Caring through a ‘plastic box’ : an inquiry into the use of remote care technology in later life

(1)

Caring through a ‘Plastic Box’:

An Inquiry into the Use of

Remote Care Technology in Later Life

Kay Polidano (11127511)

polkay3@gmail.com

Supervisor: Dr. Mutsumi Karasaki Second Reader: Dr. Christian Bröer

A Thesis submitted in partial fulfilment of the requirements for the degree of M.Sc. in Sociology: Social Problems and Social Policy

Graduate School of Social Sciences University of Amsterdam

(2)

The research work disclosed in this publication is fully funded by the ENDEAVOUR Scholarships Scheme, Group B (Malta).

(3)

To my family,

whose unconditional love and unwavering support are felt from a thousand miles away…

(4)

Acknowledgements

First and foremost, I would like to express my sincere gratitude to my supervisor, Dr. Mutsumi Karasaki, for his utmost commitment to the development and supervision of this research project. His keen insight, guidance, and encouragement were immensely valuable throughout the entire thesis process.

I am also grateful to all my participants who shared their time, stories and experiences; and without whom this research would have not been possible.

Finally, a heartfelt thanks go to my family and friends, particularly to my friend Maria, for always managing to put a smile on my face whenever the journey gets tough; Calvin, for supporting me every step of the way since the day we met; my brother Carlin whose perseverance, passion and sacrifice are a true inspiration; and to my loving parents Jesmond and Mariella, for always finding the right words that keep me going, and for believing in me - way more than I have ever believed in myself. Thank you and I hope to make you all proud!

(5)

Abstract

In light of the forecasted challenges related to the sustainability of health and long-term care systems in Malta, brought forth by population ageing, the Maltese government is lately promoting Telecare service as the ideal way forward to providing care for the elderly. Against this backdrop, this research set out to investigate the social dynamics and mechanisms underlying the use of such technology, and its possible effects on older adults’ sense of wellbeing, place and self-identity. A qualitative case study approach was adopted, and data was collected through a combination of policy analysis, in-depth interviews, and observation.

Findings illustrate that for many older adults, telecare played a remarkable role in their ageing trajectory, by restoring the various disruptions sustained along the way, and allowing them to regain control over their biography. This renewed sense of confidence, control, and continuity does not merely derive from the instrumental functions of telecare, but also from its capacity to forge affective social relations with its users, allowing for the nurturing of trust. Different outcomes emerged from telecare use, each depending on the meaning ascribed to the device, and how it was integrated in everyday life. In the majority of cases, telecare was found to have favourable outcomes, by enhancing sense of wellbeing; bolstering sense of place; and fostering a positive sense of self. In other cases, however, telecare also risked diminishing human contact, and affirming a negative self-identity.

This study contends that if remote care technologies are deployed in the right circumstances and used in the right manner, they may indeed be construed as a ‘technological fix’ to ageing problems; on both a micro- and macro-level. This becomes especially so if more emphasis is placed on improving the technology’s design, and strengthening the services’ psychosocial support function. Nevertheless, for optimal outcomes, remote care must be balanced with human-centred care, and therefore it is concluded that Telecare service does not necessarily represent a definite and stand-alone solution to the so-called ‘care crisis’.

(6)

Chapter 1 A ‘Technological Fix’ to Population Ageing?

1.1 Introduction

As human populations across the globe are living longer than ever before, discourses of an “apocalyptic demography” (Malta Today, 2015), a “silver tsunami” (Times of Malta, 2014) and an “ageing time bomb” (Times of Malta, 2006) are circulating widely. Indeed, the phenomenon of population ageing, which arises as a direct consequence of falling fertility rates and a steady increase in life expectancy (United Nations, 2013), is often being conceptualised as a societal threat - bringing forth unprecedented economic, medical, social, public health and public policy challenges (Sander et al, 2015).

Amid these challenges, a number of concerns surrounding the sustainability of pensions, health, and social care systems are dominating much of policy and academic discussions. As the median age of population increases, the number of people with chronic conditions and functional disabilities, who are in need of care and assistance, are also projected to increase remarkably. (McLean et al, 2011; Christensen et al, 2009). Meanwhile, a rise in the old-age dependency ratio, which is itself a consequence of population ageing, implies that this surge in demand for care is occurring against a backdrop of reduced state tax revenue - making higher spending commitments even more challenging. It is under these circumstances, that concern about a potential ‘care crisis’ is lately gaining ground, as the high demand for formal care, risks surpassing the state’s capability to supply it; ultimately threatening the sustainability of welfare states (Domenèch and Schillmeier, 2012).

These recent budgetary challenges have therefore led policymakers to explore cost-efficient ways to deliver care to older people. The promotion of Information and Communication Technology (ICT) in health and social care delivery represents one such solution. Indeed, many governments across the European Union (EU), including Malta, are now choosing to invest in technology enabled care as part of their strategic planning for an

(9)

ageing population (European Commission, 2009, 2012; Department of Health, 2013; Parliamentary Secretariat for Health, 2014). The furtherance of this policy direction is primarily being put forward as a form of “technological fix” (Rosner, 2013) to the problems mentioned above. It is argued that by fostering more enabling and supportive environments, these new care technologies will allow more older people to age at home independently, and thus presumably solve the ensuing ‘care crisis’. Besides alleviating the strain on financial and human resources, these technological solutions are foremostly being promoted as benefiting older adults themselves, by way of enhancing their quality of life (Moser and Thygesen, 2015).

Despite the enthusiastic uptake of these technologies, the social dynamics and mechanisms underlying their use remain understudied. It is for this reason, therefore, that I endeavour to explore more critically the social processes involved in the promotion and use of these technological innovations in later life.

1.2 The Maltese Context

Taking the shape of a case study, this investigation is contextualised in Malta - a Southern European island nation, situated at the centre of the Mediterranean Sea. Malta joined the European Union in 2004, and has since then been the smallest and most densely

populated EU member state1. Like other European countries, Malta’s population is ageing.

The latest figures show that by the end of 2013, nearly a quarter of the total population (24.7%) were aged 60 and over (NSO, 2013a). Over the next quarter of the century, the proportion of people aged 65 and above is expected to expand from 16.2% to 24.8% (European Commission, 2015). This proportional increase is projected to be even more significant among those aged 75 and over, were a drastic rise will occur from 6.8% to 13.7% of the population. This gradual shift in the population’s age distribution is illustrated graphically in Figure 1.

1

Malta is an archipelago consisting of three inhabited islands, with a total land covering 316 kilometres squared. The Maltese population stands at approximately 425,834, with a population density of 1330.6 people per square kilometre (European Union, 2016).

