Health Policy and Technology (2013) 2, 10–25

Available online at www.sciencedirect.com

journal homepage: www.elsevier.com/locate/hlpt

The social considerations for moving health

services into the home: A telecare perspective
Lawrence Chidzambwa

Informatics Research Centre, Henley Business School, University of Reading, UK

Available online 18 January 2013

Abstract
Benefits of telecare have been lower than expected partly because of the social aspects in homes.
This paper examines how social aspects are dealt with in telecare design. The objective is to provide
guidelines on how social aspects can be captured and applied when designing telecare. A pilot study
was conducted in a telecare provider domain to determine how social aspects encountered were
dealt with. Social constructivism is applied to capture the user preferences and organisational
semiotics to provide structure to the social aspects. The research presents a norm based framework
that involves the user in the design process. Validation results confirm that the framework is
structurally stable and is implementable. Applying technology in homes offers challenges because of
user preferences. Capturing these preferences and applying them at source raises the quality of care.
The results of this study can be applied in introducing technology in other socially dominated
environments.
& 2012 Fellowship of Postgraduate Medicine. Published by Elsevier Ltd. All rights reserved.

Introduction of how social aspects can be applied in solution design in

It is estimated that 17.5 million people live with chronic
conditions in UK. It is also estimated that people over 65
years old will increase to 11.6 million by 2025—an
increase of 40% from 2010 figures [1]. Similar trends are
obtained in most developing countries. With an aging
population comes problems associated with chronic ill-
nesses and the inability to live independently or unsuper-
vised. This places significant strains on current and future
healthcare resources. Using technology to provide health
and social care services at home has been identified as a
viable means to reduce costs, increasing coverage and
improving the quality of life for those in care. However the
acceptance and adoption of telecare in the home has been
lower than expected. This research answers the question
Tel.: +1 778 686 4592.
E-mail address: chidzaml@yahoo.com
order to improve telecare acceptance.
In the last two decades care from home has grown in
popularity and the governments have supported and
promoted this as an alternative, more efficient and
certainly cheaper way of care than institutionalising
[2,3]. In a report on the Canadian home care sector it
was shown that the sector’s expenditure growth rate is
about four times that of other health sectors [4]. In the
province of Ontario in Canada it is reported that between
1991 and 1999 inflation adjusted spending figures in
health were as follows:
Ministry of health spending fell by 5.6%.
Acute hospital expenditure fell by 19.7%.
Equivalent physician spending fell by 16.7%.
Home care spending grew by 70.9%.
All other spending grew by 20.3%.

2211-8837/$ - see front matter & 2012 Fellowship of Postgraduate Medicine. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.hlpt.2012.12.003
Social considerations in home telecare design
In UK reports indicate that the National Health Service
(NHS) can save about 80% of the costs of some services by
providing them in the home [5]. For example hospitals have
seen the benefits of distributing drugs for diseases like
rheumatoid arthritis, cystic fibrosis, asthma, heart condi-
tions, depression, AIDS and cancer to patients’ homes.
These benefits to providers and the preferences of people
to be treated from home [6] have driven the development
of telecare. However, introducing technical devices in social
environments like home needs to respect those aspects that
make homes unique and desirable by the service users.
This paper discusses how social aspects can be applied in
the design of socio-technical systems for home telecare.
It is extracted from a four year research into telecare
systems and the relevance of applying social aspects in
home telecare. The research used literature review and a
pilot study to determine how social aspects surrounding
telecare were being applied in the solutions that were
offered by the providers. Drawing on the conclusions a
design framework was proposed that captures structures
and applies the social aspects in all the stages of telecare
design. The application of the social aspects includes their
consideration in task definition, device selection and device
configuration. Results from the validation of the framework
from telecare practitioners are discussed and the paper
concludes with a discussion on the implications of research
on applying technology in home care services as well as
other socially dominated environments.
Telecare background
Telecare is the application of monitoring, communication
and information technologies in providing care services to
people in their homes [7,8]. It has taken technological
advances and applied them in the care of individuals with
positive results like alerting users of impending danger and
automatically raising alarms for someone not capable of
doing so as in the use of epileptic sensors. Electronic signals
from the property are relayed to a call centre where
operators decide on the appropriate response. Telecare is
often used as an umbrella term that covers other related
services. It covers a person’s wellbeing e.g. monitoring a
person’s activities in the home, security e.g. preventing
strangers from entering the premises and assistive technol-
ogy e.g. reminders to take medication. Telehealth is the
monitoring of an individual’s clinical conditions from a
distance focussing on health issues and disease management
e.g. monitoring of sugar levels for diabetic people [7].
There is a realisation that the nature of services to which
technologies are being applied in telecare are personal and
present a range of ethical and social challenges to the
service providers and the users alike. The social perspective
includes issues like ethics, privacy, security and the cultural
issues [9,10]. It is therefore important to understand the
social issues that surround the home environment. This
raises the need to develop methods of designing and
implementing telecare that respect the choices of the
individual and improve acceptance.
The wellbeing of an individual is influenced by their
physical condition as well as the psychological and social
aspects such as relationships, emotions, expectations,
11
perceptions and fears [11]. These non-clinical aspects of
health become more important when a person is cared from
home where a clinical condition may become a lower
priority to other needs faced in the house like cooking and
personal care [12]. The operating models for care institu-
tions make it difficult to meet individual social needs which
are major contributors to quality in care. This is because of
the strict programmed routines, excessive control, shared
facilities of care institutions [11]. Those that are admitted
into care homes are not able to get the personal attention
they would prefer because there are so many people looked
after by few members of staff. In care homes individual
choice on services provided is also limited. Things like meals,
entertainment and occupational therapy are mostly provided
in groups and at the times that are set by the care institution.
Emphasis is on minimising risk for inmates as opposed to
improving the quality of life for the individual. Sometimes the
Procrustean bed approach, enforcing uniformity by violence,
is still evident [11]. As a result many people choose to be
cared for from their place of residence. However the costs of
home care can be prohibitive if carers have to be allocated
for their care on a daily basis. Telecare has been shown to
enable care to be provided on a more personal basis in the
home. The challenge has been to incorporate the unique
social aspects of a home in technical solutions.
The generations of telecare
The beginning of telecare can be traced back to the
introduction of community alarms in the 1960s. Community
alarms were installed in order to reduce anxiety and provide
security for users mainly in sheltered homes. These send a
radio signal when activated to call for assistance by pressing
a button or pulling a chord. They are still used in a variety of
forms but the basic features remain the same [13]. They are
very cost effective but have got a limited range especially
the pull cord which remains fixed. They are regarded as the
first generation of telecare systems. The second generation
of telecare systems use sensors which continuously transmit
information on the vital signs, physiological aspects and
lifestyle aspects to a call centre. The devices automatically
signal where assistance is required by detecting exceeded
thresholds and raising alarms without human intervention
[14]. The devices can be combined to form systems that
capture and integrate information from separate devices
such as pendants, smoke detectors, flood detectors and
others. They help to provide support at the point of need
that improves the quality of life. The third generation of
telecare is a move from reactive approaches to pre-emptive
approaches in that they aim to predict risk before it occurs
and summon help to pre-empt that risk. The Internet, web
technology and wireless technologies increased the number
of system functions that make a number of features possible
[15–17]. Examples of these devices are given in Table 1.
The complexity of needs and the uniqueness of each
home environment necessitate a detailed assessment of the
requirements in order to capture the expectations of all
stakeholders. A big proportion of home care is personal
care. Personal care includes items like bathing, toileting,
changing clothes, putting to bed, shaving and sometimes
feeding. Technology cannot replace some of these tasks
12 L. Chidzambwa

Table 1 Telecare generations.

