Elderly Care Technologies
A Master’s thesis
february 2015 - march 2017
daan oudejans
student number: 6293255
mentor: prof george demiris, phd
FACMI Alumni Endowed Professor in Nursing, School of Nursing
Professor in Biomedical and Health Informatics School of Medicine Director
Clinical Informatics and Patient Centered Technologies Graduate Program Director
University of Washington Box 357266
Seattle, WA gdemiris@uw.edu
tutor: prof monique jaspers, phd
Director (under)graduate Institute of Medical Informatics Adjunct head Department Medical Informatics
Academic Medical Center- University of Amsterdam Room J1B-114-2 PO Box 22700 1100 DE Amsterdam The Netherlands m.w.jaspers@amc.nl secretary office: (+) 31 20 5665269
This Master’s thesis consists of four articles focusing on privacy aspects in elderly care technolo-gies. The rapidly growing group of older adults (65+ years of age) requires change in the current health care setting. A possible solution might be the use of assistive health care technologies. The market for technologies in health care expands as it becomes more important. However, with these new interventions, privacy issues may occur. The first paper provided an overview of the current literature on privacy concerns in technologies in elderly care. Relevant literature regarding IT or technological interventions in elderly care, specifically mentioning privacy as an issue or concern, were included. Privacy, the right to be let alone, including the concerns regarding it, can be divided among three categories: physical (the freedom from contact with others or exposure of one’s body to others), informational (prevention of disclosure of personal information) and decisional privacy (ability to make and act on one’s personal choices without interference from others).
The second paper provides an overview of frameworks used to evaluate privacy concerns in technologies and how those frameworks could be adapted to elderly care settings. Three frame-works were found to meet the inclusion criteria: the obtrusiveness framework from Demiris et al., the J8 privacy framework from Lorenzen-Huber et al., and a framework from Bellotti and Sellen. The frameworks were merged and framework categories were clustered in physical, informational, and decisional privacy aspects. This merged framework provided groundwork for further the third and fourth paper.
The third paper is a Phase I study adapting the merged framework, evaluating privacy concerns in three technologies used in elderly care settings: a smart-TV, a wearable device, and a digital companion. This paper assesses the differences in opinions regarding privacy in elderly care technologies in various ages and technologies by filled out questionnaires. Although younger and older adults both agreed upon physical privacy aspects, this quantitative study shows that older adults have more serious privacy concerns regarding the assessed technologies on other pri-vacy aspects. These results were an incentive to provide a more in-depth analysis - the fourth paper.
The fourth and final paper is a Phase II study focusing on privacy concerns the older adults encounter, whilst using the digital companion from the third paper for three months. Next to quantitatively analyzing differences in opinions between the group of older adults from the third paper and this study’s participants, we interviewed them as well. These interviews lead to a complete coverage of the merged framework by clustering the answers on the themes of the survey. In future studies it might be interesting to perform a similar study using the framework for evaluating other elderly care technologies privacy concerns. A comparison between privacy concerns in different technologies would become available, and privacy concern trends could be discovered for disclosing privacy concerns and ensuring technology user privacy.
Deze thesis is gemaakt bestaat uit vier verschillende papers. Door de snelgroeiende demografische groep van ouderen (65+-ers) is er een verandering nodig in hoe de zorg is opgebouwd. Het ontwikkelen en gebruik van zorgtechnologieën kan een mogelijke oplossing bieden. Het mark-taandeel hierin stijgt daarbij dus ook aanzienlijk. Desalniettemin, bij deze nieuwe ontwikkelingen, kunnen privacy-gevoeligheden ontstaan of over het hoofd worden gezien. De eerste paper is een literatuur studie gericht op recente literatuur van privacy concerns* in technologieën gebruikt in de ouderenzorg. Dit kleinschalige literatuuronderzoek geeft een overzicht van bestaande literatuur rondom deze privacy concerns* in technologieën. Privacy, het recht op zelfstandigheid en om alleen gelaten te worden, en de bezorgdheden hieromheen, kunnen worden opgedeeld in drie aspecten: Physical* privacy (het voorkomen van blootstelling of contact van het lichaam met anderen), informational* privacy (het voorkomen van openbaarheid van persoonlijke en gevoelige informatie), en decisional* privacy (de vrijheid om zelf te mogen kiezen en besluitvorming te kunnen voeren zonder de invloed van anderen).
De tweede paper is gericht op frameworks die het evalueren van deze privacy concerns* in technologieën mogelijk maken, en hoe deze frameworks vervolgens toegepast zouden kunnen worden in de ouderenzorg. Drie frameworks voldeden aan de inclusie criteria: the obtrusive-ness framework van Demiris et al., the J8 privacy framework van Lorenzen-Huber et al., en het framework van Bellotti en Sellen. De frameworks zijn samengevoegd op subcategorieniveau en vervolgens weer opgedeeld onder physical*, informational*, en decisional* privacy. Dit gecom-bineerde framework gaf een basis voor de vervolgstudies. De derde paper is een Phase I studie welk de gevonden frameworks toepast op het vinden van privacy-gerelateerde meningsverschillen tussen verschillende leeftijdsgroepen over drie verschillende technologieën: een smart-TV, een draagbare monitor, en een digital companion*. Hoewel de jongeren en ouderen in deze studie dezelfde mening deelden met betrekking tot de physical privacy* aspecten, liet deze studie zien dat er meer serieuze zorgen spelen bij ouderen rondom andere privacy aspecten in de nieuwe technologieën. Dit gaf aanleiding tot een nog specifiekere studie en analyse - de vierde paper.
De vierde en laatste paper betreft een Phase II studie die gericht is op het evalueren van privacy concerns* tijdens het gebruik van de digital companion*. Naast de kwantitatieve vergelijking van de surveys met de groep ouderen in de Phase I studie, werden de participanten ook geïnterviewd. Door deze interviews kwam het hele gecombineerde framework aan bod, en konden aspecten die niet waren gedekt met slechts de questionnaires, ook worden geëvalueerd. Daarnaast konden de gemapte interviews ook worden gebruikt als onderbouwing op de antwoorden gegeven in de vragenlijsten. In de toekomst zou het interessant zijn om een soortgelijk onderzoek uit te voeren over verschillende technologieën. Op deze manier kunnen trends ontdekt en opgelost worden met betrekking tot privacy concerns* en kan duidelijker worden wanneer het waard is om de trade-off van veiligheid voor autonomie en zelfstandigheid, laten plaats te vinden.
Niet vertaalde begrippen uit het Engels, bv. door ambiguïteit (aangegeven met een asterisk): - Privacy concerns: Privacy-gerelateerde bezorgdheden.
- Physical privacy: Fysieke privacy, voorkomen van blootstelling of contact van het lichaam met anderen - Informational privacy: Informatiegerichte privacy, het voorkomen van openbaarheid van persoonlijke
interventions in long-term elderly care
facilities: An overview of the literature
D Oudejans
1,2Supervisor: Prof. G Demiris
1Mentor: Prof. M.W.M Jaspers
21Health-e, Biomedical Informatics and Education, University of Washington
2Department of Medical Informatics, Amsterdam Medical Center - University of Amsterdam daano@uw.edu
Abstract
Introduction The rapidly growing group of older adults (65+ years of age) requires change in the
current health care setting. A possible solution might be the use of assistive health care technologies. The market for technologies in health care expands as it becomes more important. However, with these new interventions, privacy issues may occur. This small literature review will provide an overview of existing privacy concerns of (elderly) care technologies.
