The population of Europe is aging rapidly. Most community-dwelling older adults (CDOAs) want to remain in their homes, particularly those experiencing functional decline. Politicians and academics repeatedly praise technological instruments for being the preferred solution for helping older adults with deteriorating health to remain at home.This study aimed to understand the perceptions of CDOAs and their informal caregivers (ICs) and professional caregivers (PCs) about technologies that can help keep older adults at home.This qualitative study used personal interviews, focus groups, and photo-elicitation interviews to better understand the perceptions of a convenience sample of 68 CDOAs, 21 ICs, and 32 PCs.A fraction of CDOAs did not perceive technological instruments to be a very useful means of helping them remain at home. However, the ICs and PCs were more positive. The CDOAs preferred and were more willing to adopt technologies related to their mobility and safety and those that would help slow down their cognitive decline. The ICs preferred technological aids that assist in the activities of daily living as well as safety-related technologies for detecting falls and helping to locate disoriented older adults. The PCs preferred integrated communication and information systems to improve collaboration between all stakeholders, housing equipped with technologies to manage complex care, high-performance ancillary equipment to transfer people with reduced mobility, and surveillance systems to ensure safety at home.Although our study reports that CDOAs have limited interest in innovative technologies to help them remain at home, their technological skills will undoubtedly improve in the future, as will those of ICs and PCs. Technological tools will play an increasingly important role in home health care. The population of Europe is aging rapidly . Most coTechnology aimed at older adults is usually termed gerontechnology (which this paper will use as a synonym of technology). It is destined to have an important future role in providing support and solutions, monitoring health status to optimize autonomy, and improving the quality of life of CDOAs, regardless of their level of dependency ,9. GeronCornet and Carre  mentioneHow are technologies that help them remain at home perceived by CDOAs, their ICs, and PCs? More specifically, how do they rate their actual and potential utility?This study, overall, aimed to examine and understand the perceptions and utility of these technologies among physically and cognitively dependent CDOAs, their ICs, and PCs.This study was guided by the theoretical framework developed by Peek et al  and is tThis international multicenter study used a qualitative design to collect data on the perceptions of CDOAs, their ICs, and PCs using one-to-one interviews, focus groups (FGs), and photo-elicitation interviews (PEIs). Reporting on the study was based on the checklist for the explicit and comprehensive reporting of qualitative studies .The study population included CDOA men and women, aged ≥65 years, living in the French department of Haute-Savoie or the French-speaking part of Switzerland’s canton Valais, and with a medical prescription or indication for home care. The reason for examining perspectives in 2 countries was not to compare their populations but rather to explore a common issue together  and codevelop implementable recommendations for clinical practice and technology companies. ICs and PCs involved in clinical practice and employed in 1 of the 5 different community health care centers (2 in France and 3 in Switzerland) were also questioned.A similar sampling strategy was applied to CDOAs in both countries. On the basis of the comprehensive geriatric assessment database in the Autonomy Scale of Gerontology and Iso-Resource Groups (AGGIR) , researcThe AGGIR scale includes 2 types of variables: discriminative and illustrative. Discriminative variables evaluate coherence, orientation, washing, dressing, feeding, excretion, transfers, moving indoors, moving outdoors, and remote communication. These elements are assessed via a clinical evaluation carried out in the home of the CDOA by a nurse, who chooses from among 3 criteria for each variable: (1) the person can complete the activity alone, (2) the person can complete the activity partially, or (3) the person cannot complete the activity. Each criterion is also evaluated based on whether the person carries out the activity spontaneously, totally, usually, and correctly.The AGGIR scale is the official national tool in France for comprehensive geriatric assessment under home health care settings. It classifies the geriatric profiles of home-dwelling adults into 6 categories . GIRs 5 and 6 designate independent CDOAs who only receive minimal home help, such as meals, cleaning, and shopping. GIRs 3 and 4 designate CDOAs with mostly physical impairments, and GIRs 1 and 2 designate CDOAs with mostly cognitive impairments but also some physical impairments. The AGGIR tool uses clinical observations and questions ICs and older adults themselves on their need for assistance in the essential activities of daily living (ADL). Indeed, AGGIR is based on the topics in the Katz ADL scale, which also classifies CDOAs as independent or physically and/or cognitively impaired. Our study did not use the mini-mental state examination. The research team’s geriatrician (NV) clinically judged the participants’ physical and mental health statuses. In agreement with the ethical committee’s expectations concerning the use of existing clinical data, psychiatric diagnoses were not explored prospectively, as this was beyond the aim of this study. A detailed explanation of the tool is provided in All 5 centers used randomized sampling to select CDOAs in their respective AGGIR categories . This study was approved by the Human Research Ethics Committee of the Canton Vaud (CER-VD – 2017/000789), Switzerland, and the French Data Protection Authority. Data collection took place from September 2017 to June 2018. After the CDOAs, their ICs, and PCs had given their written informed consent to participate, the study nurse collected the participants’ sociodemographic, professional, and health status data (only for the CDOAs) and conducted the scheduled interviews .A randomized sample of CDOAs was selected from the 3 categories defined using the AGGIR tool .Thus, CDOAs with no limitations according to the AGGIR tool were placed in the independent group, those with physical limitations  were categorized in the physically impaired group, and those with cognitive limitations  joined the cognitively impaired group. Older adults with cognitive and physical limitations were included in the group corresponding to their most pronounced limitation.Candidates were contacted by telephone and invited to participate. Potential participants received written information about the study before any data were collected. After 48 hours to reflect, a research assistant contacted the potential participants by telephone to address any queries they may have and to obtain their verbal consent to participate in the study. On their acceptance, the assistant made an appointment with the CDOAs for providing more information about the study and to collect the signed consent to participate in the study, before the interview stage. On the day of the interview, the interviewer verified that the participants understood all the information and the implications of participation. Data collection used 10 photographs of relevant technologies and an interview guide developed from a literature review . Audio rThe CDOAs identified their significant ICs. Theoretical samples of 3 to 4 ICs per type of CDOA  were selected by each of the 5 community health care centers, and they were invited to participate in a personal interview and a PEI. Those without the capacity for discernment were excluded. Audio recordings of the interviews were made.In collaboration with the supervisors at the 5 community health care centers, 4 FGs were organized (2 in France and 2 in Switzerland), each with 7 to 8 PCs. The research team proposed meeting dates and times for the FGs. The PCs who were willing to participate signed the consent form beforehand, and audio recordings of the FG discussions were made.The research team developed and tested guides for the one-to-one interviews and PEIs for the CDOAs and ICs and for the FGs. The interview guides encouraged the participants to discuss relevant research issues by asking open-ended questions. The interviewer could reformulate, reorganize, or clarify questions to gain a deeper understanding of the participant’s answers. The guides also helped the participants to better identify practical technologies that might improve health care ,31. DataDescriptive statistics were compiled to describe the participants’ sociodemographic, health, and professional characteristics as well as the technologies selected. Statistical analyses were performed using the IBM Statistical Package for the Social Sciences 25.0 . PersonaThe study sample was composed of 68 CDOAs, 21 ICs, and 32 PCs. The distribution between the French and Swiss centers was 40 and 28 CDOAs, 13 and 9 ICs, and 16 and 16 PCs, respectively.Of the 68 CDOAs, almost three-quarters were women , with an average age of 82.3 years ; approximately two-thirds  lived in urban areas. The average age of the 21 ICs was 68.4 years , with 16 women and 5 men. Most were retired (n=13), lived in urban settings (n=13), and took care of a loved one with a cognitive impairment (n=12) who required partial assistance with the ADL n=6; .A total of 4 FGs of 8 participants each brought together 32 PCs, all employed at community health care centers. Their average age was 46.7 years  and most were female. Their varied professional roles included physicians, nurses, social workers, nursing assistants, care assistants, and occupational therapists .We recorded a total of 40 hours and 53 min of personal interviews and PEIs with CDOAs  and 12 hours and 25 min with their ICs . We recorded a further 4 hours and 50 min of interviews with the 4 FGs .In light of the theoretical framework adopted , we applCDOAs perceived technology as something that could be useful, especially for other older adults with health problems, but they rarely saw any sense in using them themselves, except when they had significant difficulties with their ADLs. CDOA 6 said that technology was:For people who can’t get anything done alone.CDOA 63 thought it might be needed in future:Not for the moment, anyway. Maybe in a few years, yes, let’s say, if I have problems in a few years, because I have...well, because of my age!”CDOA 53 had negative perceptions:Because all these...these modern techniques, and everything, don’t interest me much. Because it doesn’t match my past life at all.CDOA 73, however, held an opposing view:But if something can make life easier, why not? At my age, now’s the time to try.The concept of technology, in general, was often misunderstood. CDOA 75 exemplified this:Technologies? What do you mean by technology?Some CDOAs stated that technology could be useful but not in their current situation. CDOA 9 stated that they did not see any need for it in their current situation:It works automatically, huh? Of course, but for the moment, it’s not for me.CDOA 13 thought that some devices might be useful to them if they had more severe health problems:I think that I’d have to be really bad, huh, to put this thing on.The (positive or negative) interest in technologies was also often stated by this group. CDOA 9’s positive perceptions of technology were typical:Well, I think it’s...it’s 2017; I think it’s a necessity, isn’t it?CDOA 85 spoke