Generation Features Devices Device example

1st  No intelligence. Pendant worn around the

 User activated by pressing a button neck/wrist
or pulling a cord.
 Single state devices.
 No assistance called if user gets
unconscious.
 Used in conjunction with a base
unit but designed as standalone. Pendant activated by pressing
the red button. Non-configurable.
2nd  Limited intelligence. Fall detectors, Flood alarms,
 Monitoring only one aspect per Smoke detectors, Movement
device. detectors, Door exit sensors.
 Can be operated as standalone i.e. Natural gas detectors
not networked.
 Reactive, raise alarm after event.
 Networked.
 No interactivity.
Waist worn fall detector that
 One way transmission.
is clipped on a belt. Non-configurable.
3rd  Increased monitoring capabilities Blood pressure monitor.
e.g. lifestyle monitoring which Electrocardiogram (ECG).
enables raising an alarm before the Bluetooth and wireless enabled
event. devices like blood sugar
 Not condition centric, user centric. monitoring. Setting of
 Programmable. appointments. Library access for
 More functionality per device e.g. health education.
all vital signs can be monitored by AMON—multiparameter medical
one device. monitoring system. The device is
 Creation of virtual communities capable of measuring vitals like
and expanding services to health temperature, heart rhythm, blood
education and teleshopping are pressure and blood oxygen saturation.
some additional features of this Transmission of data is wireless to a
generation. doctor or medical station.
 Networked/internet. Configurable.
 Two way transmission of data.

relating to personal care [18]. Determining each user’s
condition and matching it to a service that addresses those
needs is the objective of user assessments that are carried
out by the majority of providers. In the home, user activity
and behaviours are a good indicator of the care needs.
Personal norms and habits
The user’s behaviour is driven by their values which, for
their internal consistency and wellbeing, force people
to ensure values and behaviour align [19]. Users’ actions
vary depending on whether they are routine unconscious
behaviours and actions or they are more conscious and
relate to deeper held beliefs that are driven by social
group pressure or personal preferences [20]. The degree
of obligation to the pattern of behaviour also shapes the
decision to act [21]. Strong personal norms have got
more influence towards behaviour than the legitimacy of
a need. This is an important observation in telecare
where users have been observed not to use devices for
personal reasons despite that it was obvious from their
condition that they would benefit from the device. As
Schwartz suggests, these behaviours can be observed as
norms built from the personal value system. The
mechanism being that values give rise to personal norms
which drive actions that can be personal unconscious
habits, conscious personally driven and socially driven
behaviour [22]. This shows that it is important therefore
not only to observe the behaviour but also to understand
what is driving that behaviour if one has to influence the
behaviour.
Researchers [16] point out that the user habits and
intentions need to be studied in more detail and respected
wherever possible. System designers are encouraged to
develop the tools to enable the incorporation of social
issues in order to improve solutions acceptability [23].It has
been argued that the current approach to telecare service
needs to closely match the needs of individuals rather than
installing a large number of standardised devices some of
which service users are pressured to accept [16,24]. Nego-
tiating with service users and providing all the necessary
information to help them participate in decision making is
Social considerations in home telecare design 13

recommended. This is what is advocated for in user centred attention in systems design is the recognition that compu-
design. ters are employed within natural environments of human
interaction and collaboration [31]. As Crabtree observes the
System design and technology acceptance home adds different set of challenges from those found in
structured environments like organisations. It exposes
in telecare
designers to new user groups including the elderly, disabled
and those mentally impaired. Bringing in tools and con-
User centred design is a term which is broadly used to
ceptual models from work environments into domestic
reflect the involvement of end users in the design of an
settings runs the risk of emphasising on values like produc-
artefact [25]. User centred design (UCD) focuses on the end
tivity and efficiency at the expense of understanding the
users at all stages of planning, design and development of a
values that make home life exciting. These work values,
product. Maloney-Krichner and others (2004) point out that
while important in organisations and even respected in
some of the attributes quoted by earlier advocates for UCD
domestic settings, are seen in a different light in the home
were that a design should make it easy for users to know
as domestic life is not organised in the same way as
what action to take when using the artefact. The aim is to
organisations. Requirements for computer systems arise in
make things visible including conceptual models and follow-
the social space and the systems designed are aimed at
ing natural mappings between user intention and the
improving the characteristics of how people achieve the
required action. Not every stakeholder can be represented
intended objectives [32]. This approach in designing infor-
on the design team but the effect that the artefact has on
mation systems is applied in organisational semiotics.
them must be thoroughly investigated [26]. The more they
Ronald Stamper shows that there are three main layers of
are affected then the more they should be involved in the
an information system as shown in Figure 1. These three
design. In telecare there are a number of stakeholders who
layers can be linked to the different phases of providing
are directly impacted by the telecare solution. For instance
care as shown in the diagram. These are the informal layer,
in the case of the elderly people, family members have as
the formal layer which is inside the informal layer and the
much an interest in the solution and are probably the main
technical layer which is part of the formal layer [33].
decision makers. It will therefore be necessary to determine
Technical aspects of an information system are only but a
the role played by the other stakeholders so that those who
small part of the complex social system. The telecare
are affected most can be given a greater role.
system is the technical system which applies automation
Koch [7] noted in a review of telehealth that there is a
to some of the care tasks. The rules on which the technical
migration from a purely technical approach to a user-
system, telecare, is based are deduced in the formal layer
centric one in telecare and telehealth designs. This shift
of the information system which are referred to as care
involves coordinating the service users, carers and family
plans in the health and social care sector.
members, clinicians and other stakeholders into the deci-
The challenge for designers is to find how technologies
sion making process. The increased awareness in society of
can be fitted in the socially dominated home environment
health issues has driven providers to adopt forms of includ-
whilst maintaining its uniqueness. Some researchers sug-
ing users and carers to help identify service redesign
gest a need to study and document the rich and some-
opportunities. In some programmes carers and social work-
times complex routines or patterns of activities in
ers are receiving specific training for this role [27]. In
domestic environments just like the studies that were
telecare the benefits of including users in solution design
done to enable office automation [34]. The problem with
bring the following benefits:
this is that each home differs from the next and within
each home things are not always done the same way. In
 Designing with the user produces an artefact of value to the home designing socio-technical systems needs to be
the end user which they actually understand [26]. done with an understanding of the user perceptions and
 UCD helps to manage user expectations as they gain preferences. This ensures the constructs that emerge are
more understanding of other factors that have an accepted and applied as intended. Linking individual
influence in the operation of the designed artefact behaviours and technology acceptance is discussed using
[28]. the theories of technology acceptance and how they
 It provides an understanding of the user’s mental model relate to home telecare.
of the domain. These are the beliefs, concepts and even
the language they apply [29]. These affect the psycho-
logical, social, ergonomic and organisational interpreta- Informal system
tion of the design and its acceptance.
 UCD provides an environment that allows cooperative Formal system
creative design of solutions to problems. This enables
potentially missing elements to be included. Technical system