Methods Relevant literature regarding IT or technological interventions in elderly care, specifically
mentioning privacy as an issue or concern, were included. PubMed was used finding literature not older than 15 years with the search strategy: "Privacy"[mesh] AND "Aged"[mesh] AND "technology".
Results The initial search considered 11 articles to be relevant, based on title and abstract 16 more
articles were included from the reference list of the initial 11 articles - a total of 27 articles were included in this review. Privacy, the right to be let alone, including the concerns regarding it, can be divided among three categories: physical (e.g. cameras, or uncomfortable wearing devices), informational (e.g. sharing information), and decisional privacy (i.e. autonomy and the dependency on the technology) con-cerns. With every new technology comes new concerns where a trade-off between privacy and safety occurs.
Conclusion To keep one’s safety, a trade-off with the adults’ independence and autonomy has to take
place. Privacy concerns could be categorized among physical, informational, and decisional privacy. Future research should explore different (validated) frameworks, focusing on privacy in elderly care technologies, in order to create a validated measure standard for scaling privacy concerns in care technologies.
I.
Introduction
Older adults (those 65 and older) are a growing demographic group projected to almost double in US population from 2000 to 2050.[1] This increased longevity is attributed to advancements in care and quality of life, though older adults also face challenges such as chronic health conditions, reduced mobility, social isolation and cognitive decline. Independence and self-efficacy are key considerations for older adults though a balance exists with the recognition that these values should not come at the cost of safety or quality of life.
The consumer market explosion of mobile health applications, wearable devices and sensors (i.e., Fitbit and Jawbone), remote monitoring devices (i.e., monitoring vital signs such as blood pressure), and other technological interventions is growing as more consumers gain access to technology and the U.S. healthcare system advances to a digitally-based health information in-frastructure. "Quantified Self" is becoming a popular term used to describe a technology use movement that combines self-monitoring and self-tracking technologies for acquisition of data to track behaviors, such as physical, mental, and social[2][3]. The fast growing elderly population re-quires a structural, might be technological, change in current health care. Mentioned technological and IT interventions are considered a useful method in changing the current care infrastructure by assisting home-bound older adults or in other methods relieving pressure of caregivers.
I.1.
Aim
The new monitoring devices can be obtrusive and invading privacy of elderly patients. This literature review will provide an overview of privacy issues occurring in technological care in-terventions and how they could be assessed. The question was, to what extent does privacy invasion occur in elderly care technologies and how can these issues be clarified by following certain frameworks that categorize privacy?
II.
Methods
We searched for relevant literature regarding the privacy issues of using IT or technological interventions in elderly care. The type of intervention was unspecified to provide a more general overview of these concerns concerning health information technology for elderly. Due to the fast evolving field of these kind of interventions, literature older than fifteen years (published before 2000) was excluded.
To find the relevant literature, we searched on PubMed with the search strategy: "Pri-vacy"[mesh] AND "Aged"[mesh] AND "technology" AND "privacy". An article was included when technology was used as an intervention in an elderly care setting. Moreover, privacy had to be discussed and explicitly mentioned as an issue or concern. The literature’s title and abstract were read carefully to see if inclusion criteria were met. When in doubt, we read the complete article, allowing us to better comprehend the article and derive a better decision on inclusion.
After reading the selected articles, we used the snowballing method including references of those articles based on title, citation, and if unclear, abstract. The same inclusion and exclusion criteria were used on the articles provided from the snowballing method.
III.
Results
III.1.
Study Characteristics
The initial literature search yielded 27 hits, of which eleven articles met the inclusion criteria. After examining the used references in these articles, the snowballing method yielded more articles of which sixteen were included based on title and abstract, supporting the statements of the ar-ticles found in the initial search. Table 1 provides an overview of the characteristics of all 27 arar-ticles. Of the 27 articles, eleven were published in a medical journal, nine in a medical technological journal (about 73% of the total), others were published in a nursing, psychology, or ethics journal. The articles consisted of five systematic reviews, three reviews, eight clinical trials, ten descriptive papers often combined with focus groups, and one evaluation study. The location were the studies took place, or where literature was sought for, almost always included North America or Europe (93%). In case of multi-continent studies, Australian and Asian studies were often taken into account as well.
III.2.
Study Population
The study population refers to what kind of participants or patients were selected during clinical trials and focus groups, and what kind of participants or patients were sought for in the (system-atic) reviews. 85% of the studies clearly stated focusing on merely older adults (65+ years of age), whilst only 7% used both older as younger adults (for comparison in opinion for example). No studies stated to have particular interest in one gender over the other.
Most studies focused on nonspecific conditions and caregiving, like care in general health problems in long term settings or dementia care. 93% of the articles covered this. In 56% of the articles a health care professional was involved in the research, this could mean a nurse in care settings, a psychologist, or a multidisciplinary team of physicians.
Table 1: Literature characteristics Study characteristics n %a Journal type Medical 11 40.7 Nursing 1 3.7 Psychological 4 14.8 Ethics/Policies 2 7.4 Technologicalb 9 33.3 Location of study North America 10 37.0 Europe 7 25.9 Asia 2 7.8 Multi-continent 8 29.6 Topic
Nonspecific conditions (e.g., general health problems) 15 55.6
Caregiving (e.g., for dementia) 10 37.0
Psychosocial issues (e.g., bereavement) 2 7.4
Study design
Systematic Review 5 18.5
Review 3 11.1
Clinical Trial 8 29.6
Descriptive (with focus group) 10 37.0
Evaluation study 1 3.7
Health professional involved
Nurse 6 22.2 Psychologist 2 7.4 Multidisciplinary team 7 25.9 None 12 44.4 Patient/Participant characteristics Age 65 and over 23 85.2 64 or less 0 0 Both 2 7.4
Unknown or not clearly stated 2 7.4
Gender
Female only 0 0
Male only 0 0
Both 22 81.5
Unknown or not clearly stated 5 18.5
Target population
Caregiver only 2 7.4
Older adults only 15 55.6
Both 10 37.0
Unknown or not clearly stated 0 0
aNumbers may not add up to 100% due to rounding
bMedical technological journals were classified as technological
III.3.
Privacy
Warren and Brandeis, in their seminal writings on the concept of privacy law, have defined privacy as the "right to be let alone."[4] Subsequently, privacy can be differentiated in three subcategories: physical, informational, and decisional privacy. [5]
Physical privacy refers to freedom from contact with others or exposure of one’s body to others. In contemporary health care, physical privacy is unavoidably limited. Patients grant their caregivers access to their bodies for medical examination and treatment, but expect caregivers to protect them from any unnecessary or embarrassing bodily contact or exposure.