out against technology:And then, it’s no good at all. Sometimes it’s completely harmful, like when things are made available to people, like me, who aren’t always able to understand.technology, without context, was not really understood. As CDOA 82 said:Among CDOAs with mainly cognitive impairments, the word I don’t know what that means.independent group mainly spoke about how technology could be useful for others. CDOA 7 gave their opinion:The relatively Well, it’s good for people who don’t have many visitors or people who don’t get any help from their families. And I’m not one of them. So then, no.technology itself, as in the other groups, came up regularly. CDOA 10 expressed this as a lack of knowledge:Misunderstandings about the term and the meaning of I don’t know which technologies, that’s the problem. That’s because I don’t understand everything...I don’t get it...because, well, I know there are a lot of things now, but I don’t know everything about them.Positive and negative assumptions appeared in similar proportions among the independent group, as they did for the other 2 groups. For example, CDOA 72 gave their opinion on the internet:Today, what I don’t agree with is the internet. It’s going to destroy the planet. That’s it, one way or another because it is so dangerous, especially because of those who know it very well, they could flatten the whole world. So, I’m really not interested in the internet; so I’m not interested in computers either.CDOA 83 shared their positive perception:If it’s easier for us, if it can help us out, why not, eh?Some ICs considered technologies potentially useful in helping CDOAs remain at home, whereas others considered them as indispensable. Their perceptions on the usefulness of a technology seemed to depend mainly on their current state of health, their own openness to technologies, and the costs involved. Different ICs expressed these aspects as follows:The thing that might encourage me is if it, err, her case worsened.IC 38She has already been offered them, but she doesn’t want them.IC 56Yes, change. I think if we change things, I think it would be complicated for her.IC 38Oh, well, that must be very expensive.IC 43PCs perceived technology as useful, but they specified that there was the risk of creating distance in their relationship with the persons in their care and that technology must complete and complement a PC’s work, not replace it:It can only be complementary. At some point, it makes sense if a real person has to be involved.FG 2Moreover, the indication chosen for the use of a specific technology should not only reassure ICs:What worries me is situations like this, where the children have even put cameras in the bedroom, not to monitor their parents, but rather to reassure themselves.FG 2Technologies that could be introduced to enhance the daily lives of CDOAs include furniture with home automation technologies, suitably adapted public transport, and an elderly friendly urban architecture in environments that facilitate transport mobility:We often have patients who have to take taxis or be driven to hospital or to a medical consultation in town...It’s a real transportation problem.FG 2Fifteen years ago, they were all at home, they didn’t move. Now you see some, I don’t know how many, in the city center, using their rollators. It’s pretty impressive. Soon, they’ll invent rollator parking lots.FG 1Urban living could also be rethought, perhaps by setting up social centers for CDOAs, on the same principle as youth centers:Architecturally, it would have to be equipped with ramps for the handicapped, for the rooms where they can meet up. As we do for youth centers, why not build a place for older people with physical difficulties?FG 1PCs highlighted their lack of knowledge about the technological devices available on the market and their lack of training on how to pass on skills to CDOAs and ICs:I don’t have much knowledge about this. It’s true and it makes sense that some training on this wouldn’t be bad.FG 2physical and cognitive impairments, encouragement to use technology by children and grandchildren was mentioned as an important strategy. Family members often gift devices that they no longer use to their older adult relatives. Children choosing devices, such as remote alarms, was also a facilitator of technology use. CDOAs mentioned that receiving financial aid for the acquisition of a device was a facilitator, as was receiving recommendations from PCs. CDOA 35 exemplified the assistance received from PCs:Encouragement from children and grandchildren, financial help for purchasing technology, and increasing feelings of safety were the main strategies identified by CDOAs themselves for improving the ease of use among their peers. For the groups with mainly There is a home for the blind; they proposed it to me. And they sold me the [talking] watch.CDOA 76 stated:Yeah, that’s right. So, my granddaughter has a tablet, and my son put my number into it.independent CDOAs, financial support for buying a device and receiving help on usage were the main facilitators of their use. CDOA 84 explained their situation:Several facilitators to improve beliefs about and attitudes toward technology emerged during the interviews, one being that a device can improve feelings of safety. Financial assistance can be considered a facilitator because it influences people’s willingness to acquire a device. Indeed, for the group of Listen, my son gave me this mobile; I didn’t want it. And he said to me, “It’ll be easy.” Anyway, there you go.CDOA 83 said:Someone should come and explain and turn it on and say “You have to do this and do that.”feel safer was the main facilitator of use among this group. CDOA 84 explained this in relation to their personal situation:Again, with regard to beliefs and attitudes, a technology that made participants And then I was unsure, and I was thinking about it, but as I said, I was putting it off and putting it off. And then there’s the personal side, you see? I have great neighbors, but the young ones work, and the old ones are no stronger than me, right? So, I said, “Oh, well!” and then it’s a bit of a safety thing, even though, as I said, I hope I’ll never need it.Devices’ properties, such as ease of use, also influenced CDOAs. CDOA 10 described using a stair-lift:Yes, usage. You press a button; there’s nothing complicated, eh? There are knobs, one at the top, one at the bottom, so it depends on where you are. Well, you grab the knob. And then, if you go up the stairs, you use the stair-lift device.Some ICs supported the use of technologies if they found them useful and easy to use. As IC 43 said:If it is a technology that can help me, I will accept it. If it can lighten the burden of helping her.Surprisingly, other ICs would only introduce certain technologies if the CDOA’s state of health deteriorated. Nevertheless, ICs often felt that they lacked the knowledge to use technologies properly. As IC 71 said:I like the technological side, but I just have one problem with it. It’s clear that people who weren’t born in the technological age, or who haven’t got themselves up to date by 50 or thereabouts (are going to have trouble). I even find that I’m often overwhelmed.ICs also noted their relatives’ lack of motivation about the introduction of new technologies:Ah, well, it’s certainly a very good thing, but she still has to want to do it. She’s not on board with all that’s modern. So, she’ll say no to thatIC 43The ease of use of technologies was overrided, as perceived by the ICs, by the fear of making mistakes when using them or of infringing on the CDOA’s privacy and autonomy.PCs mentioned that the context of technology implementation was important in its ease of use:Older adults just need to be interested in new technologies. They are pushed towards it by their children—by their grandchildren, especially.FG 2Sometimes a neighbor will say, “You know, I’ve got a rollator, and it goes great,” and that’s it. It’s not some young woman who comes in and says, “This is what you need.”FG 1Indeed, technologies were accepted more readily if relatives and ICs were involved:Sometimes they actually need their family’s support in order to be reassured.FG 1Ease of use also seemed important:There are some things that could improve autonomy as long as they remain simple and easy for people to use.FG 2According to PCs, the CDOAs who had either found a technology useful or had used technology in their working lives were more willing to use the proposed technologies:Some CDOAs are familiar with Skype, for example, using it with grandchildren abroad or even in another city.FG 3The elderly population that needs these aids now, is often a population that is unaware of the digital revolution.FG 4Although the point of view of individuals and the context in which technologies are implemented tend to be the factors that promote technology use among CDOAs, the cost involved in acquiring different technologies and the different steps required to obtain them can be seen as barriers:And I find that they’re always scared that “It’s going to be expensive; I can’t.” Sometimes they don’t realize the means they still have, whether financial or not.FG 4The emotions associated with technology use can also be a barrier when they generate stress and fear:The more things or equipment involved, the greater the source of stress, for the patient and the family.FG 4You get to a certain point in the aging process where people are not necessarily very accepting of their loss of autonomy. And consequently, in accepting any assistance that might be provided to them.FG 4For all groups of CDOAs, the acceptability of using technologies was influenced by the self-developed strategy for achieving this purpose, difficulties in using the device, and the technology’s cost. As an example of avoiding technology use, several CDOAs said that a simple bedside lamp gave out sufficient light to get to the toilet. The CDOAs found no reason, for example, to replace the home helps who came to clean their home with a robot vacuum cleaner. Help provided directly by humans was the preferred option for many CDOAs. CDOA 13’s thoughts on electronic pill dispensers began with a deep breath:I’m telling you, I don’t feel the need for one. Oh! If I have something special, my daughter still comes, three times a week, and she is a nurse.physical impairments did not find some device properties to be user-friendly, and multiple participants considered this to be the main obstacle. CDOA 35 complained about their tablet:The CDOAs with mainly Because handling this device is very complicated for me, you see? I have to turn it all over the place to find out what is going on...No, I’m just not interested.Another barrier was the cost of acquiring a new technology, as explained by CDOA 6:Oh, yes, because I can’t say I’m going to buy anything, in addition to what we have to buy every day, because we can’t afford it.cognitive impairments, the main barrier was the difficulty in using technologies. This was reflected by CDOA 20:For the CDOA group with mainly So, to start with, I don’t want a computer. That’s out of the question; I don’t want a computer. Well because I wouldn’t know how to use it. That’s why.In several interviews, the group members were found to prefer human contact over technological assistance. CDOA 76 expressed doubts about robots:Because there’s a person, the nurse, working; a robot isn’t human, whereas a nurse can talk, say something nice, give you a little smile. But a robot’s just ”Crash! Bang!”’Financial hardship was also consistently mentioned as a barrier to technology use. CDOA 76 said:Yeah, robots. Yeah, but you need the means to buy one.independent CDOA group, financial