(10)

Source: Parliamentary Secretariat for Active Ageing (2013)

Besides population ageing, other social trends are also contributing to added pressure on the Maltese long-term care system. Whilst until recently, informal care by family members, and daughters in particular, was the primary source of elderly care provision (Tabone, 1987), this trend is lately undergoing transformations. A recent surge in female labour-force participation implies that women are finding it more difficult to undertake unpaid care work. Moreover, an increase in longevity also means that informal carers like spouses or adult children, may in the long run come to require care themselves, due to growing older (Formosa, 2014). Altogether, these tendencies highlight the need for expanding formal care provision, in order to meet the care demands for present and future generations.

This escalating demand for formal care is placing further pressure on Malta’s universal-comprehensive health and long-term care (LTC) systems, which provide access to primary health care; acute general hospitals; rehabilitation hospitals; palliative care; mental health; and long-term care institutions (Azzopardi Muscat et al, 2014). While these concerns are primarily of a fiscal nature, unsustainability is also expected to arise with respect to bed capacity and the number of human resources per capita in the health and social care sector.

(11)

Although this apprehension is largely future-oriented, the national LTC system is already being stretched to the maximum2.

Under such circumstances, Maltese ageing policies have undergone major reviews, in an attempt to “steer local policy towards novel directions” (Parliamentary Secretariat for Rights of Persons with Disability and Active Ageing [PSRPDAA], 2013a, p. 4). Particularly noteworthy amongst these new policy directions are the objectives of ‘active ageing’ and ‘ageing in place’ which represent a new dawn for Maltese ageing policy. By encouraging older adults to remain active and live independently in their own homes for as long as possible, the ‘home’ has become a new locus of policy intervention. A number of community-based services have in fact been rolled out by the government to assist older people in achieving these goals, amongst which are the Home Help service, Incontinence service and Meals-on-wheels. Telecare service, which has been on offer since 1991, also forms part of this community-care programme and has lately attracted renewed attention (Pace, Vella and Dziegielewski, 2016). Indeed, in 2013, this service was revamped and upgraded to ‘Telecare Plus’, and has since then been widely promoted as a means of facilitating both active ageing and ageing in place. For this reason, this national government scheme will be the centrepiece of this investigation.

1.3 Defining ‘Remote Care Technology’

While assistive technologies including daily living aids and other forms of housing adaptations (McCreadie and Tinker, 2005) have been on the ‘silver market’ for a long time, recent technological advancements have paved the way for a digital turn. The application of digital technology in elderly care is opening up new possibilities for older people to receive remote care delivery in their own home, by means of telecommunications and computer-based systems (Porteus and Brownsell, 2000).

For the purpose of this research, remote care technology is defined as any device or system making use of ICT, connected to a remote monitoring centre which provides health

2

According to the Parliamentary Secretariat for Health (2014), there is persistent full occupancy of the 4588 LTC beds offered by the public sector. Approximately 2000 older adults are currently on the waiting list to be accepted into one of these institutions.

(12)

and social care directly to the user in and around the home (ibid.). This definition encompasses numerous forms of technology, including those of ‘telecare’, ‘telehealth’ and ‘smart homes’. Although these are closely related to one another, particularly in their mode of care delivery, they each target different needs. While telecare is mostly a reactive response system aimed at enhancing the safety of service users in their home, telehealth offers preventative monitoring of long-term conditions, whereby vital signs are monitored at a distance by professionals (Stowe and Harding, 2010). This investigation will be particularly focusing on telecare service, since current investment in Malta is clearly more pronounced in this sector.

As alluded to earlier, the Maltese Telecare service forms part of the community-care programme, and for those meeting the eligibility criteria, it is highly subsidised by state

funds3. This remote care service is advertised by the government as “provid[ing] a peace of

mind to older adults [...] thus encouraging them to continue living in their own home” (PSRPDAA, 2013b). This service offers 24 hour remote support and assistance, provided through an alarm monitoring system. At the most basic level, it provides the users with a pendant alarm usually worn around the neck, which is connected to an ‘intelligent hub’ installed in one’s home. This central hub is in turn, connected to a remote monitoring centre, where telecare operators are responsible for coordinating care and support for users. Contact with the remote centre can be initiated from both sides; either by the service user who presses the alarm button on the pendant or the hub, or by telecare operators whose voice is then heard directly coming from the central hub. Figure 2 shows the ‘intelligent hub’ currently being installed as part of the Telecare Plus scheme.

3

Eligible persons who can apply for this service include: (a) Elderly couples/persons living alone, aged sixty years and over; (b) Disabled persons and those with special needs; (c) Persons of any age who are afflicted by chronic illnesses and who are living alone and are not gainfully occupied (PSRPDAA, 2013b). Those who do not meet the eligibility criteria may still avail themselves of this service, by purchasing it through the private market.

(13)

Using Porteus and Brownsell’s (2000) classification of telecare systems, the current service offered in Malta is first generation, due to being based on an active system of care. This means that users themselves must activate an alarm call by pressing a trigger button found on both the pendant and the hub, in order to summon assistance (Stowe and Harding, 2010). For those individuals having more complex needs, the Maltese telecare system may be upgraded by purchasing add-ons which provide a more sophisticated form of remote care. These include on-wrist fall triggers, inactivity alert, bed exit and door sensors among many others (Emcare, 2015). These upgrades transform telecare from an active into a passive system, since detectors installed both on the person and in the home, are able to initiate an automatic call during alert situations, such as falls, without the need for the individual to press any buttons (Porteus and Brownsell, 2000).

The recent surge in the use of technology to meet the care demands of an ageing population, has generated considerable research interest across various academic disciplines. Therefore, following this introduction to the research problem, I now turn to examine the literature to gain a better understanding on the subject, and identify any areas which require further exploration.

(14)

1.4 Literature Review

Throughout this section, I provide an overview of relevant empirical and theoretical works related to the use of remote care technology more generally, and telecare service by older adults, in particular. These works have been grouped under three salient themes, namely technology’s effects on quality of life outcomes; home as a place of care; and older adults’ self-identity.

1.4.1 Impact on Quality of Later Life

Many empirical studies conducted on remote care technologies, tend to primarily investigate the effectiveness of these systems, in order to determine to what extent do they enhance their users’ quality of life, as promised by policy-makers. Several studies discussed below, highlight the various ways these technologies have been found to impact on older adults’ wellbeing.

1.4.1.1 Health and Physical Wellbeing

The ageing process is associated with a gradual loss of physiological functions (Walker, 2014), which therefore renders the protection of health and physical wellbeing an essential element of elderly care. Remote care technologies seek to take up such function, by ensuring that older adults living at home are better equipped to handle their altered body status, as independently as possible (Stowe and Harding, 2010). Although these functions fall mostly under the responsibility of telehealth systems, studies demonstrate that telecare may also have indirect benefits on health and physical wellbeing.