Informational privacy refers to prevention of disclosure of personal information. Informational privacy is also limited in health care by the need to communicate information about one’s condition and medical history to one’s caregivers. In disclosing this information, however, patients expect that access to it will be carefully restricted. This use of the term ’privacy’ is most closely related to the concept of confidentiality.
Decisional privacy refers to an ability to make and act on one’s personal choices without interference from others or the state. The US Supreme Court has relied on a constitutional right to privacy to protect freedom of choice about contraception[6] and abortion,[7] and state courts have used it as the basis for termination of life-sustaining medical treatment.[8]
III.3.1 Trade-off privacy and safety
It is discussed whether privacy or safety is the most important. In this case safety is described as preventing, reducing, and analyzing, for future purposes, medical errors, as well as the freedom of risk.[9] The trade-off between those two can be described as that the systems designed to promote independence or safety require varying degrees of privacy impingements.[10] For example, the use of monitoring cameras is stated to cause severe privacy violations for both the care taker as care giver.[11][12][13] Furthermore, there is currently no clear protocol of how to store the gathered data safely and concerns are expressed.[10]
Although some health care professionals and the care technology’s users worry about the technology’s privacy violations regarding the elderly patients or users[14], another study shows that the care takers merely see the used monitoring devices as a ’friendly eye in the sky’ rather than a concern.[15] Melander-Wikman et al. even argue that today’s society is being watched all the time and that these monitoring devices as cameras would not do any extra harm.[14] Plus, as discussed earlier, if elderly people feel like the trade-off in privacy and safety is appropriate, these devices are not considered as a violation of privacy.[16][17][18][19]
III.4.
Autonomy
Autonomy as a concept ensues the right to self-determination and has overlap with the discussed decisional privacy, and the right way of promoting independence in elderly care.[11] The need to give informed consent is an example of respecting one’s autonomy, despite any cognitive impairments[9] and to be able to decide when a monitoring device can be turned off.[14]
Just as in the case of privacy, autonomy also has a trade-off with (patient) safety. For example, GPS trackers on patients with dementia, allows both patient and caregiver to be more confident letting the patient go outside by themselves. [14] Therefore it can be discussed whether the device is for the benefit of the patient or the caregiver.[20] Paragraph III.6.1 will expand on this and why this could be a problem.
III.5.
Obtrusiveness
In many articles obtrusiveness is viewed upon negatively. To what extent an assistive technology or technological intervention is obtrusive, many refer to the framework of Hensel et al. Fun-damental dictionary definitions of "obtrusive" were used to develop a conceptual definition of obtrusiveness applied to home telehealth technologies. 22 different categories were identified, obtained from literature and through consideration of the research team that such technology could be perceived as obtrusive. The 22 categories were mapped under eight dimensions: Physical, usability, privacy, functional, human interaction, self-concept, routine, and sustainability.[19] The different frameworks describe some ambiguous concepts as obtrusiveness and privacy differently. For example, in the obtrusiveness framework, privacy is part of obtrusiveness, rather than the other way around as discussed in the framework of Bellotti and Sellen, where obtrusiveness is categorized under privacy.[21] In Fisk’s paper the term intrusiveness is used without giving a specific definition of the term. This article from 1997 describes intrusiveness in seven criteria: prior experience, the attitude of others, manner of promotion, presence of equipment, control, extent of interaction, and compensatory effects. He argues these are the criteria which play an important role in the acceptance of the technology in both (elderly) patients and care giver.[22]
III.6.
Examples
To clarify the principles described in the sections about privacy, autonomy, obtrusiveness, and the trade-off, three examples from the derived literature are stated.
III.6.1 GPS tracker for Dementia patients
The market has focused on the possibilities emerging for using new technologies to provide individualized aid to people with dementia in residential care,[23] more than in elderly people with dementia in the community.[24] Despite promoting autonomy of these patients, there are numerous ethical issues associated with the technology’s use.[20][25][26] As described earlier, it can be discussed whether these devices are for the benefit of the patient or the caregiver.[20] There-fore some even argue that the autonomy of people with dementia could easily be undermined by pressuring them to use these devices without being comfortable, whilst it is only used to create ’peace of mind’ for the associated care givers.[27]
Other studies, however, state that by using a tracking device, both patients and caregivers feel confident when patients with dementia go outside and decide for themselves where they go, instead of staying inside or always walking the same route in fear of getting lost.[14][28] Following the eight dimensions of the obtrusiveness framework, other literature describes surveillance devices as obtrusive. For example, the device is considered a symbol of loss of independence and a violation of the personal space of home. [19] (i.e. less human interaction) and moreover may possibly lead to a reduction in resources currently provided by care givers.[29][30] More extended research has to be performed by assessing the potentials of GPS tracking of ensuring patient safety, allowing the device to locate dementia patients whenever wherever in relation to quality of life of these patients.[31] It is clear that the views on GPS tracking of dementia patients vary due to responsibility issues of the care givers for the safety of the patient.[27]
III.6.2 Psychotherapeutical videoconferencing
Psychotherapeutical videoconferencing is a growing field and areas of concern related to ethics, patient privacy, and confidential communication online arose.[32] Its eventual effect can be compared with the related ethics and privacy concerns. Therefore the effectiveness of cognitive behaviour therapy for panic disorder delivered either face-to-face or by using videoconferencing had to be compared. Bouchard et al. show that none of the comparisons with face-to-face psychotherapy was more effective than cognitive behavioral therapy delivered by videoconference. [33]
III.6.3 Fall detection
During the development of assistive technologies in aged residential care, fall detection technolo-gies also had an uprising. And although fall prevention of older adults is needed, preventive advice on falling has been seen as a threat to the monitored older adults’ identity and autonomy and, therefore, has been rejected.[34] Nevertheless, primary research shows a fall reduction, using image-based sensors and video cameras at home.[35] However, less obtrusive techniques, like sensors on the wrist, could be used instead to preserve the older adults’ autonomy.
IV.
Discussion
IV.1.
Main Findings
The main question of this literature review was to what extent privacy invasion of users of elderly care technologies occurs and if this could be clarified by classifying the results according to certain privacy and technology related frameworks. As the technology market for health care grows, more privacy concerns occur. The first question which needs to be answered is: what is privacy? Privacy, the right to be let alone, and underlying concerns can be divided and assessed in three subcategories. (1) Physical privacy refers to the freedom from contact with others, exposure of one’s body to others (e.g. cameras), or physical strain and burden (e.g. uncomfortable wearing devices). (2) Informational privacy includes the prevention of disclosure of personal information (e.g. having too share too much personal information for a well-functioning technology). And (3) decisional privacy, or autonomy, refers to the ability to make and act on one’s personal choices without interference from others or the state. Every concern pairs with a certain trade-off between privacy and safety, e.g. a fall-detection camera can be viewed as intrusive but grants patient safety. It is clear that many privacy invasions occur in different elderly care technologies. Further research should focus on frameworks like the ones from Hensel et al. and Bellotti and Sellen and whether they are able to assess the privacy concerns. This could determine to what extent these privacy invasions occur. Furthermore, this study, for example with the GPS tracker, state different ethical issues occur, which are also addressed in a systematic review [17] which state that not only technical challenges but also ethical ones need to be addressed.