and usage difficulties were also the most frequently mentioned obstacles. Regarding financial aspects, CDOA 10 said:For the Well, let’s say, it’s a good thing. It’s good, but it must have a cost. Well, yes because...I still have to pay for the nursing home; don’t forget that. My husband’s pension, unfortunately, only pays for half of it.Regarding usage difficulties, CDOA 10 described their tablet:Right now, I do not know how to use it. My daughter, she’s got one. My grandsons have one each, but so far I’m not interested.Technologies designed to promote older adults’ home support, such as fall detectors, GPS, and brain training, are the ones that are most frequently accepted by CDOAs. CDOA 73 explained their acceptance:But we don’t know if I’ll ever be able to...it’s because I’m a little scared, that’s why I don’t go out alone. I’m a little scared to cross the street. So that’s why it’s really the fall detector that would suit me best.Regarding brain training, CDOA 63 explained:Well, because by...improving your powers of concentration, developing your vocabulary, anyway because of the propositions that are there, I think it’s good. That’s why.Perceptions about the acceptability of technology use were significantly influenced by safety, ease of use, keeping CDOAs autonomous, and the costs of devices.ICs explained how the acceptability of technologies was related to the safety of their loved ones. This result can be explained by the fact that of the 21 ICs interviewed, 12 were relatives of CDOAs with mainly cognitive impairments. Thus, the technologies chosen by the ICs were very similar to those chosen by the group of mainly cognitively impaired older adults. Opinions of the ICs regarding the acceptability of the technologies presented during the PEI interviews are as follows. For the light path selected by several ICs, the caregivers said:Yes, I think that is really good. Well because my mum gets up at night, she can’t find the light.IC 42That’s right, because I see he gets lost going to the toilet.IC 44Concerning the fall detector, accepted by about one-third of the ICs, they said:Yes, that could be the most useful there. [...] in the future there could be others [devices].IC 43Maybe rather the fall detector, I’d say.IC 55The ICs were more reluctant about the electronic pill dispenser:Ah, well [...], it could be useful because I want him to have a pillbox; the nurses come to put the pills in. But if he doesn’t think about it—if I don’t think about it, he doesn’t think about it—then it’s not much use.IC 29Yeah, it’s not bad, but I think it’s pretty expensive for how much we use it. As long as we’re here, well, they’re taken at mealtimes, so I’m here [laughs].IC 40[…] In my mother’s case [...] she’d be unable to take her medication alone.IC 42The ICs had diverse opinions about robot vacuum cleaners:For me, these robots are good. You shouldn’t have anything on the ground [laughs] [...] You shouldn’t; it doesn’t go in corners, it’s round [laughs].IC 29Well, it depends on how much it costs, huh?IC 38Not essential, in my opinion.IC 40[….] I think not. No, it might be more dangerous than useful.IC 42As for the opinions on the service robot, the ICs said:Yes, listen, yes, it’s good, but in the end, a human being is still better.IC 23[…] I find it rather stressful.IC 29Opinions on the usefulness of a GPS bracelet could be summed up by this statement:That, I, I’m for that. If she ever decided to go somewhere, it would let her know where she was...it would let us know where she was.IC 38Only a fraction of the ICs found the touchpad to be an interesting technology. There were different opinions on this:No, so my mom, my mom... she’s not interested.IC 23It might make things easier for him, but since he was not very enthusiastic, he quickly lost patience.IC 29Uh, no [laughs], there. Uh, I think it’s impossible. Because even a mobile phone would be complicated to use, so...He still manages to work the TV, but that’s all.IC 55Among the ICs interviewed, the idea of a social network for ICs raised little interest:I think it’s good… For the moment, I don’t need it, because...Well, I have a good rapport with the home help; it’s going well.IC 23I’m not…I’ve never been a person like that, not very communicative and that...So, everyone has to say what they do, what they’ve got...It’s not...No, not for me. But I’m not saying that it might not be a help to a lot of people.IC 29Oh! It’s not bad. It could...for someone who is alone, be a help, yes.IC 40Brain training technology was selected by only one IC, but the quoted text below illustrates the difficulties in using this technology:She can’t do it alone either. Well, memory exercises would be great, but maybe someone would have to help because of her not being able to use a tablet.IC 42To the ICs, activity sensors were not a promising technology to strengthen home support:Ah! Well, for people who live alone, that’s very good.IC 23Oh, yeah, sometimes he hasn’t closed [the fridge door] properly. It’s happened sometimes, when it didn’t shut properly.IC 29[…] she’ll say to me: “You don’t think I’m crazy yet, do you?” All this scares me.IC 38Yes. Yes, well that could be, err, that could be good, indeed. Yeah because in half an hour anything can happen, eh?IC 42[…] I wouldn’t even trust the sensor [...].IC 44[…] it’s true that these are technologies that are great for those who are not safe, but who are in their right mind, and everything, who don’t have all their heads and bodies; and who may be putting themselves in danger, uh, about that.IC 55Among PCs, perceptions about the acceptability of technology differed according to the constraints that technologies impose on the CDOAs. The more technologies focus on monitoring a CDOA’s behavior, the more ethical questions they raise. On the contrary, the more they increase a CDOA’s autonomy and safety and decrease the burden on ICs, the more the PCs promoted them. Opinions on the acceptability of some of the technologies proposed during the PEIs were as follows. The light path technology was broadly well-received by the PCs, and the following statement illustrates their favorable opinion of this technology:A technology that should be introduced and available for all older people.FG 1Technologies that increase safety, such as the fall detector, were mostly preferred by the PCs:[…] if it’s good, it can be very useful.FG 2The PCs showed little interest in the robot vacuum cleaner and the service robot:[…] There’s a risk of falling over the vacuum cleaner when it’s running...FG 4[…] It’s interesting if it assists caregivers [gives them time to do another activity while the robot is working].FG 1There's a risk of replacing humans […].FG 3Several PCs had questions regarding the GPS bracelet technology:[…] it’s not relevant if its only purpose is to calm the family […] .FG 3[…] there are ethical problems if it’s used as a means to monitor the person […].FG 3The touch tablet and brain training technologies were rarely chosen by the PCs. Their reluctance was expressed as follows:You have to accompany the arrival of the tablet in the person’s environment and ensure that the person is interested in using it….FG 4It might be interesting to couple a tablet to the remote alarm [to enable visualizing the person’s condition if they can’t or can no longer express themselves because of cognitive disorders]...FG 4[…] difficult to offer if the person does not know how to use a tablet…FG 4...can be a prevention tool…FG 3Although some PCs selected the social network and activity sensor technologies, there were mixed opinions:[Social networking] technology is not necessarily appropriate if the caregiver does not understand those technologies; it’s rather aimed at young caregivers [...].FG 2[…] it can make caregivers feel supported [...].FG 2Concerning activity sensors, this response was obtained:[...] Pose an ethical dilemma [...]; [...] culture can be an obstacle to the use of this technology; [...] interesting technology, and install the sensors only as needed . It can be a complementary tool in food monitoring if this problem has been previously identified [...]FG 2When choosing the most useful technology overall, the PCs differed according to their profession. Physicians, nurses, and occupational therapists chose the fall detector, whereas nursing assistants, social workers, and direct community health providers chose social network. To the best of our knowledge, this is the first research in the field to have combined personal interviews, FGs, and PEIs in the same study. Our results show that technologies are not yet well integrated into the daily care of frail or cognitively impaired CDOAs. Although technology can certainly offer solutions to some of the specific impairments typical among CDOAs, ICs and PCs still have little knowledge about their existence and how they should use them in everyday practice. The heterogeneity of participants’ profiles made it difficult to compare this study with others involving more homogeneous samples ,39.Our results indicate that most participants had both positive and negative attitudes toward technology. Positive attitudes were most often related to technologies that ensured continued mobility at a lower cost and with advanced functions (a GPS bracelet). Negative attitudes of CDOAs were often associated with the risks of becoming technology–dependent and the risk of fewer or poorer interactions with ICs and PCs, the realization that they were no longer able to stay at home, potential social problems , and the financial costs of technology use. Furthermore, the findings suggest that ICs had more positive attitudes toward assisting technology and an increased acceptance of technology than the CDOAs themselves. This could be explained by the fact that the average participating IC was 14 years younger than their CDOA and thus had more contact with technology in their daily life . NeverthTechnology use was often conditioned by the multiple expected outcomes CDOAs had with regard to remaining at home, risk control by ICs and PCs, and trying to avoid hospitalization or institutionalization. In contrast, the nonuse of technology was linked to the participants’ use of their personal and individual capacities, their health, their physical and intellectual functional capacities, and the environmental barriers they encountered . To encourage the participants to adopt technology, our findings suggest that the potential barriers to this should first be removed at the individual level , then at the technological level , and finally at the environmental level (life context). These results were consistent with the research conducted by Chen and Chan .Results from the PC FGs revealed that they had mixed attitudes toward technology, although most were interested in specific technologies for everyday use. They highlighted that each care situation was unique, uncertain, and often complex. They were particularly interested in the development of new technologies to help with the ADL. Finally, barriers to the use of technology by PCs themselves included lack of interest, a need for training, the architectural inadequacies of house design, cost issues, and their fears of being replaced by that technology and of the risks of dehumanizing care relationships with CDOAs. Our results highlight the need to pay more attention to adapting technology to users’ personal preferences, while focusing on technologies that provide solutions to individual problems. However, to date, there is little evidence to evaluate the usefulness or effectiveness of certain technologies in home care and notably to avoid hospitalization . Causal Technologies in home health care settings must also be adapted to the needs and