These findings emerge especially within the field of occupational therapy. Stewart and McKinstry’s (2011) study shows how having telecare installed in one’s home may prevent falls and minimise fall-related injury. Although the installation of fall detectors or trigger alarms, do not directly prevent older people from falling, they may however reduce fear of falling, which is a primary risk factor of falls in old age. Indeed, Brownsell and Hawley (2004b) argue that by providing a sense of reassurance, telecare reduces older adults’ fear and anxiety of falling, which in turn contributes towards a decreased incidence of falls. Moreover,

(15)

other studies also suggest that if and when older adults do eventually fall, the related consequences such as hypothermia, pressure sores, dehydration or destruction of skeletal tissue, tend to be less severe among telecare users since medical assistance can be summoned quickly just by pressing the alarm button (Lamb, 2001; Fleming and Brayne, 2008). Furthermore, according to some studies, telecare’s immediate response to crisis is associated with reduced hospital admissions, shorter lengths of stay in hospital, and a reduction of mortality rates (Martınez, 2006; Sixsmith et al, 2007). Such findings therefore illuminate telecare’s potential to mediate the physical and biological consequences of ageing and in so doing, contribute to older adults’ physical wellbeing.

1.4.1.2 Personal Safety and Autonomy

The distinctive feature of remote care technology lies in its monitoring function, which allows telecare operators to maintain a stable presence in older adults’ homes. This form of supervision has generated contrasting views among scholars, on the impact it may have on older adults’ lived experiences. Pritchard and Brittain (2014) and Percival and Hanson (2006), emphasise the intrusive and invasive nature of monitoring functions, describing them as a “nuisance” and as evoking a “sense of being watched” (p. 897). Similarly, the work of Sorrell and Draper (2012) provides a Foucauldian analysis to the promotion of telecare systems, claiming that they represent an extension of the ‘surveillance society’. However, while some scholars found remote care systems to be a violation of older adults’ privacy, (Magnusson and Hanson, 2013; Brownsell and Bradley, 2003), others tend to hold a more positive outlook.

Many older adults in various studies, indeed stated that telecare’s monitoring function provided them with a sense of safety and security, due to knowing that someone is watching over them (Cutajar, 2009). In Essen’s (2008) study, Swedish telecare service users claimed that rather than perceiving telecare monitoring as invasive or a threat to their privacy, they equated it to a “friendly eye in the sky”, whose task was to protect them (p. 134). In this regard, Formosa (2015) highlights that this appreciation was more pronounced among those older adults who have had a history of accidental falls or health emergencies, which left them weary and anxious about living alone. Furthermore, López and Domenech (2009) in their

(16)

study with Catalan telecare users, contend that this feeling of safety does not derive from telecare’s capacity to eliminate risks and hazards per se, but rather by providing a form of coverage which equips individuals to deal better with such risks if and when encountered.

An accompanying benefit of feeling safe and protected in one’s home, is a greater sense of autonomy and control over one’s later life (Formosa, 2015; Bowes and McColgan, 2013; Mort, Milligan and Moser, 2008). On a concrete level, autonomy may be understood in its practical sense, whereby individuals feel more confident to undertake simple everyday tasks on their own, such as switching on a light, stepping on a stool or doing chores in the house (Mort et al, 2008). On an abstract level, autonomy is experienced as not having to be dependent on constant direct supervision, which as described by Bowes and McColgan (2013) provides individuals with greater “confidence, freedom of safety and freedom to choose their activities” (p. 40 ).

1.4.1.3 Emotional Support: ‘Cold’ or ‘Warm’ care?

Beyond its functional capacities, remote care has also attracted criticism on its mode of delivery. Some argue that its distant and disembodied nature has implications for the quality of care received, claiming that it produces a form of ‘cold care’, which does not provide its users with concern, affection, and interest (Bauer, 2004; Onor & Misan, 2005). This ‘coldness’ tends to be juxtaposed with the ‘warmth’ of human centred-care, which on the other hand, is able to transmit emotional support (Pols, 2010). The belief is that, for those older adults who are being cared for by technology, “there will be no one to put reassuring hands on shoulders” or to provide “tender loving care” (Pols and Moser, 2009, p. 160). This can have significant implications for older individuals’ wellbeing, who are said to run the risk of becoming affectively and socially deprived. In line with this argument, Pritchard and Brittain (2014) argue that telecare has the potential to unintentionally dehumanise the person it is caring for. In this study, which focused on the alarm pendant system in England, telecare service’s overemphasis on rationality and standardisation, resulted in the “McDonaldization of older people’s care” (p. 1260). Although the large-scale, routinised and uniform nature of

(17)

the service improved the efficiency of its delivery, this was done at the cost of eroding the individuality of service users, thereby producing a form of detached and impersonal care.

Pols and Moser (2009) however seek to destabilise this notorious dichotomy between “cold technologies” and “warm care”. In their research with Dutch older people making use of the ‘Health Buddy’ - a remote patient monitoring system - users were able to develop affective relations with the device, which suggests that emotionality and rationality may indeed be reconciled. Similar findings have emerged particularly in studies conducted in the robotics community, where telecare devices are being intentionally designed to emulate human interaction by conveying mood and emotional responses (Kirby, Forlizzi and Simmons, 2010). These telecare robotic systems appear to hold promise for improving older people’s quality of life, by catering more effectively for their affective and social needs (Sorell and Heather, 2014).

1.4.1.4 Social Connectedness

The remoteness of telecare also raises concern for the social wellbeing of its users, especially with regard to older adults’ level of social engagement and participation in the community. Similar to the arguments outlined above by those emphasising technology’s dehumanising potential, some scholars express concern over the possibility that overreliance on telecare reduces human contact, and may hence contribute to increased social isolation (Rogers et al, 2011; Percival and Hanson, 2006). Robert and Mort (2009) indeed found that by providing greater peace of mind for family members, technology reduced their need to check up every day on the person they cared for. This in turn, induced feelings of loneliness and isolation among older adults who were left alone in the company of sensors and devices. Moreover, participants who reported a heightened sense of loneliness, were often observed to turn to technology itself to fulfil their social needs, by ‘misusing’ the service for the sole purpose of having someone to talk to (Mort et al, 2013; López et al, 2011; Milligan, Roberts and Mort, 2011).