IV.2.
Study Limitations
Only PubMed was used to extract relevant articles for the primary article search. The initial search yielded 11 articles matching the inclusion criteria. From the references of those articles, 16 more were included. The high number of included references could indicate that the initial search was too specific and therefore data could have been missed. This could have led to an inadequate overview. Furthermore, this paper is focused on older adults and can not be generalized to other groups of patients. Furthermore, not only original studies yielded from the search strategy were used, but a snowballing method as well, meaning, for instance, that the search strategy could be expanded. In future researches, we could expand the search with more synonyms, in different medical databases. At last, two or more reviewers could have been used including or excluding articles, as well as for the data extraction.
IV.3.
Future research
For future research, it would be interesting to look into the evaluation of certain privacy concerns among patients using assistive technologies, trying to match newly found results and concepts in literature reviews in settings with older adults. For this purpose, we could expand the search and the number of databases which were used for literature extraction as well.
The next step would be a more comprehensive description of the privacy frameworks and how they could be adapted to real-world situations. Existing, validated frameworks could be found in literature. The subcategories of those frameworks could then be adapted by constructing survey or interview questions regarding privacy concerns in elderly care technologies. The results of 9
this future research will assess all privacy concerns in the evaluated technologies, and moreover, provide an overview whether the frameworks gave sufficient coverage of privacy concerns. If the coverage is believed to be complete, the frameworks could then be reused in more studies evaluating privacy concerns in (elderly) care technologies.
IV.4.
Conclusion
For an elderly care technology to function properly, a trade-off has to take place between the adults’ independence and autonomy and the adults’ safety. Privacy concerns found in (elderly care) technologies could be categorized among physical, informational, and decisional privacy. Future research should explore different (validated) frameworks which can be clustered into those three categories. Those frameworks could then assess the individual privacy concerns, and moreover, become a validated measure standard for scaling privacy concerns in care technologies, and to what extent they occur.
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Concerns in Elderly Care Technologies
D Oudejans
1,2Supervisor: Prof. G Demiris
1Mentor: Prof. M.W.M Jaspers
21Health-e, Biomedical Informatics and Education, University of Washington, Seattle, USA 2Department of Medical Informatics, Amsterdam Medical Center
- University of Amsterdam, The Netherlands daano@uw.edu
Abstract
Introduction To assess privacy concerns in technologies, different studies created and evaluated
privacy and technology related frameworks. This paper aims to provide an overview of existing frameworks which might be applicable to elderly care technologies. The final aim was to create a comprehensive framework focusing on privacy of users in elderly care technologies.
Methods The search strategy ("privacy" and "framework" and "technology") for finding frameworks
regarding the evaluation of privacy in technologies were performed in PubMed or provided by professor Demiris. Frameworks, were included when it was applied to assess privacy of users of technology. Subse-quently, it was examined whether the frameworks were applicable to elderly care technologies as well to achieve a comprehensive approach for evaluating elderly care technologies regarding privacy concerns. Frameworks found by the literature review were merged into one. This was done by mapping and matching subcategories. Parts of the frameworks were excluded if they were not applicable to either (elderly) care technologies and privacy.
Results Three frameworks were found to meet the inclusion criteria: the obtrusiveness framework
from Demiris et al., the J8 privacy framework from Lorenzen-Huber et al., and a framework from Bellotti and Sellen. The frameworks were merged and categories were divided in physical, informational, and decisional privacy aspects.
Discussion The three frameworks distracted from the literature provided a basis for the development
of a merged framework concerning any privacy concerns in elderly care technologies. In future research the newly merged framework could be used to evaluate privacy concerns of older adults using elderly care technologies.
I.
Introduction
Chapter 1, the literature review, describes the current state of privacy in technology in geriatric care. It is of high importance to comprehend the concept of autonomy, obtrusiveness, and the trade-off in privacy and safety when technology is implemented. To assess privacy concerns in technologies, different studies created and evaluated privacy and technology related frameworks. These frameworks are to be used in qualitative and quantitative analysis of different privacy aspects regarding new technologies.
I.1.
Aim
The aim of this paper is to provide an overview of existing technological and privacy related frameworks described in current literature and combine them to one which could be applied to real world scenarios. The final aim was to create a comprehensive framework focusing on privacy of users in elderly care technologies.
II.
Methods
We searched the Pubmed library for frameworks used in elderly care regarding the evaluation of privacy and obtrusiveness in care technologies ("frameworks" and "technology" and "privacy"). Professor Demiris provided us with some of the frameworks as well. The frameworks were included if they consisted of a clearly stated categorization of concepts relating to privacy aspects in technologies. Studies describing the use of the framework in a real world situation were preferred. The framework could also be included if it consisted of a larger variety of subjects like usability aspects of the technology. Furthermore, parts of the selected frameworks were excluded if they were not applicable to either (elderly) care technologies and or did not focus on privacy issues. To create a comprehensive framework for evaluating privacy concerns in elderly care technolo-gies, the frameworks were merged by mapping and matching similar subcategories, whereupon these merged categories were divided among three categories, physical, informational, and de-cisional privacy, provided by Warren and Brandeis as described in Chapter 1. The challenge to properly merge those frameworks concerns the fact that the frameworks often overlapped in a reversed hierarchical manner. Studies providing these frameworks seemed inconsistent in defining concepts with a concept often being a part of another concept. For example, some studies placed privacy as a subcategory of obtrusiveness, others defined obtrusiveness as a subcategory of privacy. The classification of privacy concerns into physical, informational, and decisional privacy supported the consistent categorization and merging of concepts defined by the various frameworks in the comprehensive framework we developed.
III.
Results
III.1.
Selection
Frameworks have been developed for evaluating privacy concerns in (elderly) care related tech-nologies. Three established privacy frameworks were chosen based on the inclusion and exclusion criteria. The frameworks included are: Obtrusiveness Framework [1], J8 Privacy Framework [2], and the Belotti and Sellen Framework. [3] These frameworks have a clearly stated categorization of concepts relating to privacy and technological aspects of technologies.
III.1.1 Obtrusiveness Framework
B. K. Hensel, G. Demiris, and K. L. Courtney used fundamental dictionary definitions of "obtrusive" to develop a conceptual definition of obtrusiveness applied to home telehealth technologies. 22 different categories were identified, obtained from literature and through consideration of their research team that such technology could be perceived as obtrusive. By grouping the more specific categories, eight broader dimensions were formed as shown in figure 1.[1] This framework is used to assess the scale of obtrusiveness of an used technology, in the broadest definition of the word obtrusiveness.
Figure 1: Twenty-two subcategories of obtrusiveness from the literature.[1]
III.1.2 J8 Privacy Framework
Lorenzen-Huber et al. proposed a privacy framework that could inform the development, adoption, and use of home-based ubiquitous technologies for older adults. Lorenzen-Huber et al. divided privacy into five dimensions. The five dimensions covered are:
• Seclusion: The right to be left alone • Autonomy: The right to self determination
• Property: The right to determine uses and dissemination of personal data • Spatial: The right to determine physical and virtual boundaries
• Data Protection: Data is transparent, verifiable, and correctable
Lorenzen-Huber et al. proposed a new framework derived from this five-dimensional initial privacy framework, shown in Table 1.