Telecare Specification

Formal care plan

Socio-technical systems
Informal care from community

Information systems have social as well as technical dimen-

sions [30]. The reason social aspects are now being given Figure 1 The semiotic perspective of telecare.
14
Technology acceptance theories and the home
environment
Predictive behavioural models show a number of factors
that have an impact on technology acceptance. The models
of the Theory of Reasoned Action (TRA) [35], the Theory of
Planned Behaviour (TPB) [36], the Technology Acceptance
Model (TAM) [37], the Unified Theory of Acceptance and Use
of Technology (UTAUT) [38] and the Perceptions of System
Attributes-Behavioural Intention (PSA-BI) [39] provide a
range of perceptions which affect attitude towards beha-
viour. TRA predicts behaviour intention and actual beha-
viour from the attitudes towards the action and the
subjective norms of the individual. In other words if a
person believes that the outcome of the action is good for
him and values the outcome, his intention towards the
behaviour is likely to be positive. Likewise their internal
beliefs of whether people important to them think the
behaviour should be performed forms part of the subjective
norms. This opinion of a referent, weighed against their
motivation towards complying with the wishes of the
referent, forms a set of subjective norms which has a
positive correlation to the behaviour intention. In tele-
care settings the role of the referent is quite important
in the form of carers or family members particularly with
the elderly. TPB adds the perceived behavioural control to the
subjective norms and attitude towards behaviour and the
three drive the behavioural intention and subsequently
the behaviour. Perceived behavioural control is defined as
one’s perception of the difficulty of performing the behaviour.
TAM, which is an adaptation of TRA to IS, suggests that
perceived usefulness (PU) and perceived ease of use (PEU)
drive behavioural intention to use and then the actual
system use. Perceived ease of use is said to have a direct
impact on the perceived usefulness. TAM was designed to
predict acceptance of software applications and computer
systems in organisations which is different from home
telecare applications. The acceptance referred to in TAM
is mostly after the installation of the system. Telecare
differs from this perspective in that it has to be accepted
before it is installed. The installation of telecare devices
does not mean the system is being utilised as intended as
was observed during the pilot study. It is important to note
that intention to use is an attitude and actual use is a
behaviour and the link between the two has not been
specified [40]. The three constituents of attitude are
cognition or knowing which is referred to as attitude beliefs
(AB) in TRA, affective or feeling which is referred to as
subjective norms (SN) in TRA and conative or willing
referred to as behaviour intention (BI). All three variables
are subjective and difficult to measure. Ajzen observed that
general attitude cannot be used to predict specific beha-
viour and introduced another concept of behavioural control
which came from the concept of self-efficacy by Bandura
[57]. Despite the strong links between AB, BC, and SN they
are not capable of predicting actual behaviour [41].
Results in the application of modified TAM in telecare
indicate that perceived usefulness (PU) has to be raised
significantly in order to raise acceptance [40]. Individual
training raises the costs to providers and maintaining the
training in regards to the changing technology is also
L. Chidzambwa
expensive. The most practical way to raise the PU and user
knowledge or cognition is during the assessment. Related to
this is the fact that self-efficacy is known to be directly
linked to self-management [42]. Raising self-efficacy
through user participation and giving them more knowledge
about telecare and devices will improve their confidence
and make users more comfortable in applying telecare.
Methodology
The research was approached in four phases. The first phase
was a literature review followed by a pilot study. The results
of the two phases were then used in the third phase of
framework design which was followed by a validation phase.
The literature review looked at over 200 articles on telecare
and telehealth, intelligent buildings, pervasive informatics,
telecare IT architectures, cooperative design approaches,
system design, constructivism and organisational semiotics.
The articles helped to understand the various aspects
surrounding telecare service like the economic, technical,
cultural issues. Particular attention was paid to social
aspects and the way they influenced solution design. A
number of social aspects were identified from the literature
and the ways they influence telecare implementation were
documented. It was evident that various issues were
considered important by users.
Data collection
Primary data was collected during the pilot study and the
validation stage of the research. The pilot study was
conducted to understand the solution design process from
prospective user assessment, to solution design and finally
the implementation process in one of the City of London
boroughs. The first two visits were focussed on the user
assessment tasks and the solution design process. The third
visit was focussed on device installation and the device
call-out visits by the telecare technicians. The data collec-
tion methods applied were task observation of assessors as
they performed their tasks and interviewing of assessors,
team leaders, device technicians and managers on issues
about telecare solution design and the reasons for some of
those tasks. No users were included in the study for patient
confidentiality reasons.
There were a total of 14 observations. Seven of the cases
observed were for initial assessments and initial device
installations. The other seven were for scheduled mainte-
nance and call outs for emergency device maintenance.
There were 10 semi-structured interviews which were
conducted. Assessors and technicians were asked about
the tasks they carried out and some issues that were
identified in the observations. Supervisors and managers
were interviewed on administrative and policy issues in
addition to the field work. The interviews lasted between
40 min and 1 h for each interviewee. Data on what took
place in the assessments and the device installation visits
were recorded manually but some interviews were audio-
taped and transcribed. Data on the user condition, their age
and gender, the type of task and what transpired during the
visit were recorded. Special attention was given to social
aspects to determine how they were identified if any, and
Social considerations in home telecare design
how they were dealt with. Examples of data collected are
given in section 5. Twenty five blank assessment forms were
collected from different service providers in the England,
Scotland and Wales to determine the data that was used in
decision making and whether there were any similarities.
The findings and conclusions are discussed below.
Two questionnaires were used for the Delphi study which
validated the framework structure and one questionnaire
was used for the framework usefulness validation. Six
experts participated in the Delphi study with experience
ranging from academic to industrial experience in telecare
systems. Eighteen assessors mainly from telecare providers
in the UK and two from Canada participated in the valida-
tion. Validation responses were compiled on spread sheets.
Data from the usefulness validation highlighted what social
aspects were encountered in implementing telecare and
their relevance to telecare acceptance. Some participants
did not answer all the questions in questionnaire and in
some cases follow-up telephone calls were conducted to
clarify answers or to request additional information. The
details of these responses are discussed in the section on
validation. All the data that was collected was qualitative.
Content analysis and narrative summaries were applied in
analysing the data and drawing the conclusions.
Theoretical foundation, social constructivism
and organisational semiotics
In recognition of the fact that there is need for knowledge
exchange between the stakeholders in solution design,
social constructivism was applied. Constructivism is a way
of thinking that has found its way mainly in the educational
fields where it was used to explore ways of knowledge
assimilation [43]. Constructivism postulates that knowledge
is a reality constructed or interpreted by each person based
on their perceptions and prior experience [44,45]. It is
based on the belief that the knowable world is the one
which is given meaning by individuals [46]. It is a form of
thinking encompassed by the interpretivist paradigm in
which the study of social aspects is met by a multiplicity
of complex conceptual structures which are superimposed
on one another and have to be first grasped and then made
understandable to others [47]. The conceptual structures
are synonymous with the multiple stakeholders who con-
tribute to the telecare service who have differing individual
experiences, professional and social backgrounds which
need to be understood by others in order to appreciate
their contribution. The sum of the knowledge from the
stakeholders is applied to address the issues that are
perceived by the service user as problem areas. One of
the beliefs in constructivism is that understanding is socially