concerns of PCs . In lineThe development of technologies to strengthen home support and prevent the loss of autonomy is a demographic, human, social, and economic imperative; it must be accompanied by the development of multidisciplinary skills . AcademiThe significant sample of CDOAs, ICs, and PCs involved in this study suggests that our results may be transferable to other regions of Western Europe. The PEIs made it possible to clarify perceptions and specify acceptable technologies. Another strength of this study was its use of a novel combination of methodological approaches, via one-to-one interviews, FGs, and PEIs. This approach illustrated which technologies might be acceptable and useful to CDOAs, ICs, and PCs in the context of home care support. Our research population’s heterogeneity did not permit a thorough comparison with other studies in the literature as they involved more homogeneous samples -20. In aDespite the omnipresence of technology in modern society, research into perceptions about it and its use to improve the daily lives of frail and cognitively impaired CDOAs is poor compared with research into its impact on younger populations. Despite some evidence that technologies promote independence among CDOAs, they are often underused in daily home health care. With this in mind, this study explored the perceptions about technology’s place in home health care among CDOAs, ICs, and PCs. Our findings showed that although many technologies were available to support independent living for CDOAs, they were significantly underused. Our results also affirmed that efforts should be made to adapt technologies to the needs of CDOAs, their ICs, and PCs. It seems important to continue searching for empirical evidence of the relevance and effectiveness of new technologies. This will help to specify the most important areas requiring intervention and indications for technology use among different profiles of CDOAs, their ICs, and PCs. Technology will also help to optimize the management of CDOAs’ health problems and slow their loss of autonomy, both of which will strengthen home health care. Progress toward this goal will only be achieved through close cooperation between technical experts, home health care experts, and the end users—CDOAs, ICs, and PCs—who need the appropriate technological tools to meet their needs and expectations. Finally, as the mean age of the population is rising, the proportion of older adults with an interest in technology and with technological skills will increase. The findings in this study will enable future CDOAs to clearly express the advantages and limitations of the technologies in their lives. The current situation is therefore very fluid, and research will have to adjust to this dynamic process. Although there is no doubt that technologies will play an increasingly important role in health care services for CDOAs and in the work of their ICs and PCs, it is more difficult to predict which types of interventions may develop. Establishing convincing results based on robust scientific evidence will be difficult, but clinical research will play a key role.


Diabetes self-management apps have the potential to improve self-management in people with type 2 diabetes (T2D). Although efficacy trials provide evidence of health benefits, premature disengagement from apps is common. Therefore, it is important to understand the factors that influence engagement in real-world settings.My Diabetes Coach (MDC) self-management app.This study aims to explore users’ real-world experiences with the We conducted telephone-based interviews with participants who had accessed the MDC self-management app via their smartphone for up to 12 months. Interviews focused on user characteristics; the context within which the app was used; barriers and facilitators of app use; and the design, content, and delivery of support within the app.A total of 19 adults with T2D  were interviewed. Of the 19 interviewees, 8 (42%) had T2D for <5 years, 42% (n=8) had T2D for 5-10 years, and 16% (n=3) had T2D for >10 years. In total, 2 themes were constructed from interview data: (1) the moderating effect of diabetes self-management styles on needs, preferences, and expectations and (2) factors influencing users’ engagement with the app: one size does not fit all.User characteristics, the context of use, and features of the app interact and influence engagement. Promoting engagement is vital if diabetes self-management apps are to become a useful complement to clinical care in supporting optimal self-management.Australia New Zealand Clinical Trials Registry CTRN126140012296; URL https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=366925&isReview=true By 2045, 693 million people will be living with diabetes, the majority with type 2 diabetes (T2D) . DiabeteThe evidence for the efficacy and acceptability of diabetes self-management apps is increasingly robust -11. Howecutting edge news and links for further reading ) accessed via personal devices and used in the context of everyday life over a prolonged period and to understand the interplay between users’ characteristics, needs, and preferences and engagement with a diabetes self-management app.Therefore, this study aimed to investigate users’ experiences of a diabetes self-management app  ,29. The appointments with an embodied conversational agent Laura , enabling the automated upload of glucose data to the MDC app. Finally, the app had inbuilt links to a website with diabetes resources and a user guide for the app.Invitations to participate in the MDC trial were sent by mail to adults with T2D  registered with the National Diabetes Services Scheme (NDSS). Participants were eligible if they were adults aged 18 years or older, diagnosed with T2D, registered with the NDSS for <10 years, had access to a smartphone (with an operating system of at least iOS 8.0 for Apple devices or OS 4.2 for Android), and fluent in the English language. The exclusion criteria were as follows: women who were pregnant or planning to become pregnant; individuals reporting severe comorbid conditions that would prevent participation in the trial; and individuals on nonstable doses of diabetes-related medications.Interview participants for the qualitative study were recruited from the intervention arm of the MDC trial, all of whom had accessed the MDC app for up to 12 months. Purposive sampling was used to achieve variation in user characteristics, including age, gender, education, occupation location, duration of T2D, and use of the app .Participants were sent a plain language statement describing the study and were required to provide written consent. Participant characteristics were collected at baseline via a self-report questionnaire, including demographic and clinical details and current health app use.An interview guide was developed to include questions about the user’s self-reported diabetes expertise, how they managed their diabetes, when and how they engaged with the app, and their experiences using it. In-depth semistructured interviews were conducted through telephone (by SB) and recorded using SmartInteraction Suite, a cloud architecture voice recording solution (CTI Group). SB has several years of experience in diabetes-related research, including conducting telephone interviews. She worked as a research assistant on the MDC project and was involved with program development, participant recruitment, and data collection. Many of the participants had previously interacted with her. At the beginning of each interview, SB summarized the research and reasons for her interest in it.The first 2 interviews were analyzed, and changes were made to the interview guide to capture additional information on the context of use and feedback on the timing and delivery of sessions. Data included researcher observations and postinterview notes. Data collection continued until saturation was achieved (19 interviews), as indicated by the recurrence of themes and no new themes emerging. Recordings were stored in a secure cloud-based location and transcribed verbatim by an accredited transcription service with privacy certification. During each interview, SB kept notes of points of interest and used these as prompts. Immediately after each interview, SB prepared a written summary of the interview and relevant observations. These were used to communicate interim findings to the wider research team. When appropriate, additional questions were added to the interview guide, allowing for further exploration of issues raised by participants that were relevant to the research aims. These notes were also used to guide meaningful interpretation of data during data analysis.Descriptive statistics were computed for demographic and clinical characteristics and current app use using SPSS version 25 (IBM Corp). Data are presented as mean (SD) or number (percentage). Raw interview data were imported into NVivo 11  for coding and analysis. We followed 6 steps for the thematic analysis with the development of themes guided by a priori objectives identified in the aims: (1) data familiarization, (2) identifying initial codes and developing a coding framework, (3) identifying potential themes, (4) matching themes to the supporting data, (5) defining and naming themes, and (6) extracting relevant themes and producing a description of findings ,33. SB a1c, and used the app twice as much as those in the intervention arm of the MDC trial. The mean duration of the interviews was 51 min (range 29-79 min).A total of 19 adults with T2D were interviewed . Additional participant characteristics are detailed in A total of 2 high-level themes were constructed from the data: (1) the moderating effect of diabetes self-management styles on needs, preferences, and expectations and (2) factors influencing users’ engagement with the app: one size does not fit all. These comprised several subthemes, as described in the following sections , which for them did not “add or detract from the experience” and were dismissed as examples of “the same information presented in a different way.”This may explain why this group appreciated attempts at gamification and making learning fun, describing novel features of the app, such as IVR and the relational agent, as being “exciting,” “more interactive,” “cool and unique,” and increasing their Perhaps because of their experience using other health apps, the group expressing more self-directed self-management styles had higher expectations of the MDC app and were less tolerant of technical issues:It has to be reliable because that's my expectation now of apps and other things and I can always find an alternative these days.They expected flexibility in navigating through the MDC app in a way that suited them. For example, “a little less linearly,” with “a higher degree of user control in terms of being able to investigate down particular information paths and then back out of them.” They wanted the choice to be able to skip a particular topic if it was not “relevant” or “to go back over information” later through increased “searchability” if they found a topic particularly interesting.:On the other hand, participants from the other group did not have much experience with using apps and, therefore, were more forgiving of technical issues, for example, “just teething problems because it was so new.” However, because this group tended to limit their smartphone use to phone calls, they expected to be able to use the MDC app on their tablet deviceI'm one of these people that think a mobile phone is a mobile phone, and if I want to do anything else I go to the iPad.This theme describes how participants engaged with the app, specifically the context, mode, frequency, and