This framework is focused on the development of home-based technologies increasing older adults’ independence. The technologies should improve the user’s quality of life by enhancing relationships with loved ones, and/or providing practical support.
Table 1: J8 proposed framework [2] Dimension Relevant Factors Description Perceived
usefulness
Awareness of Perceived Vulnerability
Other, "older" people could use
ubiquitous technologies; subjects did not perceive a personal need
Critical Event Monitoring Useful for emergencies, not daily use Social relationships Importance of Key
Relationships
Concern about not intruding on adult children’s lives
Maintenance of Autonomy and Independence
Awareness of potential trade-off between autonomy and privacy; awareness that adult children might be making decisions for subjects; considerations of potential cognitive decline
Data Recipient Nature of relationships, and preferred shared data, vary among potential caregivers
Technology Should not replace human contact preferences and needs for human caregiving are contextual
Reciprocal Exchange Elders as full participants, not passive subjects, in sharing data
Data granularity Level of Granularity Level of acceptable granularity is highly contextual
Data Transparency Older adults’ naïve mental models about data suggest a need to make data visible, verifiable and controllable
Sensitivity of activity
Activity vs. Space A range of activities, with different privacy needs, can occur in any given space
III.1.3 Belotti and Sellen Framework
This framework describes the design for privacy in ubiquitous computing environments focusing on seven main privacy criteria.[3]
• Trustworthiness: Systems must be technically reliable and instill confidence in users. In order to satisfy this criterion, they must be understandable by their users. The consequences of actions must be confined to situations which can be apprehended in the context in which they take place and thus appropriately controlled.
• Appropriate timing: Feedback should be provided at a time when control is most likely to be required and effective.
• Perceptibility: Feedback should be noticeable.
• Unobtrusiveness: Feedback should not distract or annoy. It should also be selective and relevant and should not overload the recipient with information.
• Minimal intrusiveness: Feedback should not involve information which compromises the privacy of others.
• Fail-safety: In cases where users omit to take explicit action to protect their privacy, the system should minimize information capture, construction and access.
• Flexibility: What counts as private varies according to context and interpersonal relation-ships. Thus mechanisms of control over user and system behaviors may need to be tailorable to some extent by the individuals concerned.
This framework serves three important purposes. Primarily, it helps to clarify the existing state of affairs with respect to privacy problems in the evaluated technology. Secondly, by clarifying these problems, it helps to point to possible technological design solutions in the specific category of the concern revealed. And thirdly, these technological improvements could be assessed in terms of how they might reduce the existing privacy problems as well as how they might cause new ones.
III.2.
Combined Privacy Framework
To create one merged privacy framework for evaluating privacy concerns in (elderly) care tech-nologies, the three frameworks were clustered in physical, informational, and decisional privacy, see Table 2. All categories of the different frameworks were thoroughly examined and were either mapped on physical, informational, or decisional privacy, or excluded. Categories that not specifically focused on privacy aspects of technology were excluded from the merged privacy framework. For example, symbol of loss of independence concerns decisional privacy, since it interferes with one’s ability to act on one’s personal choice, as described in Chapter I (the literature review). Whereas perceived usefulness, usability, functionality, and sustainability of the technology do not concern privacy issues and therefore were excluded from the newly proposed privacy framework, see Table 2.
Table 2: Proposed privacy framework Privacy categories Framework and description
Physical Obtrusiveness framework • Functional dependence • Discomfort or strain • Excessive noise
• Obstruction or impediment in space • Aesthetic incongruence
• Violation of the personal space of home Belotti & Sellen
• Appropriate timing: Feedback should be provided at a time when control is most likely to be required and effective.
• Unobtrusiveness: Feedback should not distract or annoy. It should also be selective and relevant and should not overload the recipient with information.
J8
• Importance of Key Relationships: Concern about not intruding on adult children’s lives
Informational Obtrusiveness framework
• Invasion of personal information Belotti & Sellen
• Trustworthiness: Systems must be technically reliable and instill confidence in users. In order to satisfy this criterion, they must be understandable by their users. The consequences of actions must be confined to situations which can be apprehended in the context in which they take place and thus appropriately controlled.
• Minimal intrusiveness: Feedback should not involve information which compromises the privacy of others.
J8
• Importance of Key Relationships: Concern about not intruding on adult children’s lives
• Data Transparency: Older adults’ naïve mental models about data suggest a need to make data visible, verifiable and controllable
• Reciprocal Exchange: Elders as full participants, not passive subjects, in sharing data
• Data Recipient: Nature of relationships, and preferred shared data, vary
Privacy categories Framework and description Decisional Obtrusiveness framework
• Symbol of loss of independence • Interference with daily activities • Acquisition of new rituals Belotti & Sellen
• Perceptibility: Feedback should be noticeable.
• Fail-safety: In cases where users omit to take explicit action to protect their privacy, the system should minimize information capture, construction and access.
• Flexibility: What counts as private varies according to context and interpersonal relationships. Thus mechanisms of control over user and system behaviors may need to be tailorable to some extent by the individuals concerned.
J8
• Importance of Key Relationships: Concern about not intruding on adult children’s lives
• Reciprocal Exchange: Elders as full participants, not passive subjects, in sharing data
• Maintenance of Autonomy and Independence: Awareness of potential trade-off between autonomy and privacy; awareness that adult children might be making decisions for subjects; considerations of potential cognitive decline
The Belotti & Sellen framework is completely included. The perceived usefulness aspect from the J8 framework does not meet the inclusion criteria, since this aspect is covering (perceived) usability, not privacy. The subcategory Technology and Data Granularity was excluded for similar reasons. Sensitivity of activity was excluded because the obtrusiveness framework covers this aspect in more detail. The Importance of Key Relationships, the concern not intruding a live, is a far-reaching concern and of high importance. It relates to each of the three different privacy subcategories. The same applies for Reciprocal exchange where technology users are to decide what information to share and more importantly, what information not to share. Users of technologies can either have decisional or informational reasoning for the withhold of data sharing.
IV.
Discussion
IV.1.
Main Findings
The aim of this paper was to create a comprehensive framework focusing on privacy of users in elderly care technologies. We reviewed the literature to provide an overview of existing technological and privacy related frameworks and combine them to one which could be applied to real world scenarios. After the literature review, three frameworks were considered and examined which describe and assess privacy, autonomy, and obtrusiveness in technologies. The categories of the three frameworks overlap, and hierarchical contrasts, which made it difficult to merge them in one comprehensive framework. However, the frameworks do agree on the trade-off which occurs between (users) autonomy, privacy, and safety - to ensure users safety, more privacy concerns will occur. The categories of the three frameworks were clustered in the aspects physical, informational, and decisional privacy.
IV.2.