negotiated [48] and this is termed social constructivism.
Collaboration provides people with the opportunity to hear
how others perceive or understand a service concept. It also
acts as a forum for an individual to check their under-
standing against that of others and therefore exposes the
individual to viewpoints that may challenge their initial
understanding. The aim in this approach is to understand
why and how individuals create, modify and interpret the
world that surrounds them [49] in the way they do. This
understanding is then applied to design a system that is
15
more acceptable to the stakeholders. The ambiguous and
imprecise social aspects cannot be applied in a solution as
they are. This is where organisational semiotics is applied.
Semiotics is the doctrine of signs [33,48]. Semiotics
considers the sign as the primitive notion upon which
complex concepts like communication and information
systems can be built. A sign is defined as that which stands
for something to someone in some form or capacity [30],
within a community or social context. The basis for inter-
pretation of signs, in any context is the norm, or accepted
beliefs and standards of a community, applied in that social
space. This means that there is a shared meaning of the
signs that are exchanged in that community. Signs in the
form of words, diagrams, meetings, emails and other forms
of documentation are used to mediate the sharing of
meanings. Organisational semiotics (OS) regards the use of
computers, language and texts as based on the narration
and interpretation of signs and information systems as the
development of models for understanding the interpreta-
tion of signs [50].
In OS information systems design is approached from the
point of analysing the actions and the meanings attached to
the actions of agents. This is because each community
builds its own knowledge on what to do (behavioural norms)
in order to create an ideal state of affairs. It also deter-
mines how things should happen including beliefs and future
state of affairs as in expectations (cognitive norms) and how
those things done should be judged and provide a basis of
comparison so that one can choose based on some rules
(evaluative norms) [51]. Organisational semiotics provides a
method of precisely describing these social norms. Norms
are defined as socially accepted rules by a community to
govern the behaviour of the members within that commu-
nity. The norm specification will take the context into
consideration and a norm will be specified in the format
below.
Whenever ocontext4 if ocondition4 thenosome agent4
is odeontic operator4 to do oaction4[52]
A deontic operator, derived from deontic logic, can be
obligatory, permitted or prohibitive in nature. With this
understanding that increasing the knowledge as is done in
social constructivism will raise acceptance it was decided to
find out how telecare is being implemented by conducting a
pilot study.
Determining current methods of telecare
design using a pilot study
The pilot study was conducted to gather information on the
procedures of implementing telecare services in the UK from a
practical point of view. It was conducted in one of London’s
inner city suburbs. The study was conducted as follows:
 Seven cases of initial assessments by assessors and device
installations by technicians were observed.
 Seven cases of device maintenance by technicians,
scheduled and unscheduled were observed.
 Ten interviews with technicians, assessors, team leaders
and a manager were conducted.
 Twenty-five blank assessment forms from different tele-
care providers were analysed.
16
The observed people were encouraged to conduct their
tasks as they would normally do although it was noted that
this might be difficult to achieve. Observations allowed the
analysis of the verbal and non-verbal communication that
was taking place and understand their context. Several
observations were made in order to capture the repeatable
behaviours. More attention was given to how the social
aspects relating to the user were handled or discussed.
After each session clarifications were requested on some
issues from the assessor after leaving the user’s premises.
This was in the form of semi-structured interviews.
Semi-structured interviews were conducted using a guide
of open-ended questions in order to ensure important points
were not left out in the study. The approach was used in order
to provide the interviewee the opportunity to state things in
their own way and using the language comfortable to them.
This form of interviewing allows follow-up questions and also
gave the opportunity to ask questions that were not on the
original list on issues that arose during the interview.
User assessment forms used by assessors from service
providers in England, Scotland and Wales were analysed to
determine the information used to decide what solution to
provide. Information fields from the assessment forms were
coded and compared for content. These revealed that
providers were using very different approaches in providing
telecare and information used to make decisions was very
different in form and amount.
The following conclusions were made from the pilot study
data:
 Assessors were of the opinion that users had little
understanding about telecare devices and therefore
made decisions for them.
 Although the majority of users gave consent on the
installation of devices, adoption which is the actual
usage of some devices was low especially body worn
devices.
 Assessments were biased towards technical issues and
little attention was paid to user social aspects. Users
were expected to adjust their routines to fit the
equipment.
 Where social aspects or user expectations were cap-
tured, assessors found it challenging to apply these to
the solutions designed or device configuration.
 Device selection was based on clinical needs and device
configuration was minimal.
Proposing a design framework to guide
personalising solutions
Results from the literature survey and the pilot study
indicated the need to provide a guideline to design telecare
solutions which would consider the preferences and social
aspects of users. A norm based conceptual framework is
proposed. A framework is a guide on how to approach a
problem while at the same time invoking critical thinking on
the processes undertaken. It assists in building the relation-
ships between the concepts applied and address questions
of why they have to be applied and how they are going to be
applied [53,54]. Figure 2 shows the high level diagram of
L. Chidzambwa
1 4
User Defined Care Profile Device specification
2 3
User Approved Care Plan User Approved Telecare Specs
Figure 2 High level representation of Normative Home
Telecare Framework.
the normative home telecare framework. The proposed
components which form the stages of the normative home
telecare framework in consecutive order are:
1. User defined care profile. This helps to understand the
prospective user needs from user point of view. Every-
thing in the solution needs to be centred on the user
needs, clinical and social, and these have to be captured
accurately at the beginning of the process.
2. User approved care specification. This combines the user
defined care profile and the clinical needs to compile the
care objectives. The care specification is an extension to
care plans that are currently drafted by applying norm
analysis on care objectives.
3. User approved telecare specification. This component
provides a method of selecting the care tasks on which
technology can be applied and applies norm analysis on
the selected tasks. This defines how telecare tasks are
performed in a manner that is approved by the user. User
preferences are applied on telecare specifications.
4. Device specification component. This stage applies the
identified user preferences and home social factors in
the configuration of selected devices. The component
applies technology acceptance factors and enables the
linking of social aspects to device operation. The need
for a systematic method to configure devices was identi-
fied in the pilot study as well as in the literature review.
Besides determining the user preferences the first stage
also determines the values that influence those preferences in
order to ensure that the designed solution is not in conflict
with the user values. Epistemic and axiological norms are
applied in determining the perceptions and values of the user
which are taken into consideration on the three other stages
of solution design. In recognition of the difficulties that might
be encountered in compiling the care profile, methods to
promote user participation and assisting the assessor are
proposed. The framework highlights that telecare is part of
the overall care regime. In stage 2 the framework provides a
method of determining tasks where technology can be applied
with the user’s approval. The importance of this approach is
that technology selection will depend on the needs, approval
and participation of the user. This places the user interests at
the centre of the solution design process.
Stage 3 of the framework emphasises the importance of
considering the care needs in selecting the technology. The
stage uses a method to select the tasks where automation
can be applied in agreement with the user and then
specifies how those tasks will be performed. The emphasis
is on the fact that technology applied must be determined
by the needs and preferences and not the other way round.
Social considerations in home telecare design 17