Contrasting findings however also shed light on technology’s capacity to foster increased social participation and connectedness. By allowing older adults to live in their

(18)

home and age more autonomously, Bowes and McColgan (2013) argue that telecare provides individuals with the possibility to maintain contact with friends, neighbours and other community members; thus guaranteeing more opportunities for social engagement. This finding also emerged in Formosa’s (2015) research with Maltese older adults, where participants acknowledged that if it was not for telecare which allowed them to stay in their community, they would have to miss out on various treasured activities; like attending daily mass, or attending the annual village feast. In such cases, telecare may therefore prove to have indirect benefits for older people’s social wellbeing, by creating the necessary preconditions which allow them to remain active in cultural, social and civic activities.

Telecare’s potential to enable older people to age in place, however does not always yield positive outcomes. Studies by Milligan et al (2011), and Aceros, Pols and Domènech (2015), highlight how the spatial limitations inscribed into remote care technologies, risk narrowing the meaning of ageing in place, where ‘place’ comes to be equated solely with the ‘home’. Since many of these devices only operate within the perimeters of the house, a security zone is only established within the user's’ home. Therefore, while staying at home is associated with safety and protection due to telecare’s presence, going out comes to be perceived as risky. This in turn, may lead to social isolation, since older adults are discouraged to leave their “safe haven”, resulting in the shrinking of their social network (Aceros et al, 2015).

The studies examined so far have uncovered the multidimensional effects that remote care technologies may have on the quality of later life. Another emerging theme, which is closely connected to wellbeing, is telecare’ ability to mediate older people’s relationship to place. In this section, I review literature on sense of place and belonging in later life, and how these are influenced by the use of care technology.

1.4.2 Home as the Locus of Care

A central assumption underlying the promotion of remote care technology, is that delivering care directly to older adults’ homes, will encourage them to stay put for a while longer. This itself derives from the premise that the home is the preferred site of care among

(19)

older adults (Milligan, 2009). Below, I uncover the underlying importance of the home as a site of care in later life.

1.4.2.1 A Sense of Place: The Meaningfulness of Home

One main reason why the home has become a matter of great concern among scholars, derives from the understanding that ‘home’ does not merely designate a ‘dwelling’ where one lives (Williams, 2002). Apart from being a physical space, the home is principally an affective space; shaped by social relations, personal meanings, memories and emotions (Blunt 2005; Angus, Kontos, Dyck, McKeever and Poland, 2005; Friedewald and Da Costa, 2003). All these factors are believed to instil in the individual a sense of belonging, which is ultimately what makes ageing at home so desirable (Sixsmith, 1986).

Place-attachment, which as explained by Altman and Low, (1992) involves in the development of bonds which bind a person emotionally to a specific place, is typically felt at its strongest in one’s home (Brown, Altman and Werner, 2012; Rubinstein and Parmelee, 1992). Temporality plays an important role, whereby the longer individuals have lived in a place, the more likely they develop strong affective ties to it (ibid.) This factor is indeed relevant when conducting research with older adults, because of their likelihood to have resided for a longer period of time in their home, compared to their younger counterparts. The concept of ‘autobiographical insideness’, developed by Rowles (1983), makes a strong case for this argument. As he explains, this feeling of insideness among older people living at home “stems from the temporal legacy of having lived one’s life in the environment” (p. 114). The personal history that an individual has in relation to a place, instils a stronger sense of belonging since it comes to symbolise who a person was and who they have become.

Indeed, various theorists postulate that when attachment to a place grows, individuals will start identifying themselves with it, and ultimately incorporate it into their self-concept (Hauge, 2007). Proshansky (1983), one of the pioneers of place-identity theory, defines this type of identity as a “potpourri of memories, conceptions, interpretations, ideas, and related feelings about specific physical settings” (p. 60). Place-identity transcends attachment, when the place - in this case the home - becomes a symbol of the self (Hauge, 2007). Self-identity

(20)

in this case becomes partly shaped by where individuals are situated, and whether they feel as belonging in that particular place (Cuba and Hummon, 1993). In this light, remote care technology which enables older people to age at home, has the potential to foster their self-identity by allowing them to grow older in a meaningful and symbolic place. This is reflected in both Milligan’s (2009) and Bowes and McColgan’s (2013) research with telecare service users, where it has been found that by being able to maintain attachment to their homes and meaningful possessions, older adults are more likely to preserve a positive sense of identity.

Other studies have additionally established a connection between place and wellbeing (Lager, Hoven and Meijering, 2012; Fuller, 2016; Smith, 2009). In their research with older people in New Zealand, Wiles et al (2009) argue that ‘feeling at home’ has helped participants adjust more successfully to old age, by endowing them with a greater sense of autonomy, control and confidence. Drawing on Gesler’s (1992) notion of ‘therapeutic landscape’ helps provide a theoretical understanding of how this connection between place and wellbeing comes about. This concept emphasises the restorative power of certain places, whereby several factors come together to produce an atmosphere which has therapeutic qualities. More specifically, “the natural surroundings, the built environment, symbol complexes, beliefs and expectations, sense of place, social relations [...] and everyday activities, all influence physical, mental and spiritual well-being’’ (Gesler, 1993, p. 186). According to Cutchin (2005), this framework translates well for inquiring about older adults living at home, and how this may contribute to their maintenance of health and wellbeing. By virtue of allowing people to age in an authentic landscape, remote care technology is viewed as carrying great potential for maintaining or enhancing older people’s well-being.

1.4.2.2 Shifting experiences of ‘Home’

Place as a site of care is not a stable and static physical environment. As maintained by Milligan (2009), the home is primarily a “dynamic, negotiated and contested space”, which implies that both the physical structure, and how this is subjectively experienced, may undergo changes (p. 68). These transformations to the meaning of ‘home’ arise from a number of reasons; the first one being directly related to the ageing process. As ageing

(21)

progresses, and older adults’ health and functional status starts declining, certain physical aspects of the home which were previously taken for granted, may come to be experienced as barriers; inhibiting individuals from moving around safely in the house (Sixsmith and Sixsmith, 2008). This fact may thus challenge older adult's attachment to place, and may even undermine its therapeutic qualities. One of the primary purposes of remote care technology is indeed to restore individuals’ relationship with their physical environment. While many times telecare is successful in this endeavour, allowing people to regain their sense of belonging at home (Mort et al, 2013), other works illuminate how the deployment of care technology itself, may reshape the meaning and practices of place (Oudshoorn, 2012).