Study Limitations
Three frameworks were included for their completeness and detailed description of privacy con-cepts in technologies, however, we could have missed newly developed and validated frameworks in our review. Key factors in privacy concerns might therefore be missed. Future use of the merged framework in evaluation of technological privacy concerns might be affected by this. However, the frameworks seem to include all factors concerning privacy technology issued. The merged framework provides an even more complete overview of privacy issues of technology.
IV.3.
Future Research
The merged framework could be used as a reference to what extent certain privacy concerns occur in new health care technologies and how this is perceived by the technologyâ ˘A ´Zs user. For each subcategory of the merged framework, one or more questions should be created and subsequently validated with a large intended user population of the technology under study . Assuming the research is applied in an elderly care setting, the participants have to be elderly and still mentally able to fill out the validated survey and be interviewed for detail information based on their survey answers . The aim would be to assess to what extent privacy concerns occur and how these are perceived by the technology users, regarding possibly intrusive or privacy invading technologies. This can be done in either participants who actually use the technology, or gathering opinions on how they imagine they would feel if using a possibly intrusive technology. This way, new privacy concerns can be brought to light and developers might be able to keep that in mind during the production or optimization phase of possibly privacy invading technologies.
IV.4.
Conclusion
Despite the fact that new or other (validated) frameworks might be created, the three frameworks described provide a basis for the evaluation method of any privacy concerns in elderly care technologies. In future research surveys or interviews could be created and validated, using the newly merged framework as a reference. The aim could be to assess the perceived privacy concerns of older adults using elderly care technologies.
References
[1] B. K. Hensel, G. Demiris, and K. L. Courtney. Defining obtrusiveness in home telehealth technologies: a conceptual framework. J Am Med Inform Assoc, 13(4):428–431, 2006.
[2] Boutain M. Camp L. J. Shankar K. & Connelly K. H. Lorenzen-Huber, L. Privacy, technology, and aging: A proposed framework. Ageing International, 36(2):232–252, 2011.
[3] V. Bellotti and A. Sellen. Design for Privacy in Ubiquitous Computing Environment. Proceedings of the third conference on European Conference on Computer-Supported Cooperative Work, pages 77–92, September 1993.
Smart TV, and a Smart Watch, Used in
Elderly Care
D Oudejans
1,2Supervisor: Prof. G Demiris
1Mentor: Prof. M.W.M Jaspers
21Health-e, Biomedical Informatics and Education, University of Washington, Seattle, USA 2Department of Medical Informatics, Amsterdam Medical Center
- University of Amsterdam, The Netherlands daano@uw.edu
Abstract
Introduction
New technological interventions are useful to enhance autonomy and safety in older adults. However, these technologies can be obtrusive by monitoring the elderly at home or during the day recording all activities. Younger adults seem more open to the ideas of technological interventions in care. To find out whether this is indeed the case, the research question is: What are the differences in opinion regarding privacy in elderly care technologies in various ages and technologies?
Methods
This Phase I study consisted of a seven-point Likert-scale eighteen-question survey filled out by two distinct age categories. Three interventions were assessed: a smart-TV, a wearable device, and a digital companion. The questions were derived from a merged framework consisting of three different frameworks used in privacy concerns in technologies. The framework is focuses on physical (the freedom from contact with others or exposure of one’s body to others), informational (prevention of disclosure of personal information) and decisional privacy (ability to make and act on one’s personal choices without interference from others)
Results
A total of 172 usable surveys was gathered, 78 from older adults (mean age 72) and 94 from younger adults (mean age 26). Results from the questionnaires were assessed on physical, informational, and decisional privacy of technology users. Both age categories agreed on physical privacy concerns. The younger adults did seem to be slightly more tolerant to a technology being with them all the time. Regarding informational privacy, the older adults were more reluctant sharing personal in formation with others, especially in sharing all daily activities whenever wherever. For decisional privacy, especially learning new routines, and fitting the new technologies in their daily activities, seem concerning to the older adults.
Discussion
This study shows that older adults have some serious privacy concerns regarding the assessed technologies. This paper lays groundwork to follow-up papers with qualitative methods focusing on defining the actual concerns of technology users with privacy issues, providing more detailed insights into the stated concerns.
I.
Introduction
There are many applications used in elderly care home-based settings. Three of them are chosen to be evaluated on privacy concerns in this study: a digital companion or pet (GeriJoy), a wearable device (CarePredict), and an interactive TV (Independa). These three examples were chosen for their distinctive and unique characteristics and value to users. Nevertheless, some privacy concerns which might have been overlooked, may come to light once the technologies are being used by the older adults. Phase I (in this study, assessment of different users opinions of privacy concerns by surveys) or II (in this study, follow up interviewing of users concerning privacy concerns) evaluations can provide an overview of existing privacy concerns with the use of questions based on the merged framework concerning technology privacy issues, described in the previous chapter. The aim of this paper is to assess whether or not younger adults are more open in a later part of life to assistive living technologies. Technologies are often developed by technology driven companies led by (younger) adults. Older retired adults are the consumers of these technologies. This research aims to provide an overview if the ideas and products of these companies, especially the privacy concerns, match with the older adults’ point of views. Moreover, the interventions are focused on the future, younger adults as they are the elderly consumers of the future. It is therefore of interest to evaluate whether there exist differences in opinion regarding privacy in elderly care technologies in various ages and technologies.
I.1.
Elderly Care Technologies
I.1.1 CarePredictNew SWBS technologies (i.e., CarePredict system) are designed to detect and record older adults’ activities and status within their living spaces. CarePredict monitors activities of daily living including sleep, going to the restroom, brushing teeth, bathing, cooking, relaxing, eating, drinking, and walking. By keeping track of these kinds of activities for a longer period of time, activity trends can be visualized and behavioral activities can be assessed. SWBS technologies have the potential to support older adults in living independently by connecting them with their adult children and/or other caregivers. Despite the surge of new SWBS technologies to improve health outcomes and quality of life in older adults, there remains a challenge of older adults accepting and using SWBS technologies.
I.1.2 GeriJoy
Loneliness and social isolation is a problem for many older adults, including those experiencing memory issues. The company GeriJoy intends to evaluate a commercially available digital pet companion with older adults experiencing early signs of memory issues and cognitive impairment. The company will investigate whether use of the device affects scores on a set of standardized instruments, perceptions the adults have of the pet and their relationship with it, and the percep-tions of family members.
older adult opted in for that option. The caregiver can also send pictures to the device to share with the older adult.
The device allows the human on the other side of the tablet to see the older adult in their room (when the pet is "awake," signified by its eyes being open) to determine if they are interested in engaging in conversation and to add a dimension to the interaction.
I.1.3 Independa
Independa, a company located in San Diego, tries to understand the difficulties associated with caring for aging loved ones. The company’s product is an interactive TV with multiple functions as video chat, photo sharing, smart reminders (as medication or planned visits), and messaging. The TV is focused on older adults who are homebound and watch TV all day, or at least a bigger amount of the day. The caregivers, mostly close friends or family, are able to video chat, view (or add) reminders, and send messages from a back-end application.