Compile service Compile user’s

users’ care needs care preferences Device
specifications

Compile device
Service user Service user configuration
care needs care preferences

Negotiate &Reconcile Device list

contradictions

Select devices
User defined
care profile

User Approved
Compile care plan Telecare Specifications

Clinical needs

Norm analysis:
Generating norms from
User approved telecare solution
User approved
care plan care specification

User approved
telecare solution
Norm analysis:
Generating norms from
personal care plan Design telecare
Cost & Business
objectives solution

Figure 3 A Normative Home Telecare Framework.

Stage 4 shows the importance of device configuration. It was
observed that despite the functional relevance of a device,
users might still find it unacceptable based on a number of
factors. For example the monitoring of an individual who
might wander outside their home at night the following
considerations might need to be taken into account:
 Agreed start time and end time of monitoring exit.
 Method of detecting exit e.g. door mat, magnetic
sensors, infra-red sensors.
 Agreed warning signal on detecting exit e.g. audio or
visual.
 Agreed recorded message.
 Agreed voice used for recorded message e.g. male,
female or family member.
 Agreed levels of system tolerance e.g. elapsed time
before alarm is raised.
 Agreed method of intervention or person to intervene.
The normative framework provides a method to capture
these details and then apply them to the solution in a way
that is approved by the user. This will minimise cases like
one narrated during an interview where a female service
user was getting paranoid because she thought the recorded
message she heard was an invisible male living in the house
which resulted in the device being removed. The diagram of
the proposed framework is given in Figure 3.
Validation of the framework
There was a need to determine from other people who were
not involved in the research whether the knowledge claims
that are presented in the framework can be obtained. By
following the models proposed by Pedersen et al. [56] and
Maxwell [54], the validation exercise was divided into two
parts as shown in Figure 4. The first part of the validation
was to determine whether the NHTF design is structurally
stable. This is determined by looking at the relevance of
components that have been used to build the framework
and the relationship between them. Each component has to
have internal consistency in its structure. Also related to
structure the plan checks whether these selected compo-
nents have been arranged in a logical manner that the
intended results will be obtained. A Delphi Study was
deemed appropriate for this part. Six experts on telecare
systems from industry and academia participated in the
Delphi study.
For the usefulness validation, assessors were identified as
respondents and those from several service providers were
requested to participate. Determining usefulness is an
interpretive exercise and it was felt assessors were the
18
NHTF Validation
Structural validity
Design experts looking at:
• Are the individual components
appropriate for the framework?
• Is the arrangement of components logical?
• Is there internal consistency in the
framework between components and
within the components?
Validated Home Telecare Framework
Figure 4 Validation plan.
best to give this view on the framework as they are in the
situation intended for the framework, what is termed
‘‘experience-near’’ by Maxwell [54]. Validity here is con-
sidered to be an exercise of collecting evidence from the
different domains represented by the assessors on the
possible application of the framework. An online question-
naire was designed and used for the exercise because of the
geographical spread of the people who were invited to
participate. In some cases follow-up interviews were con-
ducted to clarify some of the responses provided to the
questionnaire. Eighteen assessors participated in the valida-
tion exercise and all were from different telecare providers
across the UK.
Validation results and analysis
Qualitative data was collected and therefore qualitative
analysis methods were applied to the data. The sample sizes
used for validation were small but the diversity and the
quality of the inputs provided very useful information. In
the Delphi study the effect of the small sample size can be
reduced by the vast experience of the participants who in
some instances were not only confined to telecare but had
experience in other fields like telehealth and gerontology.
The responses of each question were analysed in relation
first to the question that was asked and secondly in relation
to the objectives of the research. In cases of lengthy
responses summaries were drawn in order to facilitate
comparison with other responses and then conclusions were
drawn from the comparisons.
Structural validation results
This is important to validate because the construct has to be
able to deliver what it is constructed to do and in this
research it must be able to capture and structure social
aspects so that they can be included in solution design
together with technical aspects of the solution. The first
Delphi questionnaire produced the results as summarised in
L. Chidzambwa
Usefulness validity
Telecare assessors looking at:
• Are the concepts applied in NHTF
relevant to improving acceptance
• Does the approach provide the
intended improved acceptance
• Is it feasible to implement the NHTF
Table 2. The telecare experts were divided into three
groups with one group composed of people who had more
industrial experience, the second group was composed of
people who had both academic and industrial experience
and the third group was composed of people with mainly
academic experience in design of telecare and related
systems. Questions 2.2 and 2.3 of the first Delphi ques-
tionnaire requested information on the relevance of the
framework components and their arrangement. Comments
like ‘‘The framework appears logical and easy to follow from
gathering user specifications to designing a solution’’ and ‘‘I
believe the framework provides a positive engaging process
which attempts to involve the service use’’ were received.
Another response said ‘‘The framework makes sense. It is
user centred and the arrangement makes sense’’. These
responses show that the participants recognised that one of
the major objectives of the framework was to involve users
in the decisions about their care and feel that the frame-
work is doing a good job on the issue. The responses give
confidence on the framework which is a pre-requisite before
one makes plans to do field testing. The important points
that came out of the first Delphi study were the following:
 The components applied are all relevant to achieve the
objective of the framework.
 The components were arranged in a logical manner.
 The framework can lead to improved telecare acceptance.
However arrangement does not guarantee that the
deliverables are the ones required or expected. The issue
of deliverables and the inputs that enable them to be
obtained is dealt within the second Delphi questionnaire.
The second Delphi study provided answers on the ade-
quacy of the inputs and the likelihood of the deliverables to
be obtained. Table 3 provides the responses and comments
on these responses. The responses shown in the table are
extracts from the various respondents that were compiled.
These actual words used by the respondents are the ones
 Social considerations in home telecare design
Table 2 Analysis of the responses of the Delphi study 1st questionnaire.

Question 2.1 Question 2.2 Question 2.3 Question 2.4 Question 2.5 Question 2.6

Do you agree that Is the process of solution Are the components as Is the approach in the Would service providers Does the NHTF
obtaining and utilising design as shown in the given in the framework framework comprehensive find the home telecare lead to
user preferences is framework logical and enough to provide a user enough to be used over a framework (NHTF) improvement of
important and can feasible for a telecare centred approach to broad spectrum of cases practical enough to be telecare
improve the acceptance setting? designing solutions as much which require simple as applied and if not why? acceptance by
of home telecare as possible? well as complex solutions? users as
solutions? Is there anything you would intended?
add or change?
Industry Overall =Yes Strongly felt The process is logical Most Overall = Yes Yes and No Issues were Overall = Yes The need for Overall = Yes
experts this is a good approach. comments were centred on Implementation issues raised on the ability of all more information was Involving users
Some comments pointed difficulties which might be were raised in some users to provide valuable commented on. The was quoted as a
out the limitations of encountered in comments that the degree input One response said ability of staff to use good way to get
meeting user implementation e.g. ‘‘it is of user involvement might they could not comment framework was given as users committed
requirements caused by sometimes difficult to align differ depending on type of either way because there an issue to consider
current products in the service user needs and user are no examples of tools
market. preferences and (forms) that will be used
expectations with
capabilities of the
service’’.
Industry and Yes They increase level of The process is logical It was Yes and No The comments Yes and No Full user Yes Reservations were Yes The
academic acceptance and empower pointed out that although from those who said ‘‘No’’ participation was expressed on availability involvement of
experience users. A comment was it is easy to follow some of were that the framework questioned. Examples of of appropriate skills Some the user was
given that this might lead the terms used are not well does not involve all users. old people and their commented on the terms given as the
to devices that are known (See below) This point is explained difficulties were given as used in the framework as main reason
tailored to dynamic user below as the framework is issues that might limit a possible problem area
needs. intended for all users wide application
Academic Yes This is the usual The process is logical Yes Some comments were No definite yes or no on all Some = Yes Some= No Yes Involvement
experts approach in designing Comments on unfamiliar given that the framework responses The comments Complications on some of users was also
systems terms in the framework needs to show the iterative were centred on how the parts of the framework the main
were made- these terms processes - This has now framework will be were given especially the reason. The use
are defined below A been included in the implemented e.g. ‘‘might ability of elderly to of the
comment on inputs says, diagram but was already need to be consideration engage in meaningful framework as a
‘‘the framework does a explained in the text for the context of where/ discussion by those who guide was
good job of taking into how the telecare solution said it would not be easy acknowledged
account a variety of inputs will be implemented’’
and rationalising them’’

