand for health care professionals and families.
However, after this initial effort, most health care professionals
and families experienced that the tablet facilitated their
caregiving roles.
Immigrant populations typically have limited involvement in
the development, refinement, and implementation of health care
technology. This may be reflected in lower levels of adoption
of health care technology. The citizens’science approach within
this study was important for this specific target group. A citizen
science approach calls for the optimal involvement of the target
group as co-researchers. This extra time and dedication was
positively experienced by the older adult immigrant group. It
was mentioned that it felt like having a real purpose and gave
a sense of fulfillment. This collaboration resulted in an
alignment of the technology with the needs and practices of the
participants. In future studies, the citizen science approach could
also be applied in the development of new technologies as this
study focused on the refinement of a technology for a specific
target population. Citizen science for health and well-being
could provide an effective way to involve vulnerable groups
within society to participate in research.
Recommendations for Future Research
Future research could examine ways to increase the
implementation of technology among older adult immigrants
living with dementia and how to develop the technology
competencies of clients, caregivers, and health care
professionals. Furthermore, for future research conducting mixed
method research using both qualitative and quantitative research
methods is recommended to provide more insight into the added
value of these kinds of assistive technologies for end users and
professionals or family members.
Strengths and Limitations
Although we included only 13 older adults, they were involved
in the entire process and collaborated with the researchers as
well as with the other participants and their health care
professionals. All older adults of the 2 organizations with whom
the company Anne4Care started collaboration in the Twente
region were invited for this study. The 13 participants who were
interested in collaborating were all involved in this study.
Another strength of our study was the quadruple collaboration.
In our citizen science approach, there was active collaboration
between the researchers, older adults, health care professionals,
and the company that developed Anne4Care. However, we only
involved older adults with an early-stage form of dementia, and
5 older adults were not able to join the second interview, due
to COVID-19 illness. In addition, assessing exact levels of
health literacy would have provided additional information
about the influence of these kinds of assistive technologies on
health literacy levels. Finally, a care professional was present
and served as an interpreter. This may have impacted the quality
of the data collected and nuances in the conversations may have
been missed. On the other hand, the presence of the care
professional ensured a safe and trustworthy environment.
In this study, a qualitative descriptive research design with a
naturalistic inquiry has been used. Four themes were found to
be related to acceptance of Anne4Care: (1) use of Anne4Care,
(2) positive aspects of Anne4Care, (3) challenges with
Anne4Care, and (4) expectations. Data saturation regarding the
acceptance of Anne4Care was reached. During the data analysis,
similar and confirmation of all findings appeared when
analyzing and coding the transcripts. However, besides these 4
themes, there might be other factors relevant to the acceptance
of digital personal assistant technology for older persons to stay
safe in their homes and be able to age in place.
Conclusions
Although older adult immigrants living with dementia had no
experience with digital assistive technology specifically, the
acceptance of the digital personal assistant, called Anne4Care,
by older adult immigrants living with dementia was rather high.
In our study, older adult immigrants living with dementia
learned and used Anne4Care with the help of family caregivers.
Most older adults accepted Anne4Care into their lives in which
Anne4Care offered companionship and helped them to perform
daily activities. Older adults provided suggestions for the
continued development of Anne4Care.
Acknowledgments
The authors thank the company Anne4Care, which made the device available for the research, and the health care professionals
and participants for collaborating with us in every research phase and giving valuable insight. This study was powered by the
Twente Regional Deal and received financial support from the Central Government’s Regional Budget, the Province of Overijssel,
the Region of Twente, and the Twente Board. The funders had no role in study design, data collection and analysis, the decision
to publish, or the preparation of the manuscript.
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Authors' Contributions
MB, CMvL, TJJO, ES, and ZM conducted the interviews. MB, CMvL, and TJJO performed the analysis of 2 transcripts and
compared codes. Peer debriefing took place at weekly meetings with the project team when scientific and organizational aspects
were discussed. All authors contributed to writing the paper and have approved the latest version of the paper.
Conflicts of Interest
None declared.
Multimedia Appendix 1
Interview guide for first and second interviews with older adults with an immigration background.
[DOCX File , 17 KB-Multimedia Appendix 1]
Multimedia Appendix 2
Interview guide for interviews with health care professionals.
[DOCX File , 17 KB-Multimedia Appendix 2]
Multimedia Appendix 3
Coding tree.
[DOCX File , 134 KB-Multimedia Appendix 3]
Multimedia Appendix 4
Visual information about Anne4Care.
[DOCX File , 727 KB-Multimedia Appendix 4]
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Edited by M O'Connell; submitted 23.06.23; peer-reviewed by S Snipes, G Goodall; comments to author 21.11.23; revised version
received 15.01.24; accepted 21.02.24; published 19.04.24
Please cite as:
Bults M, van Leersum CM, Olthuis TJJ, Siebrand E, Malik Z, Liu L, Miguel-Cruz A, Jukema JS, den Ouden MEM
Acceptance of a Digital Assistant (Anne4Care) for Older Adult Immigrants Living With Dementia: Qualitative Descriptive Study
JMIR Aging 2024;7:e50219
URL: https://aging.jmir.org/2024/1/e50219
doi: 10.2196/50219
PMID:
©Marloes Bults, Catharina Margaretha van Leersum, Theodorus Johannes Josef Olthuis, Egbert Siebrand, Zohrah Malik, Lili
Liu, Antonio Miguel-Cruz, Jan Seerp Jukema, Marjolein Elisabeth Maria den Ouden. Originally published in JMIR Aging
(https://aging.jmir.org), 19.04.2024. 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 JMIR Aging, is properly cited. The complete bibliographic information,
a link to the original publication on https://aging.jmir.org, as well as this copyright and license information must be included.
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