duration of interactions and the factors influencing these choices.Participants could choose one of the multiple ways to interact with the MDC app. First, they could use the built-in IVR technology to listen to what the embodied conversational agent Laura said and respond using the microphone. Second, they could listen to what Laura said but respond by touching one of the options on the screen. Third, they could choose to ignore or mute Laura’s voice, read the text on the screen, and respond by touching an option on the screen.The novelty of being able to interact with Laura using IVR was described by some as “exciting” and “more interactive.” However, most users, regardless of their self-management style, soon discontinued their use of IVR, choosing instead to read the text and respond by touching one of the options on the screen. The primary reasons were that IVR did not offer any obvious advantages and had some drawbacks. For example, using IVR as a mode of receiving and responding to messages within a session took much longer than reading the text and tapping in a reply:There was nothing wrong with the pace of her speech, it was just that I could read quicker, so I chose to not listen to her.Technical difficulties were also a hindrance:She didn't understand me [laughs]. I found that frustrating.The context of use also influenced the choices of users. For example, many described the IVR function as inconvenient because of their surroundings, for example, “I was always doing it in the bedroom in the morning when my husband was still in bed asleep” or “I didn't use it, because most of the time I was on the train.” Some participants also described talking to the phone as unnatural: “I think it just looked silly, to be talking to your phone.”Giving the user a choice to opt out of using IVR and use other interaction modes was critical. As one participant put it:If I had to have talked to her, I think I would have pulled out!The MDC app required participants to complete a session with Laura once a week at a time that suited them. A weekly appointment suited most, as “any more would become a chore” or “just too much.” The discipline of a regular weekly appointment was viewed favorably because it increased commitment:If I did it my own way, I wouldn't have done it. I think an appointment time kept me accountable.Another positive attribute was that they mimicked offline appointments, encouraging automaticity:It was like an appointment with a doctor or going out for dinner with friends. You knew that at 6:30 Friday, you had to sit down and talk to Laura.Another participant said:Even my grandchildren would say to me, oh grandma, it's Thursday, and you’ve got to speak to Laura. I structured things outside of those times because I knew that time was taken. I did things around that time because it was to me a standard appointment.Those in paid employment appreciated being able to choose a time that suited them:I'm glad I could choose a time that suited me.They also valued the flexibility of being able to complete chats within a certain time frame:[If I missed my time] that was easy to get around, because you had 24 hours to actually go in and have the chat with Laura.On the other hand, those who were retired had a set time every week and made the chat part of their schedule, with little to no variation from 1 week to the next “I'm retired now [laughs], so what else do I do?” or “I'm a creature of habit, and I like things to be ordered and I like the regularity, [so] I put it in the calendar.”For those with busy schedules, the fact that the MDC intervention was divided into 15 to 30 minute chats, over several months, was a benefit and compared favorably with face-to-face diabetes self-management education and support programs:It wasn't a problem to find a half an hour. When you've got to go off to some of these diabetes [education things] it's four-and-a-half hours! You try and find four-and-a-half hours when you work a 16-hour day, it just doesn't work.Participants unanimously emphasized the importance of access to an app supporting self-management immediately after the diagnosis of T2D as a means to come to terms with their diagnosis:You need to get that in front of people when they're in the first days, [and thinking] “Whoa, what just happened to me?!”Participants suggested that having an “introduction to the basic stuff, in a fairly accessible manner,” resulted in “the greatest benefit” and “greatest impact and usefulness.”Many participants described diabetes education as nonexistent or insufficient:Other than being prescribed medication, there was really nothing to supportself- managementOthers who had access described diabetes education as being “blunt, didactic stuff, do this, do that, do this,” with no attempt to account for their personal circumstances.Insufficient time spent with the health care team was described as another barrier to receiving comprehensive information and understanding it:I think for most people, they’re getting information [from the app] they wouldn’t otherwise have heard, unless their diabetes educators are very, very thorough, and you’re visiting them once a week, and we don’t do that. They [educators] don’t have the time for that. Your GPs don’t have the time to go through that information with you.In some cases, the lack of education had the effect of delaying attempts at initiating lifestyle changes and self-management behaviors:So, I was able to reject [my diabetes] and lived in a bit of denial. It took me quite a while to find and assemble a team of people that I felt could help me.Participants consistently expressed the view that MDC would be “useful for someone who was newly diagnosed” to “help them transition”:They need to be pointed in the right direction, because it will take them a while to find it if they're not pointed in that direction.Many also acknowledged the potential role of health care professionals in facilitating access to and adoption of apps following diagnosis:I would see a real benefit in ensuring that people like GPs, diabetic educators are made very aware of the app and that they actively engage patients on diagnosis with the app.Another said:The GP should be going, well here's your blood test results, download this app and learn what's happening and why it's happening.This qualitative study investigated users’ experiences of a T2D self-management app accessed via their own smartphones over a 9-month period in the context of their everyday lives. We identified 2 main themes: (1) the moderating effect of diabetes self-management styles on needs, preferences, and expectations and (2) factors influencing users’ engagement with the app—one size does not fit all. We found that the needs, preferences, and expectations of diabetes self-management apps differed based on participants’ self-management styles. The broad implication is that, in addition to previously identified characteristics, such as age, gender, and socioeconomic status, self-management styles also influence engagement and need to be investigated further ,34,35.health consciousness, defined as the extent to which an individual takes ownership of their own health condition [Participants expressing self-directed rather than externally directed self-management styles were more likely to be proactive in seeking diabetes-related information and using other health apps ,37. A poondition . Our datondition .how app preferences can be personalized based on a specific user characteristic—diabetes self-management style [Our findings corroborate previous research on the benefits of personalization and tailoring while providing preliminary evidence on nt style ,26,36,40nt style . AdditioOur study also corroborates previous research that shows that people who present a more externally directed self-management style may need additional encouragement to sustain engagement. Previous research suggests that changing attitudes to and motivations for diabetes self-management may be especially important for this group ,42. As dAlmost invariably, the participants did not use IVR because it did not provide any additional benefit. Our findings add to existing research that suggests that features, such as IVR, although novel and interesting initially, can deter or distract from the main objective of using an app over time, especially if they do not improve usability and require additional effort . The impMany participants described receiving little to no diabetes education and support following diagnosis, and in some cases, this delayed engagement in self-management . Making Our findings suggest that the proposed contact frequency and duration  was acceptable (even for those with busy schedules) and enhanced engagement, potentially through increasing accountability and automaticity . EnablinFinally, our data suggest that although diabetes self-management apps may be helpful in initiating and maintaining self-management behaviors, people with T2D are more likely to engage with an app when it is endorsed by their health care professional. There is some evidence to suggest that although health care professionals think apps may be useful, sourcing evidence-based, high-quality apps from the thousands available on the app stores remains a challenge ,52,53. Tin the wild, that is, in the context of their everyday lives via their own familiar devices, addressing some of the limitations of previous trials. Participants also had access to the app for up to 9 months, making it possible to explore their real-world use and changes over time. This was a significant strength relative to most previous research where participants only used an app once or for a short period . The purposive interview sampling strategy was successful in recruiting participants with a range of experience, facilitating examination of the interplay between user characteristics, app preferences, and engagement. One exception is that expert app users and those expressing a more autonomous self-management style were overrepresented, perhaps because these characteristics made them more likely to want to participate in the interview study. In addition, interview participants used the app twice as much as those in the intervention arm of the MDC trial, suggesting that we were less successful at recruiting less engaged users. We recommend that future research focuses on identifying the experiences and needs of users who are less autonomous and less experienced with technology because they are likely to have different diabetes education and support needs. Finally, our sample did not include younger adults with T2D, a burgeoning cohort with clear unmet needs [A key strength of this study is that it was conducted in the context of a randomized controlled trial of the MDC app. In contrast with many previous trials of self-management apps, participants used the app et needs . FurtherOur study is one of the first to investigate the use of a diabetes self-management app in the wild. Our findings suggest several ways in which user experiences can be engineered to improve engagement with T2D self-management education and support via an app, such as personalizing app features to user characteristics, recommending a potential optimal time to intervene, developing resources to assist health professionals make evidence-based recommendations for diabetes apps, and recommend potential frequency and scheduling of the intervention. Further research investigating interactions between user characteristics, including self-management autonomy and engagement, is warranted to determine specific strategies to improve engagement with T2D self-management apps if diabetes self-management apps are to become a useful complement to clinical care.