19
20
that are in italics. It has to be admitted as mentioned above
that the sample size was small and the respondents can only
give a response based on their experiences. The fact that
the participants were not in contact with each other and
reached their decisions independently gives confidence that
the framework stands a good chance of delivering the
expected results and contributing to the overall research
objective as intended. The important conclusions that were
made from the second Delphi study are that the inputs of
each stage are adequate to provide the required outputs.
The second important conclusion was that the deliverables
of each stage of the framework were confirmed to be
contributing to the overall objective of user centred solu-
tion design. The next stage of the validation was to
determine the usefulness of the framework from the
assessors since it was not possible to validate with users
for user data protection reasons.
Results from usefulness validation
The usefulness view adopted in the research is the one given
by Maxwell [54] that validity in qualitative studies should be
based on purpose and circumstances. Usefulness, which is a
form of external validation, can be determined by applying
the solution to a number of examples that have differing
contexts in order to determine whether the solution will
generate useful results [55]. In this research the usefulness
has been determined by the different home telecare
assessors from different providers who have given their
view on the framework and its underlying concepts. The
challenge faced in this research is that of sophistication
disjunction [56]. This type of challenge is faced when new
information is introduced that is consistent with the current
construct but requires an altered way of understanding that
enables constructors to apply the new knowledge. It was
with this in mind that it was accepted there would be
differences in the responses provided to questions relating
to the understanding that each respondent has about the
concepts applied in the NHTF.
Responses to question 2 in the second questionnaire of
the Delphi study showed that each of the framework stage
deliverables was useful and contributing to the objective of
the framework as shown in Table 4. The assessors’ ques-
tionnaire investigated usefulness from a number of angles as
shown in Figure 5. Each aspect investigated is linked to a
section of the questionnaire as shown in the diagram. The
usefulness of capturing user preferences is highlighted by
the responses to Question B4. The question was ‘‘How do
the following user preference factors affect telecare accep-
tance’’ and a list of social, non-functional device attributes
were listed with the option to answer between very low to
very high. Although some of the factors were being con-
sidered by telecare assessors, the majority of the factors
listed in the question were not considered in the design of
the telecare solutions. However Table 4, which shows
examples of responses from 14 assessors who responded to
this question, indicates that the majority assessors consider
the factors to have a moderate to very high effect on
acceptance.
Device configuration is an important part of the frame-
work. Its usefulness was inquired on in validating the
L. Chidzambwa
framework in the assessors’ questionnaire as shown in
Table 5.
Discussion and conclusion
This paper has looked at the role that user related social
aspects can be applied in telecare design in order to ensure
that the application of technology in the home is more
acceptable. A normative home telecare framework is pro-
posed to enable the capturing and applying of social aspects
in telecare system design. The framework provides a guide
on capturing the user preferences and involving the user in
the design of their telecare solution. Linking the user
preferences to the relevant device attributes helps to
ensure that the telecare system operates in a way accep-
table to the user.
The paper argues that each home is unique and that
uniqueness has to be maintained as much as possible. The
preference by telecare users to be cared from home has
been shown to be driven by the desire for personalised
service which care institutions cannot provide due to their
mode of operation. Personalised service, when in sync with
user expectations, raises the quality of service and manages
the user expectations. These expectations or care prefer-
ences cannot be standardised because of personal circum-
stances, individual background, age, gender and cultural
differences. It is important that the enabling environment
of the home is taken advantage of and the partenalistic
approach in institutions is not carried over to the home. As
the needs of users are multi-dimentional and more than
clinical, this requires the cooperation of the different
stakeholders in order to ensure that choices made
do not have a negative impact on any part of the service
proposed. Social needs have not played a prominent role yet
they are in the ones that the user is very articulate on. The
clinical needs are identified and recommended by the
clinician. The technical aspects are the domain of the
technician and system administrators. The social aspects
and their effect are issues that the user has to live with. As
has been shown by the pilot study and the validation of the
NHTF that social aspects vary from user to user and a one
size fits all approach in providing telecare and telehealth
services in the home is bound to meet with some resistance,
hence the low acceptance levels observed in telecare
service.
Although service providers are of the opinion that they are
providing user centred service the pilot study showed that
decisions on solutions were being made by the assessors with
no user involvement. The research has proposed a social
constructivism approach in which the assessor acts as a
facilitator in encouraging the user to participate in the solution
design. In fact the word ‘‘assessor’’ may need to be dropped in
favour of a more appropriate role name like ‘‘facilitator’’ in
order to prevent the judgemental connotation attached to
assessment. The cooperative approach will help to build more
commitment from the user. It is shown that the telecare
acceptance theories do not adequately explain telecare
acceptance models especially when technology is implemented
in the home.
Our research has also shown that it is not only the care
preferences that have to be understood but the individual
 Social considerations in home telecare design
Table 3 Summary of responses and analysis of Delphi 2.

Stage 1: Compiling user Stage 2: Compiling user approved care Stage 3: Compiling user approved Stage 4: Device
defined care profile specification telecare specification configuration
specification

Question 1: For each Older people need more specific The assessors may need to be good in Risks have to be more specific, need to Need to respect
stage of questions about their needs especially drafting care plans; There might be find out how users reacted when risk user’s
the framework about their daily tasks; There might need to consider business constraints occurred before they install devices; choice; sleep in
explain whether need to consider the site there maybe like cost; The stage might need to Inputs are appropriate. Business the chair; Is the
there is adequate limitations; There is adequate input consider business objectives as well as strategic focus is important to response method
input to provide the but there might be need to look at the the inputs indicated. consider; Inputs are all adequate. considered here?
anticipated effect of constraints. It might affect
deliverable? Is there configuration: It
anything missing that shows the device
is required to provide selection is
the output? needs driven.
Analysis of question 1  An important observation on physical and user capacity constraints in compiling care profile is made. Determining this is the reason for stage 1
responses of the framework.
 A comment about assessor competence is important as the approach proposed by the framework will require new skills that the provider has to
equip the assessors with.
 Business constraints, including response method, should only affect those tasks that the provider is responsible for. Some care tasks are the
user’s responsibility so the analysis of all the needs has to be done first as proposed and then responsibilities allocated.
 The comments showed that respondents understood and critically looked at the relation between inputs and outputs. They indicated that
inputs and outputs are linked.
Question 2: For each With the right questions a useful Care plan acts as the reference point User involvement not clear although This depends on
stage of the profile can be obtained; All the for everyone; Indicates telecare is not their approval is required; If the user what the service
framework, explain outputs are possible and will improve everything. Its more explicit; Yes. The is involved acceptance will improve; provides. Its
whether the acceptance; Yes, users have to be care plan is an important document Its possible. Its limited by device important to set
deliverable stated is involved. used for reviews like the annual availability. how device is
useful in telecare review. applied; Yes;
solution design and Competent
why or why not? assessors are
able to do this,
sometimes done
by external
technicians.
Analysis of question 2  The responses indicate that user participation will improve telecare acceptance.
responses  A comment is made on the importance of asking the user the right questions, this is crucial and highlighted in the checklists at the end of
each stage.
 The issue of how users will be involved depend on the case. Having user at each stage will help with this.
 The issue on the ability of assessors to link preferences to device attributes is addressed by applying the tools proposed like the
configuration table.