I.2.
Aim
The new interventions could be useful to enhance autonomy and safety of the older adults or patients. However, the new monitoring devices can be obtrusive and invading privacy of elderly patients and older adults by tracking them everywhere and observe them closely. To what extent this trade-off between privacy and autonomy or safety occurs, as explained in the first chapter, needs to be clarified. IT interventions tend and need to be focused on the (far) future and therefore it is useful to include and compare opinions among various ages, clarifying to what extent these opinions vary between younger (future users) and older (current users) adults. Therefore the research question was: What are the differences in these opinions regarding privacy in elderly care home-based technologies in various ages and technologies?
II.
Methods
To assess the physical, informational, and decisional privacy concerns of the wearable device, the digital companion and the interactive TV, we conducted a Phase I study, a quantitative analysis over questions derived from a seven point Likert scale survey based on the merged framework from the previous chapter. Questions were made that providing answers to all of the questions would cover the complete framework. For example, the decisional privacy element "Interference with daily activities" would be translated to as "The technology would interfere with my daily activities". These questions passed an expert in this field within the IRB and professor G. Demiris. As shown in the previous chapter in Table 2, physical privacy consists of the assessment of functional dependence, discomfort or strain, excessive noise, obstruction or impediment in space, aesthetic incongruence, violation of the personal space of home, appropriate timing, unobtrusive-ness, and importance of key relationships. These subcategories were constructed as easy-to-answer questions. Functional dependence became: "I would depend on this technology for everyday tasks", discomfort or strain became: "This technology causes me discomfort", "This technology would require some physical strain for me to operate" and "This technology would be a physical burden to me", aesthetic incongruence became: "The appearance of this technology would be distracting", obstruction or impediment in space and violation of the personal space of home became: "This technology would violate my personal space", and so forth. Similar methods were used for informational and decisional privacy. The expert within the IRB provided feedback and reconstructed three questions, making them non-ambiguous, and allowing participants to provide clear answers.
Table 1 shows the baseline of categories from the merged privacy framework which were assessed by asking relating questions in a questionnaire (7point Likert scale Strongly agree -Strongly disagree). The survey required to fill out 18 questions, covering each of the subconcepts of the merged framework, scaled on a Likert scale from 1 through 7. Where one is strongly agree and 7 is strongly disagree. A "don’t know"-option was given, defining whether a person didn’t know an appropriate answer. The raw data considered "Don’t know" as 0, but this answer category was not taken into account in the eventual statistic, numeric analysis, neither was missing data. The "don’t know" -option was however used to translate the analysis to a real-world explanation. In Appendix B, the three questionnaires used, one for each technology, are attached.
II.1.
Sample
This Phase I study consists of a seven-point Likert-scale eighteen-question survey filled out by two study populations of distinct age categories. To give meaning to the differences, we assumed the difference in means to be 1, with a standard deviation of 1 as well. According to the a priori power analysis, to reach a power of 0.95, it would require us to have two groups of 27 participants per technology. Therefore, we surveyed 90 participants per age category.
Table 1: Proposed privacy framework and related questions per subcategory Privacy categories Questions
Physical Questionnaire:
• I would depend on this technology for everyday tasks • This technology causes me discomfort
• This technology would require some physical strain for me to operate
• This technology would be a physical burden to me • The appearance of this technology would be distracting • This technology would be too noisy
• This technology would violate my personal space • I would not want other people to know I am using this
technology Informational Questionnaire:
• This technology would keep my information private
• This technology would share too much personal information with others
• I understand what information is being collected by this technology
• This technology would only collect data I am willing to share Decisional Questionnaire:
• Using this technology would reduce my independence • This technology would fit into my daily activities
• This technology would require me to learn a new routine • This technology would interfere with my daily routine
• This technology would allow me to control what information is gathered
• This technology would allow me to control when information is gathered
II.2.
Data Gathering and Analysis
Two age groups were surveyed, with a total of 180 individuals filling out the survey. To collect data on age, gender, and the participant’s opinion, an IRB form had to be approved. The group of younger adults was required to be over the age of 21. Surveys and a short introduction to the technology was handed out to students or young faculty members crossing the Red Square at the University of Washington. Participants were not to have any prior knowledge to the system to minimize bias. The opinions, age, and gender of the group of older adults were collected in home-care settings, assistive living facilities, or other places where older adults might gather. After approval of the IRB, data was gathered in student areas and elderly home facilities in different places in Seattle, US
Two-tailed tests were performed in R to reveal significant differences in opinions on privacy concerns in the age groups. Although we expected that younger adults would be more resilient and open towards privacy issues, we did not want to miss any significances by performing one-tailed statistics.
III.
Results
III.1.
Participants
The digital companion, the wearable device, and the interactive TV, were each evaluated on privacy concerns with a unique study sample. Table 2 provides an overview of the participants in this study. As shown, the average age of the participants in the group of younger persons is around 26. Due to the IRB, the minimum participating age had to be 21 years. The mean of the age of older adults involved is 72 years. The total number of surveys gathered was 172 with mostly unique persons, limiting to a maximum of one survey per person per category. Some older adults eventually filled out more than one survey (on different technologies), either because they wanted to, or to reach a sufficient number of participants. On average, it took about 10 minutes to fill out the questionnaires. There is no significant difference between the age groups of the different technologies.