Scholars are lately raising critical questions on the effects that the pervasive presence of care technology may have on the home and its inhabitant (Domenèch and Schillmeier, 2012; Willems, 2006; Milligan et al, 2011; Angus et al, 2005). In her study on telecare systems, Oudshoorn (2011a) argues that home care technologies may change “the meanings and the experience of being ‘at home’ and ‘in place’” (p. 126 ). The materiality of technological devices is the primary source of concern surrounding this shifting experience. Greenhalgh et al (2013) hold that the “dimensions, shape, colour, durability, size of buttons, brightness of screen and so on” exert powerful influence in how the home space is perceived (p. 87). For this reason, the works of Friedewald and Da Costa (2003), Milligan (2009) and López and Sánchez-Criado, (2009) emphasise the need to ‘invisibilise’ or camouflage these technologies to the best extent possible, so as not to dominate the overall function and experience of the home. Oudshoorn (2011a) however claims that although devices are now becoming more compact and can be easily stored away, they may still influence how older people feel about and relate to their home. Apart from the equipment’s physical properties, its symbolic meaning which commonly evokes imagery of ageing and deterioration, also contributes to technology being perceived as an “unwelcome intruder in the home” (p. 127).

Other research also suggests that technology users themselves may play an active role in moving these devices “from the foreground to the background” (Rogers et al 2011, p. 1080). Whilst some older adults seek to do this by hiding the devices from view (Greenhalgh et al, 2013), others do this through a process of accommodation (Rogers et al, 2011). A common

(22)

technique adopted in this regard, is to conceptualise these technological devices as everyday familiar household objects, so they are perceived as “no different than say a clock radio” (ibid., p. 1080). This technique may be viewed as a form of ‘domestication’; a process in which users shape the use of technology to make it fit their own routines, so that it becomes embedded into their everyday life, and is less noticeable (Silverstone et al, 1996). According to Pols and Willems (2011), all devices need to be domesticated, as a technology’s identity does not solely depend on the design it is given, but emerges as a result of practices in which users try to incorporate it in their day-to-day lives.

1.4.3 Ageing, Technology and Self-identity

Existing literature indicates that change brought about by remote care technology is not solely restricted to the practical experience of everyday life. Indeed, more enduring transformations seem to be implicated with telecare use, with many studies pointing out the various implications it may have on older adults’ self-identity.

As Oudshoorn (2011b) suggests, the moment in which individuals are proposed to start making use of care technology, either by healthcare professionals or relatives, can be described as a ‘fateful moment’. Originating from the work of Giddens’ (1991), this concept refers to those situations where individuals are called on to take decisions that are particularly consequential for their future lives. During these moments, “reflexivity, agency and choice are key transition points, which have major implications, not just for the circumstances of an individual’s future conduct but for self-identity […] through the lifestyle consequences which ensue”(ibid., p. 143). As maintained by Giddens’, self-identity is not a stable and static entity, but is rather a reflexive project which must be continuously negotiated and sustained by individuals themselves. Identity therefore depends on the ability to keep a narrative going, with the aim of achieving biographical continuity; explained by Giddens as an “enduring conception of aliveness” (p. 53). This trajectorial perspective, provides an insightful lens from which to interpret older people’s sense of self, and any possible changes which may be experienced throughout the ageing process, including the introduction of care technology in their lives.

(23)

1.4.3.1 Accepting Technology, Overcoming Resistance

In line with Giddens’ (1991) notion of ‘fateful moments’, many empirical works stress the fact that accepting care technology into one’s life, is by no means a “spontaneous phenomenon” (Aceros et. al, 2015, p. 105). According to Gitlin (1995), acceptance depends on several complex factors. Besides the felt-need and the perceived usefulness of the technology, acceptance is also determined by its implications for one’s identity - that is whether the individual views the device as either enabling or constraining their sense of personal identity. As Formosa highlights (2015), many individuals who at first resisted subscription to telecare, claimed to associate this service with ‘dependency’, ‘ill health’ and ‘frailty’ - images which they deemed not to reflect their view of themselves as ‘active’, ‘independent’ and ‘self-sufficient’ individuals. On the same note, Aceros et al (2015), Neven (2010) and Mort, Roberts and Callén’s (2013) studies, argue that resistance to technology emerges from a discrepancy between older adults’ self-image, and the stereotypical image of care technology users. Individuals therefore do not only reject the device, but also the identity that comes with it; imbued with age-related assumptions focused around ‘losses’ and ‘risks’ (ibid.).

Other studies moreover highlight that some subscribers, never manage to fully embrace the presence of technology in their life. In these cases, elements of resistance and subversion in the way devices are used are often observed. Several participants in a number of studies, for instance chose not to wear their pendant device, or only used it selectively on their own terms (Pritchard and Brittain, 2015; Gómez, 2015). In these cases, not abiding by the technology’s script, may be interpreted as an attempt by individuals to shield themselves from the need to re-adjust their own identity, hence ensuring that it is not threatened. Aceros et al (2015)’s research suggests that one possible way to mitigate this discrepancy in identity, and facilitate acceptance, is by engaging in ‘identity work’. Health professionals, social workers, telecare workers and relatives in this study were many times observed as trying to enforce an identity on older adults characterised by “necessities”, “risks” and “losses” (p. 105). This was done with the aim of encouraging an identity shift, so that older adults would be more willing to welcome these technology into their homes, and appreciate their benefits.

(24)

Acceptance of telecare reaches its peak when the technological device becomes embodied. This embodiment of technology, which is theorised about by Ihde (1979, 1990), occurs when the device is no longer seen as a foreign object that is external to the individual, but rather becomes a medium through which the external world is experienced. When this occurs, technology cannot be isolated from what older individuals see, feel, think and do, since it becomes a part of who they are. Indeed, it acts as a “transparent mediator between oneself and the world” (Poland, Lehoux, Holmes and Andrews, 2005, p. 175). Through this process, technological devices therefore become a (taken for granted) part of users’ selves.

This acceptance is sometimes also accompanied by a re-articulation in users’ identity (Peine et al, 2015; Chapman, 2006). One of the most significant influence in this regard, may be observed in Aceros et al (2015)’s study which argues that some older adults became ‘docile users’. By way of internalising the age-related assumptions imbued in their devices, some individuals incorporated these characteristics into their self-concept and started living up to these ageist expectations. In these circumstances, users became highly reliant on technology to feel safe and secure, which impeded them from leading active lifestyles. In other scenarios, older adults’ also claimed to encounter stigmatising because of telecare (Lupton and Seymour, 2000; Gitlin, 1995). Alarm pendant users in Pritchard and Brittain’s (2015) research for instance argued that wearing a pendant highlighted their age, which occasionally reinforced ageist social prejudices. This not only had profound implications on their social identity, but also led them to re-evaluate their personal identity.

Other studies, in contrast, carry more positive overtones with respect to technology’s influence on identity. Both Formosa’s (2015) and Bowes and McColgan’s (2013) study suggest that once participants familiarise themselves with the equipment, telecare may have positive implications for their “sense of belonging, appreciation by others, and a positive construction of the self” (p. 43). Both these studies also acknowledge the role of the social network in fostering this positive self-identity, as having friends and acquaintances subscribed to the same service helps to reduce the stigma associated with its use.