21
 22
Table 4 Sample responses and comments to validation of preferences.

Question Responses Comments

B4: How do the following user preference factors Very High = 2  The spread shows a higher concentration from moderate to very high categories. This indicates
affect telecare acceptance High = 4 that it plays an important role in user acceptance.
B4.1: User needs for privacy Moderate = 5  There is need to determine how strongly a person feels about privacy and include it in the user
Low =2 care profile.
Very Low= 1

B4.2: Discomfort from bodily worn devices High = 6  Bodily worn devices have been shown to cause concern with those that are monitored (PSA-BI).
Moderate = 6  It is shown here that they are a point of concern and each user’s preference needs to be
Low =2 respected.

B4.3: Importance of the ability to control device e.g. Very High = 2  The majority of assessors felt the need to control a device has got a moderate effect on
choose the range or time for monitoring High = 2 acceptance (7).
Moderate = 7  If the user is given their preferences on devices the need to control can be minimised.
Low =2
Very Low= 4

B4.4: Device size or obtrusiveness Very High = 3  It shows is that people are not indifferent to the size or presence of telecare equipment and they
High = 4 would rather show it to people they feel it is right to do so rather than everybody.
Moderate = 6
Low =1

B4.5: Device colour not the preferred choice Moderate = 6  Some devices are only supplied in one colour and this may cause problems to those who have sight
Low =7 problems.
Very Low= 2  The responses show that there are other device attributes that are not related to function that
influence acceptability.

L. Chidzambwa
Social considerations in home telecare design 23

QUESTIONS EXPLORED IN USEFULNESS VALIDATION OF HOME TELECARE FRAMEWORK

Is it important to consider
user preferences in Does using technology Is it important to configure Does the framework improve
designing telecare improve the quality and devices with user the current methods of telecare
solutions? efficiency of care? preferences? solution design?

Section B: Perceptions and Section D: Technology in Section C: Configuring Section E: Home Telecare
preferences care Devices Framework

TELECARE ASSESSORS QUESTIONNAIRE STRUCTURE

Figure 5 Linking usefulness validation to questionnaire structure.

Table 5 Sample responses on the validation of device configuration.

Question Responses examples Comments

C1: What device settings would you Revisit and explain devices, give
recommend to improve acceptance instruction sheets, settings should reflect
user preferences, for risk assessors decide
what setting to reduce risk, easy to use
device settings are better, no comment,
do not understand question, make it easy
for client to follow
 No specific settings were given but the
responses showed that there are issues
surrounding the understanding of
settings as some advocated for revisits
to explain and others preferred
simplified settings.
 This indicates that currently there are
issues surrounding the understanding
of setting by users and assessors.

C2: Does you organisation use devices Yes—9  Responses indicate that providers do
that allow a selection of settings on use configurable devices when they
No—2
a single device? are available.

C2.1: If answer is YES please give an Bed sensors, if activities change devices
example are changed or removed, epilepsy, pill
dispenser, temperature extremes, door
exit sensors, lifeline connect advanced
settings, chair sensor, energy usage
monitors, daily prompts, PIR inactivity
sensor
 The device settings seem to be mainly
related to time e.g. bed sensor and pill
dispenser.
 There are other settings that can be
used to provide user preferences.

C4: Has any user ever requested for
settings to be changed from initial
settings?
Yes = 9, No= 1 Part of on-going tweeking to  This indicates selection of settings
meet user needs, especially bed sensors, configured to devices seemed to be
chair occupancy, to give more control to done by trial and error.
user  It was revealed in a later question that
the selection was not methodical and
therefore wasted a lot of time.