Table 2: Overview of the participants in the different categories Category n total Female Male Mean Age
GeriJoy 65+ 30 17 13 72.93
GeriJoy 65- 34 13 21 25.65
Table 3: GeriJoy, the digital companion, questionnaire’s outcome and statistics
Cat. / Question n total n used Mean SD n of zeros Missing Statistic (t) p value
GJ 65+ Q1 30 23 4.65 1.64 7 0 -0.2 0.843 GJ 65- Q1 34 32 4.75 1.98 2 0 GJ 65+ Q2 30 29 4.69 1.67 1 0 0.387 0.700 GJ 65- Q2 34 34 4.53 1.60 0 0 GJ 65+ Q3 30 20 5.90 1.29 10 0 2.355 0.022* GJ 65- Q3 34 34 4.88 1.87 0 0 GJ 65+ Q4 30 25 6.28 1.02 5 0 2.712 0.009** GJ 65- Q4 34 33 5.30 1.70 1 0 GJ 65+ Q5 30 27 4.04 2.01 3 0 0.266 0.791 GJ 65- Q5 34 29 3.90 1.93 4 1 GJ 65+ Q6 30 17 4.06 2.05 13 0 -0.932 0.359 GJ 65- Q6 34 23 4.61 1.53 11 0 GJ 65+ Q7 30 28 3.96 2.22 2 0 -0.012 0.990 GJ 65- Q7 34 34 3.97 1.83 0 0 GJ 65+ Q8 30 21 3.14 2.08 8 1 -1.403 0.171 GJ 65- Q8 34 34 3.85 1.31 0 0 GJ 65+ Q9 30 20 4.15 2.48 9 1 -0.075 0.941 GJ 65- Q9 34 25 4.20 1.87 9 0 GJ 65+ Q10 30 18 2.44 1.72 12 0 -3.234 0.003** GJ 65- Q10 34 23 4.17 1.67 10 1 GJ 65+ Q11 30 15 3.47 2.45 14 1 -0.853 0.402 GJ 65- Q11 34 31 4.10 2.13 3 0 GJ 65+ Q12 30 19 4.74 1.91 10 1 2.241 0.031 GJ 65- Q12 34 27 3.44 1.95 7 0 GJ 65+ Q13 30 20 3.75 1.89 9 1 -1.377 0.177 GJ 65- Q13 34 31 4.45 1.59 2 1 GJ 65+ Q14 30 23 3.17 2.10 6 1 -1.37 0.178 GJ 65- Q14 34 28 3.89 1.52 5 1 GJ 65+ Q15 30 24 2.88 1.75 5 1 1.165 0.251 GJ 65- Q15 34 30 2.40 1.07 3 1 GJ 65+ Q16 30 22 3.00 1.90 7 1 -0.484 0.631 GJ 65- Q16 34 26 3.23 1.27 6 2 GJ 65+ Q17 30 15 5.20 2.31 14 1 2.157 0.040* GJ 65- Q17 34 22 3.59 2.11 12 0 GJ 65+ Q18 30 14 3.21 2.49 15 1 -1.212 0.238 GJ 65- Q18 34 26 4.15 2.03 8 0 29
Table 4: CarePredict, the wearable monitoring watch, questionnaire’s outcome and statistics
Cat. / Question n total n used Mean SD n of zeros Missing Statistic (t) p value
CP 65+ Q1 25 15 5.93 1.98 10 0 3.314 0.002** CP 65- Q1 32 31 3.84 2.07 1 0 CP 65+ Q2 25 16 3.88 1.96 9 0 -0.917 0.366 CP 65- Q2 32 30 4.43 1.98 2 0 CP 65+ Q3 25 16 4.06 2.11 8 1 -1.732 0.096 CP 65- Q3 32 29 5.10 1.54 3 0 CP 65+ Q4 25 17 4.71 2.23 8 0 -0.055 0.957 CP 65- Q4 32 31 4.74 2.08 1 0 CP 65+ Q5 25 16 2.44 1.59 7 2 -5.778 <0.001*** CP 65- Q5 32 31 5.39 1.78 1 0 CP 65+ Q6 25 10 2.60 1.51 14 1 -4.587 <0.001*** CP 65- Q6 32 14 5.50 1.56 17 1 CP 65+ Q7 25 20 2.00 1.45 4 1 -4.256 <0.001*** CP 65- Q7 32 32 4.16 2.20 0 0 CP 65+ Q8 25 18 2.33 1.33 5 2 -4.747 <0.001*** CP 65- Q8 32 30 4.63 2.03 1 1 CP 65+ Q9 25 16 4.00 2.19 7 2 0.355 0.725 CP 65- Q9 32 25 3.76 1.98 7 0 CP 65+ Q10 25 15 2.40 1.68 9 1 -3.73 0.001** CP 65- Q10 32 28 4.46 1.82 4 0 CP 65+ Q11 25 15 4.40 1.88 8 2 2.969 0.007** CP 65- Q11 32 26 2.77 1.31 6 0 CP 65+ Q12 25 12 1.92 1.73 11 2 -1.49 0.150 CP 65- Q12 32 21 2.86 1.77 11 0 CP 65+ Q13 25 14 2.86 1.83 8 3 -2.921 0.007** CP 65- Q13 32 32 4.56 1.79 0 0 CP 65+ Q14 25 19 4.68 1.45 5 1 4.944 <0.001*** CP 65- Q14 32 31 2.74 1.15 1 0 CP 65+ Q15 25 13 3.00 2.00 10 2 -1.116 0.275 CP 65- Q15 32 29 3.76 2.12 3 0 CP 65+ Q16 25 17 3.18 1.51 7 1 -3.35 0.002** CP 65- Q16 32 30 4.77 1.65 2 0 CP 65+ Q17 25 12 3.58 2.23 12 1 0.537 0.598 CP 65- Q17 32 16 3.19 1.42 16 0 CP 65+ Q18 25 13 2.85 1.68 11 1 -0.502 0.620 CP 65- Q18 32 22 3.14 1.61 10 0
Table 5: Independa, the smart-TV, questionnaire’s outcome and statistics
Cat. / Question n total n used Mean SD n of zeros Missing Statistic (t) p value
IN 65+ Q1 23 21 5.33 2.03 1 1 2.791 0.008** IN 65- Q1 28 25 3.76 1.74 3 0 IN 65+ Q2 23 20 3.60 2.44 3 0 -0.747 0.460 IN 65- Q2 28 26 4.08 1.70 2 0 IN 65+ Q3 23 16 3.94 1.69 7 0 -3.091 0.004** IN 65- Q3 28 24 5.54 1.47 4 0 IN 65+ Q4 23 19 4.95 1.58 4 0 -1.886 0.068 IN 65- Q4 28 25 5.76 1.16 3 0 IN 65+ Q5 23 21 2.43 1.36 2 0 -4.683 <0.001*** IN 65- Q5 28 26 4.54 1.73 2 0 IN 65+ Q6 23 9 3.44 2.13 14 0 -1.058 0.314 IN 65- Q6 28 24 4.25 1.36 4 0 IN 65+ Q7 23 21 2.57 1.50 2 0 -2.133 0.038* IN 65- Q7 28 28 3.57 1.77 0 0 IN 65+ Q8 23 21 3.10 2.12 1 1 -0.452 0.654 IN 65- Q8 28 25 3.36 1.80 3 0 IN 65+ Q9 23 17 4.65 2.37 5 1 -0.68 0.503 IN 65- Q9 28 21 5.10 1.48 6 1 IN 65+ Q10 23 17 3.65 2.21 6 0 0.602 0.552 IN 65- Q10 28 25 3.28 1.46 3 0 IN 65+ Q11 23 11 3.55 2.54 11 1 -0.979 0.345 IN 65- Q11 28 22 4.36 1.56 6 0 IN 65+ Q12 23 13 4.08 2.40 9 1 1.035 0.314 IN 65- Q12 28 20 3.30 1.56 8 0 IN 65+ Q13 23 18 3.89 1.91 4 1 -1.131 0.265 IN 65- Q13 28 25 4.56 1.94 2 1 IN 65+ Q14 23 21 4.33 1.98 1 1 1.188 0.242 IN 65- Q14 28 27 3.70 1.59 0 1 IN 65+ Q15 23 19 2.26 1.10 3 1 -3.803 <0.001*** IN 65- Q15 28 26 3.85 1.69 2 0 IN 65+ Q16 23 19 3.58 1.95 3 1 -1.008 0.321 IN 65- Q16 28 22 4.14 1.52 6 0 IN 65+ Q17 23 12 4.42 2.57 9 2 0.412 0.685 IN 65- Q17 28 16 4.06 1.73 12 0 IN 65+ Q18 23 14 4.93 2.34 8 1 1.791 0.087 IN 65- Q18 28 18 3.61 1.65 10 0 31