(25)

This review of existing literature indicates the pertinence of three main themes when examining the use of remote care technology in later life, namely those of wellbeing, place, and identity. As suggested above, extensive research has been conducted in relation to each of these themes. Nevertheless, it has emerged that hitherto, these important factors have been explored in a piecemeal manner; in isolation from one another. It is in this light, that this research study attempts to provide a more integrated and coherent view of the social processes underlying the use of telecare; by way of capturing their interrelating complexities in older adults’ lived experiences.

1.5 Aims and Objectives

Bearing in mind the fragmentary nature of previous studies, these research aims and objectives seek to encompass each of these three related themes. Therefore, the purpose of this research is to investigate how the introduction and use of remote care technology in Maltese households, by older adults aged 65 and over, is affecting their sense of well-being, place and self-identity. In order for this aim to be achieved, this inquiry will be guided by the following research objectives, which seek to explore and analyse:

• The patterns of remote care technology use in the home

• How the introduction of remote care technology influences older people’s meaning of

their home

• The impact of remote care technology on older adults’ access to and perception of

social networks

• How the use of remote care technology influences older adults’ self-identity

• How policy assumptions on ‘active ageing’ and ‘ageing-in-place’ relate to older

adults’ everyday practices with remote care technology.

By pursuing these objectives, this research will contribute towards a better understanding on both the usage of technology in its own right, and also in its capacity to re-shape the experience and potential outcomes of ageing. Moreover, since this inquiry is foremostly inspired by the policy context in which these technologies are being deployed, research findings emerging from older adults’ experiences, will be examined in relation to wider

(26)

policy discourses. This will ultimately illuminate whether the use of remote care technology indeed constitutes a ‘technological fix’ to population ageing in the Maltese context.

1.6 Thesis Outline

Following this introductory chapter which has explained the research problem, reviewed relevant literature and outlined the aims and objectives of this study, the rest of this thesis is organised as follows. Chapter 2 gives a detailed description of the research methodology and methods, while Chapter 3 presents a critical analysis of how growing old in Malta is discursively constructed, by looking at both policy discourses and participants’ accounts. Chapters 4 and 5 then expand on the research findings emerging from fieldwork, by focusing respectively on the meaning and role ascribed to telecare throughout the ageing process, and the nature of care that is provided through telecare. Thereafter, Chapter 6 concludes the study by synthesising and discussing the key findings in light of the research aims and objectives.

(27)

Chapter 2 Methodology and Methods

This chapter seeks to elaborate on the methodological processes underpinning this inquiry, which have ultimately led to the fulfilment of this study aims and objectives outlined earlier on. In the following sections, I will therefore be providing an elucidation of the overall research process, including the underlying philosophical and methodological decisions, the sampling and recruitment process, research methods, data collection and data analysis process. Thereafter, the ethical considerations and limitations pertaining to this research will also be discussed.

2.1 Research Approach

In order to explain the research process in a logical and coherent manner, this section will be outlining the four key decisions which were taken during the design and planning of the study. These include the epistemology, the main theoretical perspective, the research design and the methods used.

2.1.1 Constructivism

This investigation is predicated on older adults’ subjective experiences of telecare use, and for this reason, the epistemological roots of this research lie in constructivism; a tradition which attempts to steer away from objective explanations of the social world. This inquiry has therefore presupposed that reality is not inherent in phenomena, lying outside of human subjectivity. It was rather seen as being constructed by individuals themselves as they interact with and seek to interpret these phenomena. Accordingly, I presumed that a myriad of meanings will emerge from the use of remote care technology in later life, since every older adult interacts with and makes sense of these devices in their own particular way; depending on their circumstances and the social context in which they are situated. This said however, I want to clarify that this research did not subscribe to a radical form of constructivism, which negates the actual existence of phenomena. Rather, a “softer” version of constructivism was adhered to, which is in line with Crotty (1998)’s standpoint, presuming that “social

(28)

constructionism is at once realist and relativist” (p. 63). To claim that reality is socially constructed is not to say that phenomena do not exist outside human subjectivity, but it is to recognise that the way these are seen and made sense of by individuals, is a product of social interactions (ibid.). Therefore, while realism here has been put forward to acknowledge the existence of certain entities in the real world including the ageing process, the physical environment surrounding individuals and the technological devices, a relativist perspective was adopted to inquire on the meanings attributed to them. From this perspective, meaning was therefore expected to emerge from both the objective properties of these entities which exert an influence on their users, and also, from users’ unique experiences and interactions within their environment.

2.1.2 Interpretive Approach

In line with this constructivist epistemology, interpretivism was selected as the main theoretical perspective informing this study. Since the cornerstone of this research is to achieve an understanding on the meanings constructed by older adults, this approach was deemed ideal given its emphasis on the subjective component of meaning-making. Indeed, this perspective proved to be a valuable source of theoretical inspiration when probing into how meanings are created, negotiated, sustained and modified by older adults (Schwandt, 2003).

As suggested by Weber (1925) - a leading proponent of interpretivism - in order for social researchers to truly grasp the meaning of a phenomenon under investigation, they need not only look at what people do, but also focus on what they are thinking and feeling. Bearing this in mind, the principle of Verstehen played an important role throughout this research, as I sought to address the research problem directly from the point of view of those concerned; in this case, older people subscribed to telecare service. By providing these individuals with a voice, I was able to obtain first-hand accounts of the issue under investigation. During this process, I sought to remain open to new knowledge, allowing it to develop through a collaborative process with my participants.

(29)

2.1.3 A Case Study Method

As alluded to earlier on, this research takes the shape of a case study design, whose purpose is to “derive an up-close and in-depth understanding of a single case” (Yin, 2012, p. 4). I chose to do a case study for its ability to provide a thorough and focused investigation, which is at the same time, sensitive to the context in which it is located. For the purpose of this inquiry, the case under study was the use of telecare technology by Maltese older adults, with the primary unit of analysis being the meaning ascribed to these technologies. Since contextual factors are deemed to be crucial for obtaining a comprehensive and nuanced understanding of the case, the social, cultural, and political conditions of the Maltese context were treated as an integral part of the investigation.

2.2 Data collection

Following the design phase of the study, the next step of the research process was to collect data. The data collection process was initiated by selecting the participants to be included in the study. This required the identification of the study population which consisted of Maltese older adults, aged 65 and over, who are subscribed to ‘Telecare Service’ or the upgraded ‘Telecare Service Plus’. According to latest figures, this total population amounts to 9000 users, with 2500 of them being subscribed to the latter service (Malta Today, 2015). From this relatively large population size, a small sample of individuals was selected in order to gain an in-depth understanding of their experiences and views.