Multimorbidity, the co-existence of two or more chronic conditions in an individual, is present in most patients over 65 years. Primary health care (PHC) is uniquely positioned to provide the holistic and continual care recommended for this group of patients, including support for self-management. The aim of this study was to explore professionals’, patients’, and family caregivers’ perspectives on how PHC professionals should support self-management in patients with multimorbidity. This study also includes experiences of using telemedicine to support self-management.A mixed qualitative method was used to explore regular self-management support and telemedicine as a tool to support self-management. A total of 42 participants  were interviewed using focus group interviews , pair interviews (patients and family caregivers), and individual interviews . The study was performed in urban areas in central Sweden and rural areas in southern Sweden between April 2018 and October 2019. Data were analyzed using content analysis.The main theme that emerged was “Standing on common ground enables individualized support.” To achieve such support, professionals needed to understand their own views on who bears the primary responsibility for patients’ self-management, as well as patients’ self-management abilities, needs, and perspectives. Personal continuity and trustful relationships facilitated this understanding. The findings also indicated that professionals should be accessible for patients with multimorbidity, function as knowledge translators (help patients understand their symptoms and how the symptoms correlated with diseases), and coordinate between levels of care. Telemedicine supported continual monitoring and facilitated patient access to PHC professionals.Through personal continuity and patient-centered consultations, professionals could collaborate with patients to individualize self-management support. For some patients, this means that PHC professionals are in control and monitor symptoms. For others, PHC professionals play a less controlling role, empowering patients’ self-management. Development and improvement of eHealth tools for patients with multimorbidity should focus on improving the ability to set mutual goals, strengthening patients’ inner motivation, and including multiple caregivers to enhance information-sharing and care coordination.Supplementary information accompanies this paper at 10.1186/s12875-020-01290-y. Multimorbidity is most commonly defined as the co-existence of two or more chronic conditions in an individual . It is pAlthough multimorbidity is becoming increasingly common, health care is still largely organized to manage single diseases –7. In SwPHC in Sweden includes all care that does not require the resources of specialist health care or hospitals . Thus, PMost of the time, patients with multimorbidity are expected to perform daily care activities and manage complex regimens on their own or with the support of family caregivers (FCs) . It is tLiving with multimorbidity often implies a range of challenges. Symptoms of pain, fatigue, and depression are common barriers to self-management , 14, andBoth professionals and patients experience patients’ engagement in self-management as a balance between the triangle of patients’ resources, patients’ motivation, and shared responsibility between professionals and patients . To succThere is still a lack of evidence that self-management interventions improve clinical outcomes and quality of life for patients with multimorbidity , 24. HowBy addressing the holistic needs of patients with multimorbidity, eHealth  has the potential to help promote patient-centered care, and thus, self-management , 27. HowThus, more evidence is needed about the best ways for PHC to provide self-management support for people with multimorbidity. Whereas most studies on self-management support have focused on either patients’ or professionals’ experiences, this study covers the experiences of professionals, patients, and FCs. In this study, the professionals include physicians and RNs, the largest groups of professionals in PHC. The study also includes experiences of using telemedicine  to support self-management.The aim of this study was thus to explore professionals’, patients’, and family caregivers’ perspectives on how PHC professionals should support self-management in patients with multimorbidity.Because the study included two sets of data, we deemed a qualitative mixed methods design appropriate . Focus gThe study was carried out between April 2018 and October 2019 in urban areas in central Sweden, and in a rural area in southern Sweden , 3 RNs , 12 patients (6 women) and 7 FCs , were interviewed in the study  Individualized support and patient-professional relationships, 2) Professionals as knowledge translators to help patients learn self-management skills, 3) Managing and coordinating multimorbidity in a system focused on single diseases, and 4) Shifting roles and differing views of responsibility for self-management. Categories and subcategories are presented in Table individualized by taking the patients’ agendas into account and considering their knowledge about and capacity for self-management. Although patients had been invited for follow-up PHC visits about their chronic conditions, they were not always interested in talking about them, but rather could prefer to discuss symptoms or other concerns, such as a new skin lesion or hip pain. Professionals emphasized the importance of answering patients’ questions before bringing up their own agenda for the visits. They noted that if they did not answer patients’ questions, the patients sought care at other places or trusted what they read in newspapers or what neighbors said more than health care guidelines. Several of the patients brought up examples of feeling disappointed when their questions were not answered. One said, “I’m worried about my leg that becomes numb. Instead of investigating it, they gave me a walker and transportation service, but that doesn’t solve the problem” (Patient 1).Patients and professionals said that health care should be Professionals and patients brought up the importance of patients’ individual goals. When discussing goal-setting, physicians and RNs mostly thought of clinical goals such as blood pressure and blood sugar. Patients, on the other hand, talked about symptom relief and health goals related to things they appreciated in their everyday lives, such as working in the garden or being with their grandchildren. One patient was clear about not wanting preventive drugs, only those that gave symptom relief: “My goal is not to become 100, but to have pain relief, nothing else” (Patient 2).trustful relationship facilitated self-management support. Patients and FCs appreciated to encounter professionals they knew and trusted. Even though a new professional could have read the information in the medical record, they preferred to see someone they had known for a long time. They thought that this person knew them, which meant they did not have to repeat their medical history and that the person cared about them. PHC physicians thought they had a better opportunity than hospital physicians to see their patients as individuals because they had known the patients for a longer time and were familiar with their family situations. This was something that RNs also mentioned as important. “Through home visits, I can get another picture of the person and the FC. It’s a whole image that you can’t achieve by reading the medical record” (RN 1).Participants said that a Several things could negatively influence patient-professional relationships, such as a lack of trust in the professional’s competence. A couple of patients brought up not trusting their PHC physician’s competence in treating heart disease. Difficulty understanding a physician whose native language was not Swedish could also influence patient trust. One patient said: “And then there is this language problem that results in misunderstandings. It makes me feel so helpless” (Patient 1).support that went beyond information and disease management. Physicians mentioned that patients often wanted to contact them because of anxiety, stress, or loneliness, not primarily because of disease. Patients brought up loneliness as something frightening, and one patient had continued to participate in the telemedicine program not for health reasons, but because she wanted the social contact.Physicians, patients, and FCs, talked about knowledge and understanding of their diseases, symptoms, and treatments were important for both self-management abilities and reducing anxiety. They thought that PHC had an important role to play as knowledge translator. Physicians saw it as their role to help patients understand their symptoms and how these symptoms correlated with their diseases. This was especially important when patients had several diseases that could cause the same symptoms . “Patients know their symptoms, but why they have these symptoms and these problems and how they’re correlated with their disease, it’s our role to try to explain it to the patients” (Focus group 2).Physicians and patients reported that Patients gave examples of how they had learned to act in response to different symptoms, e.g. increase their dose of medicine to decrease swelling in their feet. Patients also talked about when to initiate contact with the PHC center. For example, one patient would call her doctor if increasing the dose did not sufficiently decrease swelling. Patients brought up lack of knowledge and lack of ability using technology as barriers to self-management. Sometimes health problems  made it hard for patients to understand new information; in these cases physicians needed the support of FCs.Patients also gave examples of how knowledge and understanding could reduce anxiety. It was more frightening to experience symptoms that they could not interpret than to experience those that they understood. Some diseases, such as myocardial infarction, were more frightening than the chronic pain they had lived with for a long time, and those that were threatening made them more prone to make lifestyle changes.pedagogical failings, professionals focused on their pedagogical strengths. Examples of pedagogical failings that patients mentioned included not answering patients’ questions and not explaining why different health parameters were to be checked (e.g. why patients needed to monitor their oxygen saturation). “Then I have this little tool that measures the oxygen level in my blood and that is new. I haven’t seen it elsewhere, and don’t really mind” (Patient 6). One patient who smoked also said that she was often met with admonitions that did not make her more likely to quit. As examples of pedagogical strengths, professionals noted the pedagogical tools they used in their consultations with patients. Physicians used analogies and pictures to explain concepts and sometimes printed out patients’ medicine lists and wrote clarifying information on them. To confirm that patients had understood them, physicians and RNs used questions that required the patients to summarize what the professional had said. One RN gave an example of how she could reassure herself that the patient had understand the physician’s prescription: “And then I ask about the blood pressure medicine, were you suppose to continue with it or not?... I try to have a conversation with the patient and see if they understood the information, and if they didn’t, I try to help them to understand.” (RN 3). The same RN also gave an example of a pedagogical failing neglegting to set goals for patients who feel unwell. “Normally I don’t set health goals with my patients if they’re too sick” (RN 3).Whereas patients talked about professionals’ self-monitoring of health parameters. Patients sometimes initiated this monitoring on their own and sometimes at the request of professionals. Such monitoring could help patients better understand their diseases and thus facilitate self-management. For instance, patients felt they understood their blood pressure and blood sugar by measuring them, and in some cases, they learned how to respond to the results of the measures by changing medication regimens themselves. “Recording my weight has become like a compass. It helps me to adjust my medication” (Patient 10).Physicians, patients, and FCs also talked about role in coordinating care in a fragmented system. Fragmentation of care forced patients with multimorbidity to visit different specialists every year for their diseases. Physicians reported that younger patients could have the energy to come to many visits, but older patients often appreciated being able to consult the same physician about all of their health problems. “It becomes an involuntary full-time job for the patients; it’s their 40-hour week” (Focus group 3).This category deals with problems related to a health care system that the professionals and patients both saw as focused on single diseases. This meant that PHC played an important Care coordination could be a bothersome issue for patients with multimorbidity. Physicians, patients, and FCs all gave examples of such problems. Patients mentioned that they did not know whether their PHC physician and hospital specialist communicated or not, and they did not even know if the different professionals at the PHC communicated with each other. Home care patients and FCs who registered health parameters in the telemedicine program could only share this information with the PHC center, not with the nurses who provided in-home care. This was because the home care nurses were employed by the municipality, whereas the PHC center belonged to the region. Physicians not only thought that specialized care was fragmented, but also experienced fragmentation at their PHC centers, where RNs have become increasingly specialized in different areas, such as diabetes or COPD. One said, “Our RNs have become more and more specialized, while we as physicians are the only ones left who have the general picture” (Focus group 3).According to physicians, existing electronic medical records were a technical barrier to coordinated care, as were health apps, both of which they described as disease-oriented.On the other hand, there were examples of better care coordination. The RNs talked about their role as coordinators of different caregivers for patients with multimorbidity. FCs, home care providers, care managers, and allied health professionals often played a crucial role for patients with multimorbidity, and the RNs saw themselves as being the person who pulled it all together. Patients also gave examples of coordinated care. One FC appreciated that the cardiologist made visits to the PHC center: “They’re an incredible team, together with all of you who take care of my husband” (FC 1).Most physicians also saw it as their role to coordinate care and keep medication to a reasonable level for their older patients with multimorbidity. Some regarded themselves as their patients’ advocate in dealings with other specialists. One physician said: “I’m the patient’s gladiator against the system” (Focus group 1).Accessibility to health care and time for patients with multimorbidity was also important for supporting self-management. Physicians wished for more time with these patients so that they could clinically evaluate the patients’ complex health problems. Physicians explained that patients with multimorbidity were crowded out because of increased access to PHC visits for people with all sorts of health problems, even problems earlier regarded as manageable at home. This was the result of changes in regional health care policy and led to long waiting times that made some patients with multimorbidity accumulate health concerns they wanted to bring up. One physician said, “It’s hard to solve everything at one visit, it just becomes messy” (Focus group 2).Patients also brought up the importance of easy accessibility to PHC. When one patient first started to participate in the telemedicine program for chronic heart failure, he worried that he would lose this accessibility. “From the beginning, I didn’t think I could meet with doctors or nurses,” he said. When asked about what self-management meant to him, he replied, “It’s when the doctors don’t have the time for us anymore” (Patient 5).This category describes the shifting roles that PHC professionals took to support patients’ self-management, as well as differing views of who is responsible for self-management.A professional’s role in supporting self-management could shift by patient. Some patients with multimorbidity coordinated and managed their care independently, whereas others needed more support. Views of responsibility for self-management also differed, not just among professionals, but also among patients and FCs. Some preferred the professional to take a more controlling role; others emphasized the need for the professional to let go of control and to empower patients.professionals were in control, patients adhered to treatment better and felt safer and less anxious. One physician who believed it was important for her to maintain control said that she had to schedule regular checkups for patients to prevent their health from deteriorating. Otherwise, she thought they would not follow her advice. “I assume no one does what I say,” she stated (Focus group 2). Personal continuity could help physicians feel in control because it was easier to see changes in the clinical status of patients they had met before. Patients appreciated it when professionals had control of patient-related information, both through familiarity with a patient’s medical history and through ongoing monitoring. Several patients in the telemedicine program felt secure knowing that someone was keeping track of their health parameters and that the nurse would contact them if there was a change. This knowledge even prevented some from going to the emergency department. “I feel very secure,” said one patient. “Before, when I got chest pain or was anxious, I considered calling the ambulance. Now I don’t need to anymore” (Patient 8).Professionals, patients, and FCs could believe that when FCs could also play an important part in helping professionals see changes in the patients’ conditions: “I notice changes in my husband’s condition by being there every day,” said one person (FC1). For patients with more severe disability, support from a FC was not enough, and they needed extra assistance from the home care unit.patient empowerment to help patients take more responsibility for self-management, and believed that with the right knowledge, patients could manage their diseases better. The professionals were more likely to hand responsibility over to patients after having made sure the patients had such knowledge. “We want them to at least have the knowledge to make them live in symbiosis with their diseases in some way, and not let the disease become a monster that someone else takes care of” (Focus group 1).Some professionals regarded it as their role to motivate patients to take more responsibility for self-management. They favored Professionals also described how patients who managed their diseases more independently gave the professionals valuable time to see other patients in need. For most patients and FCs in the telemedicine program, recording the information felt meaningful and became an important daily routine. For others, this shift in responsibility felt challenging at times, and some patients were so sick that their FC had to record the information on their behalf.Professionals also brought up personal continuity as an important tool to motivate patients in the long term. One said, “If you want to achieve a goal, it’s much easier to follow up your patient on a regular basis than to say, ‘See you in half a year’” (Focus group 1).Professionals could find it challenging to motivate patients to take more responsibility, but it was easier with patients who already had a degree of motivation than those who did not. Physicians promoted group activities for patients and collaborated with RNs at the PHC center to talk about lifestyle changes with the patients. They also thought eHealth tools could play a role in this motivational work but could find it challenging to motivate patients to continue using these tools. “It’s not as fun to brush your teeth with an old toothbrush as with a new one” (Focus group 1).Whereas some patients preferred professionals to take a lot of responsibility for managing the patients’ diseases and coordinating their care, others preferred to maintain overall control. They contacted the PHC center when they felt they needed to, and some would also independently change their medication regimens in agreement with their GP. “Then I increase my cortisone dosage myself, with the knowledge of my physician,” said one patient (Patient 2).This qualitative study explored the perspectives of PHC professionals, patients, and FCs about how professionals should best support self-management in people with multimorbidity. Professionals, patients, and FCs thought it was important for the professionals to be accessible and support patient self-management. This was enabled by personal continuity, which facilitated trustful relationships. According to participants, PHC professionals should also function as knowledge translators and should coordinate between levels of care. Two perspectives on responsibility emerged. Professionals, patients, and FCs could consider professionals responsible for managing patients’ diseases or could think that professionals should support patients in taking the lead in self-management. Latent in the findings was the desire for individual support for self-management, and the overall theme that emerged was that standing on common ground enables such support. In other words, to support patients’ self-management, the professionals must first understand their own perspectives on who is primarily responsible for self-management. They must also understand patients’ and FCs’ preferences, needs, and perspectives on self-management and seek common ground with them on the support they need and on the distribution of responsibility.(a) explores the patients’ main reason for the visit, concerns, and need for information; (b) seeks an integrated understanding of the patients’ world—that is, their whole person, emotional needs, and life issues; (c) finds common ground on what the problem is and mutually agrees on management; (d) enhances prevention and health promotion; and (e) enhances the continuing relationship between the patient and the doctor” [Professionals’, patients’, and FCs’ wishes for mutual agreement enabled by trustful relationships and personal continuity are congruent with recommendations on patient-centered care (PCC) for people with multimorbidity . PCC “. Additionally, our study excluded some of the frailest older adults, such as those with cognitive impairment and dementia.The inclusion of professionals, patients, and FCs from both urban and rural areas increased data variation. Using a mixed qualitative design gave us the opportunity to gather data on telemedicine as a tool for supporting self-management. Such data are of particular relevance, since many people with multimorbidity have been reluctant to use eHealth , 29. TheThe authors come from different disciplines . This brought a multidisciplinary perspective to the research and helped ensure triangulation. JF and GN were able to call on their experience as clinically active GPs. ME and MF, on the other hand, were experienced in home health care delivery and in interviewing patients and professionals about care transitions. GN’s and ME’s academic experience of the organization of care delivery enriched the discussion section. Credibility was increased through peer-debriefing with two groups of researchers, one in health care implementation sciences, and one in multimorbidity.The findings of this study imply a need for ongoing training in patient-centered communication and shared decision-making. It should also be a priority to develop guidelines for managing multimorbidity that focus on personal continuity, individualized consultation length, and multidisciplinary care. Development and improvement of eHealth tools for patients with multimorbidity should focus on tailoring the tools to the needs of both clinicians and patients. The tools should not only help control disease but also empower patients. In practical terms, this means improving the ability to set mutual goals, strengthen patients’ inner motivation, and include multiple caregivers to enhance information-sharing and care coordination.In this study, we found that PHC played an important role in supporting self-management for patients with multimorbidity. Through personal continuity and patient-centered consultations, professionals could collaborate with patients to individualize this support. For some patients, this means that PHC professionals are in control and monitor symptoms. For others, PHC professionals play a less controlling role, empowering patients’ self-management. Customized support requires a personal care plan that is revised as patients’ circumstances change. This plan should take into account clinical goals, patients’ abilities and knowledge, support from other caregivers, and above all, patients’ own goals, which often focus on improving quality of life.Because it supports continual monitoring and easy access to PHC, telemedicine is a potential tool for supporting self-management, especially for patients with multimorbidity who are at risk of rapid somatic deterioration. It might also be useful for patients who want extra support, such as those who feel anxious or alone. We also found that self-monitoring helped some patients learn to understand their diseases and symptoms better and became an important part of their daily routine.Additional file 1. Examples of categories, subcategories, and codes/quotations color-coded by origin: black for physicians, green for RNs, blue for patients, and red for FCs.