2.2.1 Sampling Strategy

In line with the qualitative nature of this study, I opted for a purposive type of non-probability sampling. This granted me a higher degree of flexibility in the sampling process, thereby allowing me to be strategic in my decisions on who ought to be selected or not. More specifically, I followed the principles of theoretical sampling to guide me through this process, whereby sampling was carried out on the basis of concepts emerging during data collection itself, which proved to have theoretical relevance to the developing theory (Corbin and Strauss, 1990). The initial stages of sampling required the formulation of a set of eligibility criteria which determined the requisite characteristics individuals must possess to

(30)

be selected as research participants. It was decided, that the first few participants had to be: (a) of a Maltese nationality (b) aged 65 years and over, and (c) subscribed to Telecare Service. Once data collection with the first three participants was underway, data was simultaneously coded and analysed, which then led to the formation of tentative concepts and categories considered to be central to the research question. In order to further pursue these ideas, the sampling criteria had to be adjusted in mid-course, so as to ensure that the data generated by selected participants, reflected and built on the emerging concepts and categories. One important adjustment was the inclusion of both homebound and active older adults in the sampling criteria. This was done with the aim of further pursuing certain ideas, which were raised by other participants regarding telecare use vis-a-vis users’ level of activity. Ultimately, this strategy helped ensuring that newly selected participants were able to contribute substantially to the development of this idea.

Besides theoretical sampling which laid out the framework for participant selection, snowball sampling also came in handy, especially when recruiting hard-to-find participants. This was particularly the case when recruiting homebound older adults who proved to be more difficult to locate than the rest. In the course of some interviews, I therefore started asking participants if they knew anybody from their personal network who possessed these characteristics and fitted the purposes of my study. After verifying that the recommended individuals did indeed qualify for inclusion, arrangements were made to establish contact with them. However, bearing in mind that sampling bias is a strong limitation inherent in snowball sampling, as participants are more likely to nominate those individuals who possess similar traits, effort was made to not rely on this technique more than necessary.

Given that the sampling process was primarily driven by theoretical sampling, the principle of theoretical saturation was applied to determine the study’s sample size. As explained by Glaser and Strauss (1967), theoretical saturation occurs when “no additional data are being found whereby the sociologist can develop properties of the category” (p. 61). Taking into account the time and resource constraints characterising this Master’s research project, a practical decision was taken to reach saturation only for those categories considered

(31)

as central to the research findings. Under these circumstances, saturation was approximated after data collection had taken place with fourteen participants.

Overall, although this sampling procedure proved to be quite complex at times, particularly due to its iterative nature, it has been equally productive by allowing me to explore the use of telecare from a multiplicity of viewpoints. Being able to select a varied set of participants, helped yield more diverse and richer data, in terms of both the properties and dimensions of emergent concepts and categories.

2.2.2 Recruitment Process

The recruitment of participants was carried out through a variety of strategies, and was spread over a total period of eight weeks. The necessary preparations started four weeks prior to entering the field, while the remainder of the recruitment process was carried out in tandem with data collection. The first step was to identify gatekeepers who are in close contact with older populations, which included both personal contacts and organisations. Two particular gatekeepers, namely a community care nurse and a home helper, were indispensable during this phase. After ensuring that they were adequately informed about the study, these gatekeepers were asked to present the research project on my behalf, and pass on to me the contact details of those older adults’ who gave consent. I later contacted those older adults who had shown interest, to provide them with additional information on the study, double-checking their eligibility, and scheduling an appointment for the interview. This recruitment strategy was by far the most successful.

Another recruitment approach I adopted was to attend various day centre facilities located around the island, whose services target particularly those older individuals who live alone and are not engaged in any social activities (Department for the Elderly and Community Care, 2013). With the permission of the centres’ managers, I was able to present my research project during information sessions for which the elderly were all present. At the end of this brief presentation, I chatted with those who were interested and I took the opportunity to schedule an appointment for the interview. In order to vary the participants’ background, I decided to attend other activities aside day centres, including a coffee morning

(32)

organised by a parish church, and a local band club4. Similar recruitment strategies were pursued in both settings. A final strategy, which proved to be the least effective of all, was the placing of flyers in various venues, including eight doctors’ offices, some local councils, and churches. On these flyers, I inserted a brief description of the research, details on participation and my contact details (See Appendix A).

Overall, the recruitment process was plain-sailing and no major obstacles were encountered. Generally, older people, most particularly women, tended to welcome the opportunity to share their stories and views on their ageing experience and appeared to enjoy the company of a researcher in their homes.

2.2.3 The Participants

Fourteen participants, eleven women and three men, were interviewed in total, with their ages varying from sixty-five to ninety-four years of age. All participants were Maltese, either living alone or with a spouse, and all of them were subscribed to Telecare service. Twelve participants owned the standard pendant alarm system, while another two made use of fall detectors. Moreover, research participants also displayed varying levels of functional capacity, with some claiming to be in good health and still leading active lifestyles, and others to a lesser degree. Additionally, two key informants were also recruited: one being an 80 year old woman who had a wide personal network in the community, and a 75 year old woman who despite not being subscribed to telecare was extremely helpful in providing me with general information on the ageing experience in Malta. An overview of the participants’ characteristics can be found in Table 3. Pseudonyms are used in order to protect the anonymity of individuals.

4

Maltese band clubs are meeting point for locals, situated in every village around Malta, where people engage in activities related to village festas, play snooker and cards. Since these band clubs represent traditional village life, they are mostly frequented by male older people. Indeed, I visited a band club to specifically recruit older males.

(33)

Name Age Living Arrangement Duration of Subscription Technological System Recruitment

Dolores 75 Alone 7 Pendant System Personal

Contact

Stella 83 Spouse 7 Pendant System Community

Care Nurse

Frida 79 Spouse 18 Pendant System Community

Care Nurse

Giorgia 72 Alone 10 Pendant System Community

Care Nurse

Sandra 83 Alone 18 Pendant System Snowball

Connie 78 Alone 8 Pendant System Day Centre

Rose 65 Alone 6 Pendant System Home Helper

Marianne 74 Alone 10 Pendant System Day Centre

Carmen 79 Alone 13 Pendant System Day Centre

Catherine 80 Alone 2 Pendant System Coffee Morning

Edward 94

Alone/ Residential

Home

3 Pendant System Home helper

Anthony 69 Spouse 2 Pendant System Band club

Nina 70 Grandchild 18 Fall Detector +

Pendant Flyer

Saviour 75 Alone 5 Fall Detector +

(34)

2.3 Data Collection Techniques

Empirical data was collected using a multi-method approach, comprising of policy document analysis, in-depth interviewing, and observation. Data generated from these varied methods were believed to complement one another; shedding light on both ageing assumptions at an institutional level, and first hand experiences at the individual level.