Information geometry has offered a way to formally study the efficacy of scientific models by quantifying the impact of model parameters on the predicted effects. However, there has been little formal investigation of causation in this framework, despite causal models being a fundamental part of science and explanation. Here, we introduce causal geometry, which formalizes not only how outcomes are impacted by parameters, but also how the parameters of a model can be intervened upon. Therefore, we introduce a geometric version of “effective information”—a known measure of the informativeness of a causal relationship. We show that it is given by the matching between the space of effects and the space of interventions, in the form of their geometric congruence. Therefore, given a fixed intervention capability, an effective causal model is one that is well matched to those interventions. This is a consequence of “causal emergence,” wherein macroscopic causal relationships may carry more information than “fundamental” microscopic ones. We thus argue that a coarse-grained model may, paradoxically, be more informative than the microscopic one, especially when it better matches the scale of accessible interventions—as we illustrate on toy examples. Many complex real-world phenomena admit surprisingly simple descriptions, from the smallest of microphysics to aspects of economics ,2,3. WhiOne compelling argument for the first hypothesis has been made from information geometry. The approach starts by associating with any given model a particular “model manifold,” whose geometric properties can tell us whether and which simplifications can be helpful ,10. It tThe second perspective instead takes as its starting point the well-known aphorism that “all models are wrong, but some are useful” . One wayDespite the fundamental role causality plays in science and its applications, its formal study has been scarce and elusive, until recently . Especiat depends on its growth rate t). The role of the Consider for example some bacterial population, whose size operator : do(θ=θ0s p(y|θ) . See AppBuilding on this, Judea Pearl developed the “causal calculus” framework, providing a set of tools to reliably work with intricate causal structures . Furtheren model . In a phen model ,24.In this work, we extend the causal emergence framework to continuous systems and show that in that context, it is naturally related to information geometry and sloppy models. This leads to a novel construction, which we term causal geometry, where finding the causally most informative model translates to a geometric matching between our intervention capabilities and the effects on system behaviors, both expressed as distance metrics on the model’s parameter space. This framework captures precisely how the inherent properties of the system’s behavior (its sloppiness structure) and their relation to its use context (matching to intervention capabilities) both play a role in optimal model selection, thereby reconciling the two above perspectives. This comes up because, on the one hand, intervention capabilities are never unlimited in their degree or fineness and perfection of control, and on the other, because the behaviors of open physical systems are never without noise. This helps to formalize how neither the “simplest” nor the most “fundamental” reductionist model may be universally seen as preferable.We take a moment here to further clarify how this work fits within the current literature context. Besides sloppiness and causal emergence, there have been other approaches developed for optimal model selection ,26. For In  example  and showFor the purposes of this work, we formalize a causal model as a set of input-output relations, or more precisely, a map from all possible interventions to the full description of all effects within the context of some system . While tal model . In thisp is the probability density over effect space x. Note that this is distinct from As the focus of this paper is on continuous systems, we consider calculus . This opThe notion of causality is then formalized as a counterfactual: How does the effect of rvention ,30.Averaging over all accessible interventions gives the information of the system’s entire causal structure, termed the total “effective information”: Discrete versions of this effective information have been explored in Boolean networks  and grapI ,24.EI varies across families of simple physical systems. As such, we show how it may be used to select the systems that are in some sense “best controllable,” in that they best associate unique effects with unique interventions  a. To quaEI for different dimmer profiles With this setup, we can now use Equation  to expliEquation  below anEquation :(4)EI≃−1 of f(θ) b.EI is maximal iff A slightly more interesting version of this example is when our detector (eyes) perceives light brightness on a log, rather than linear, scale , in whiEquation  still holication , so our EI is larger than the 1 bit for the discrete switch. However, as we increase the errors, we see a crossover in the two EI values. In this regime, the errors are so large that the intermediate switch positions of the continuous profile become essentially useless and are “distracting” from the more useful endpoint settings. Formally, such causal emergence arises due to the averaging over the set of all interventions in Equation  macroscopic model emerges as the more informative system description for modeling causation . To giveEquation . PracticEI [EI” we introduce may be viewed as a supplement to the usual EI in Equation  [Taking inspiration from information geometry, we can construct a more intuitive geometric expression for the EI . For stuEquation . While tentions) , but as entions) . This sud-dimensional manifold, with parameters As we are focusing on continuous systems, we assume that our parameter space To understand the role of various parameters  we get: DKLpIwithl(θ)=rmation: EIg=logVIEquation  for the g is degenerate anywhere on the manifold. Second, while In Equation  can be dEquation  when bot“Sloppiness” is the property empirically observed in many real-world models, when the eigenvalues of the Fisher information matrix g values ,11,14. Ag values ,13.The trouble with this approach is that the components of the matrix ifold ME ,28. Sinctructure .g as is usually done [g in terms of the coordinates for which Here, we show that by explicitly considering intervention capabilities, we can construct a local, but still coordinate independent sloppiness metric. This becomes possible since interventions give a second independent distance metric on Θ . The matEquation  is then lly done . If we tl. This recovers the standard intuition of sloppiness: we can best improve our model’s descriptive efficacy by projecting out the smallest-From this perspective, we see that the usual discussion of sloppiness, which does not study interventions explicitly , may be Equation  can hererections . By seeiIt is worth noting that in the construction in Equation , it may Equation  are stilEquation  thus takEquation —which maIn order to illustrate our causal geometry framework explicitly and show how higher level descriptions can emerge within it, we use a simple toy model .A, such that Imagine an experimenter has a mixed population of two non-interacting bacterial species that they are treating with two different antibiotics. The experimenter’s measurements cannot distinguish between the bacteria, and so, they are monitoring only the total population size over time This setup allows us to flesh-out the causal geometry construction and illustrate causal emergence here. Our main question is: When is this system best modeled microscopically, as the two independent species, and when does it behave more like a single homogeneous population, or something else ? To idenEquation  for the x, having some uniform error tolerance y is constructed by measuring the population size at several time-points, spaced out at intervals y are given by N. We first specify the quantities for the construction in Equation . Our intEquation  for varyWe can similarly find the d as we scale errors, with low-dimensional models being preferred at large noise. Since noise is ubiquitous in all real-world complex systems, this argument suggests why reductionist microscopic descriptions are rarely optimal from the perspective of informative interventions.The crossover seen in Equation  that l becomesEI  and infoEI  depend oble ones .We hope that causal geometry can contribute to further development in both formal principled methods for optimal model building in complex systems, as well as an abstract understanding of what it means to develop informative scientific theories.