2.3.1 Policy Analysis

The use of policy document analysis was motivated by the objective to explore how Maltese ageing policy discourses on population ageing, caregiving and the use of technology, relate to older adults’ everyday practices and experiences. To carry out this analysis, I made use of Bacchi’s (2014) ‘What’s the Problem represented to be’ (WPR) approach. This approach steers away from the conventional view that policy problems exist ‘out there’ waiting to be discovered and solved by policy-makers. Instead, it presumes that policies themselves are problematising activities constituted in discourse. By their very attempt to solve ‘problems’ - in this case population ageing - they imply a certain understanding of what needs to be changed, which thus contributes to the shaping of these problems (p. x). The first step involved in carrying this out was to choose which official documents were pertinent to the research. Following a review of a number of policies and parliamentary debates, featuring the topics of old age, care and technology, I settled on analysing the ‘National Strategic Policy for Active Ageing’ (PSRPDAA, 2013a) Applying Bacchi’s approach to this documents, has granted me the opportunity to engage in a critical mode of analysis, devoting my attention not to the contents of the policies per se - but rather to their underlying problematisation of ageing, and the assumptions underpinning these constructions. This, in turn, has provided me with a better contextualisation of telecare promotion from a top-down perspective.

2.3.2 In-depth Interviewing

In contrast to the institutional perspective gained through policy analysis, in-depth interviews allowed me to gain access to older adults’ stories thoughts, attitudes and experiences on the use of telecare in their daily life. Using this research method as a primary

(35)

source of data collection has complemented earlier methodological decisions, by way of reinforcing the interpretivist properties of this inquiry.

All interviews were carried out in participants’ own homes. Besides ensuring participants’ convenience, the home was regarded as an ideal interview site due to granting me access to two important issues in this investigation; namely the telecare system which is installed in the household, and the household itself. The sessions lasted approximately an hour and were conducted in the Maltese language - the native language of both the interviewer and participants. Interviews followed a semi-structured approach, and were conducted in a friendly and informal manner. A set of interview questions reflecting the themes which emerged from the literature review, were prepared from beforehand in order to guide me during the session (See Appendix B). These questions focused particularly on the decision-making process, patterns of telecare use, subjective wellbeing, social support network, attachment to place, the materiality of technology and the effects of telecare use on self-identity. I initiated the interviews by introducing myself and the research, and invited participants to tell me something about themselves. At this stage, many interviewees started chatting about their children and grandchildren, pointing to photo frames on walls, and taking out photo albums from their drawers. I welcomed these occasions as an opportunity to break the ice, and develop a rapport with them. Following this introductory phase, I proceeded to asking the questions found on the interview schedule, in a flexible manner as possible. This allowed participants to express themselves freely, and also enabled me to pursue new ideas which emerged in the course of the interview. Probing questions were particularly useful in this regard, allowing me to prompt participants into expanding more on an interesting response, or clarifying what has just been said. The flexibility in the interview schedule also proved beneficial since every participant had a unique story to recount and I was thus able to adapt the questions to the particular situation at hand.

During these interviews, an object-elicitation method was used, inspired by the work of Woodward (2015). Before the start of each interview, participants were advised to make their technological devices accessible, in order to guide our discussion. Throughout the interview, participants were then invited to purposely engage with their pendant alarm, especially when

(36)

asked questions on the design and the material properties of the technology. While answering these questions, many participants have paused a couple of times to look and touch their device before resuming to talk about it. Sometimes they even handed me the device, asking me to see for myself, wanting me to affirm what they have just said. Choosing to introduce this object-elicitation method, was a methodological attempt at generating data related to the socio-material aspect of technology. Since this latter perspective recognises the mutual dependence between the material and the social dimensions of technology in shaping one another, it was deemed crucial to not only collect data evoking the social reality of remote care technology, but also shed light on its material elements contributing to the shaping of this reality. As asserted by Woodward (2015), “the material properties of things are central to understanding the sensual, tactile, material and embodied ways in which social lives are lived and experienced” (p. 1). In this light, the object-elicitation method has greatly facilitated the participants’ task to express their views on the materiality of the device. By wearing the pendant alarm around their neck, or holding it in their hands, participants were able to articulate their thoughts in a more concrete manner, by way of translating their embodied experiences into verbal accounts. Ultimately, this method helped generating more detailed and richer data, since I was also able to acquire multisensory data rather than mere verbal accounts.

2.3.2 Observation

Although observation has played a less central role in the data collection process, it proved nonetheless indispensable to further contextualise the data obtained from the interviews. Observation was conducted in two different situations and was motivated by different aims. In the first scenario, I conducted observation at some participants’ homes; usually in the first few moments preceding the interview, and for a more extended period afterwards. During this observation period, I invited older adults to show me around their house, where I paid close attention to the aesthetics of the home, and how care technology fitted into their rooms. During these moments, I also sought to acquire multisensory data, by paying attention to not only what I was seeing, but also to what I was hearing, smelling and touching. Acquiring a form of embodied knowledge through these observations helped me

(37)

generate richer data, by way of corroborating participants’ accounts emerging during the interview.

Another form of observation was conducted in a number of community settings, attended primarily by older people. Bearing in mind that a case study design upholds the importance of contextual factors, I decided to observe Maltese older adults in a number of social settings, including two government day centres, a parish church and a local band club5. These sessions helped me gain better insight on some aspects of Maltese later life, which then proved insightful when making sense of the overall data gathered in this research.

Following all fieldwork sessions, extensive field notes were written down, comprising both descriptive information on the actors, context, behaviours, and conversations; and reflective information including personal thoughts and preliminary ideas for analysis. These field notes were later found to be extremely useful, especially when analysing my data and writing down memos. This latter process will be explored in greater detail below.

2.4 Data Analysis

Thematic analysis was used to analyse and interpret the data gathered through in-depth interviewing and observation. In its most simplest form, this procedure involves in searching through data to identify, analyse, and develop different themes (Braun and Clarke, 2006). Using this analytic technique offered a high degree of flexibility to the interpretation of data as with contrast to alternative methods, it is not bounded by a theoretical framework which focuses the analysis upon a certain aspect or phenomenon. This benefit however, may at times also prove to be a weakness, since it does not guide the researcher on how to find codes or themes from a text (Bryman, 2008). In order to minimise this risk, thematic analysis followed the ‘logic of abduction’, whereby coding, categorisation and the generation of themes was guided both by the data itself, and also by the main theoretical approaches outlined in the literature review (Timmermans and Tavory, 2012).

5

Observation in these settings took place on the same day that I attended these centres/ activities to recruit participants.

Caring through a ‘plastic box’ : an inquiry into the use of remote care technology in later life