C4.1: If the answer is YES please give
an example of the reason to change
settings and how important it is to
the user?
Change to summer and winter timings, fit  A more thorough assessment would
user lifestyle, reduce inappropriate avoid some repeat visits that were
triggers e.g. when user is needing more caused by inappropriate settings being
time to use bathroom, reduce false configured.
alarms and irritation, family need changes
24
Table 5 (continued )
Question Responses examples
C6: Does having device settings Very much =4
improve acceptance of telecare
Only slight = 3
Unlikely = 1
Do not know= 3
values that drive those preferences as they are more stable
than the exhibited behaviour. Norm analysis, a behaviour
analysis tool from organisational semiotics, has been
applied to enable the structuring of user behaviour. It is
argued that implementing a solution that contradicts the
individual values will be resisted by the user. It is for this
reason that a personal approach to acceptance is applied by
capturing and structuring the individual preferences.
Telecare and telehealth are being implemented in
socially dominated environments. These environments will
have an effect on how technology is adopted and used by
individual especially in the home. The research has shown
that even non-functional attributes of devices like colour do
affect technology adoption despite the clinical needs being
present. For instance certain colours are negatively inter-
preted in certain cultures and therefore by determining the
underlying reason for a colour preference contradictions
can be avoided. When the technology crosses what an
individual considers a personal boundary whether function-
ally or physically it causes suspicion and resentment. Some
of this is a result of the lack of understanding. The influence
of family, community, culture, gender and prior experiences
of an individual all need to be understood. While ‘‘asses-
sors’’ did encounter some of these social aspects, they did
not have the tools to apply them in solution design as
provided in the framework. Social aspects will continue to
offer some challenges in the implementation of technology
but tools to apply them now make it possible to design truly
socio-technical systems.
One of the weaknesses of the framework is that it
assumes user cooperation in the solution design process.
The validation and the pilot study revealed that there will
be challenges in getting user cooperation in some cases. The
majority of the users are elderly and their capacity to make
decisions may be affected by age. Some care patients have
got learning difficulties that inhibit their ability to con-
tribute. While proxy users in the form of family members or
carers may be asked to contribute there is a chance that
they might make the decisions that are still not acceptable
to the user. More work might need to be done in order to
determine the best method of user participation.
Further research will need to be done in applying the
framework in the field and determining telecare users
response to the solutions. The validation with the assessors
will also need to be done on a bigger sample size over a
longer period of time than the one afforded by the research.
Despite these areas of weaknesses the research has pro-
vided a validated method of applying social aspects in
applying technology in care that can be applied in similar
contexts.
L. Chidzambwa
Comments
 Assessors indicated that having device
settings improves acceptance.
 Linking user preferences and device
settings will help to realise the
benefit.
References
[1] DoH UG. A review of the evidence base for telecare. London-
councils; 2011 [cited 2012 4th March]. Available from:
/http://www.londoncouncils.gov.uk/search.
htm?cx=012816060298198299354%3Aulbaum7l6aw
&cof=FORID%3A11&ie=UTF-8&q=Telecare+ evidence&sa=goS.
[2] Mattke S, Klautzer L, Mengistu T, Garnett J, Hu J, Wu H.
Identifying and addressing obstacles to telecare uptake.
International Journal of Integrated Care 2011:11.
[3] Hawizy L, Phillips IW, Connolly JH, editors. Intention model-
ling: a semiotic view. In: Proceedings of the international
conference on applied computing: IADIS; 2006.
[4] Coyte PC. Home care in Canada—passing the buck. Canadian
Journal of Nursing Research 2001;33(2):11–25.
[5] Hall K. Telemedicine in the NHS—the benefits and costs of
implementing telecare services. ComputerWeekly [Internet]
2012.
[6] Lawson S, Nutter D. Technology to support ageing in place.
SPARC 2008.
[7] Koch S. Home telehealth—current state and future trends.
International Journal of Medical Informatics 2006;7(8):565–76.
[8] Von Niman B, Rodriguez-Ascaso A, Sund T, Brown SJ, editors. User
experience design guidelines for telecare services. In: Proceed-
ings of the 8th conference on human–computer interaction with
mobile devices and services. Helsinki, Finland: ACM; 2006.
[9] Perry J, Beyer S. Ethical issues in the use of telecare. London:
Social Care Institute for Excellence; 2010.
[10] Sethi R, Azzi D, Khusainov R. Trend and issues in community
telecare in the United Kingdom. In: Proceedings of the IET
conference on assisted living. London; 2011.
[11] Kane R. Long term care and a good quality of life—bringing
them together. Gerontologist 2001;41(3):293–304.
[12] Mattke S, Klautzer L, Mengistu T, Garnett J, Hu J, Wu H. Health
and wellbeing in the home. California: The RAND Corporation;
2010.
[13] Porteous J, Brownsell SJ. Using telecare: exploring technologies
for independent living for older people. London: Anchor Trust;
2000.
[14] Martin T, Majeed B, Lee B-S, Clarke NA. Third generation
telecare system using fuzzy ambient intelligence. Studies in
Computer Intelligence 2007;72:155–75.
[15] Varshney U. Pervasive healthcare and wireless health monitor-
ing. Mobile Networks and Applications 2007;12(2–3):113–27.
[16] Chan M, Esteve D, Escriba C, Campo EA. Review of
smart homes—present state and future challenges. Computer
Methods and Programs in Biomedicine 2008;91(1):55–81.
[17] Fang A, Xu X, Yang W, Zhang L, editors. The realization of
intelligent home by ZigBee wireless network technology. In:
Proceedings of the 2009 Pacific-Asia conference on circuits,
communications and systems. IEEE Computer Society; 2009.
[18] Poole T. Telecare and older people. UK: King’s Fund; 2006.
[19] Bardi A, Schwartz SH. Values and behavior—strength and
structure of relations. Personality & Social Psychology Bulletin
2003;29:1207.
Social considerations in home telecare design
[20] Lindbeck A. Welfare state disincentives with endogenous
habits and norms. The Scandinavian Journal of Economics
1995;97(4):477–94.
[21] Schwartz SH, Fleishman JA. Personal norms and the mediation
of legitimacy effects on helping. Social Psychology
1978;41(4):306–15.
[22] Chidzambwa L, Michell V. Capturing social aspects of home
telecare by applying semiotics. ICICTH 2011. Samos, Greece:
ACM; 2011.
[23] Ackerman MS. The intellectual challenge of CSCW: the gap
between social requirements and technical feasibility. Human
Computer Interaction 2000;15:179–203.
[24] Percival J, Hanson J. Big brother or brave new world? Telecare
and its implications for older people’s independence and social
inclusion Critical Social Policy 2006;26(24):888–909.
[25] Abras C, Maloney-Krichmar D, Preece J. User-centred design.
In: Bainbridge W, editor. Encyclopedia of human–computer
interaction. Sage Publications; 2004.
[26] Kramer J, Noronha S, Vergo JA. User centred design approach
to personalisation. Communications of ACM 2000;43:8.
[27] Clark M, Goodwin N. Sustaining innovation in telehealth and
telecare. WSD Action Network [Internet] 2010.
[28] Abras C, Maloney-Krichmar D, Preece J. User centred design.
Human Computer Interaction [Internet] 2004.
[29] Baek E-O, Cagiltay K, Boling E, Frick T. User centred design and
development. In: Spector J, Merrill M, Merrienboer J, Driscoll M,
editors. Handbook of research on educational communication and
technology. 3rd ed. New York: Taylor & Francis Group, LLC; 2008.
[30] Liu K. Semiotics in information systems engineering. Cambridge:
Cambridge University Press; 2000.
[31] Crabtree A. In: Diaper D, Sanger C, editors. Designing collabora-
tive systems: a practical guide to ethnography. Springer; 2003.
[32] Stamper R, Liu K, Hafkamp M, Ades Y. Understanding the roles
of signs and norms in organisations—a semiotic approach to
information systems. Journal of Behaviour & Information
Technology 2000;19(1):13.
[33] Stamper R. Signs, information, norms and systems. Cambridge
University Press; 1995.
[34] Tolmie P, Pycock J, Diggins T, Maclean A, Karsenty A, editors.
Unremarkable computing. In: Proceedings of the 2002 CHI
conference on human factors in computing systems; 2002.
[35] Fishbein M, Ajzen I. Belief, attitude, intention and behaviour:
an introduction to research. Reading: Addison-Wesley; 1975.
[36] Azjen I. The theory of planned behaviour. Organisational
behaviour and human decisions processes 1991;50:179.
[37] Davies FD. A technology acceptance model for emperically
testing new end-user information systems: theory and results.
Massachussets Institute of Technology; 1985.
[38] Venkatesh V, Morris MG, Davis GB, Davis FD. User acceptance
of information technology: towards a unified view. MIS Quar-
tely 2003;27(3):425–78.
25
[39] Moran S, Chidzambwa L, Nakata K. Assessment of assistive
technologies based on the PSA-BI model. PETRA 2011; Crete,
Greece: ICM; 2011.
[40] Bouwhuis DG, Meesters LMJ, Sponselee AAM. Models for the
acceptance of telecare solutions—intention vs behaviour.
Gerontechnology 2012;11:1.
[41] Ajzen I. The theory of planned behaviour. Organisational
Behaviour and Human Decision Processes 1991;50(2):179–211.
[42] Gallagher R, Donoghue J, Chenoweth L, Stein-Parbury J. Self-
management in older patients with chronic illness. Interna-
tional Journal of Nursing Practice 2008;14(5):373–82.
[43] Cobb T. Applying constructivism: a test for the learner as
scientist. Educational Technology Research & Development
1999;47(3):15–31.
[44] Phillips DC. How, why, what when and where: perspectives on
constructivism in psychology and education. Issues in Educa-
tion 1997;3.
[45] Sun L, Williams S, Liu K. Knowledge construction in E-learning;
designing an E-learning environment. Interprise information
systems V. Netherlands: Kluwer Academic Publishers; 2005.
[46] Pickard A, Dixon P. The applicability of constructivist user
studies—how can constructivist inquiry infprm service provi-
ders and system designers. Innformation Research 2004;9:3.
[47] Walshman G. Interpretive case studies in IS research: nature
and method. European Journal of Information Systems
1995;4(2):74–81.
[48] Uden L, Liu K, Shank G. Linking radical constructivism and
semiotics to design a constructivist learning environment.
Journal of Computing in Higher Education 2001;12(2):34–51.
[49] Hirschheim R, Klein HK. Four paradigms of information systems
development. Social Aspects of Computing 1989;32(10):
1199–216.
[50] Gazendam HWM. Organisational semiotics. Semiotix 2004;1:1.
[51] Gazendam H, Liu K. The evolution of organisational semiotics
2003.
[52] Salter A, Liu K. Using semantic analysis and norm analysis to
model organisations. ICEIS 2002.
[53] Jabareen Y. Building a conceptual framework: philosophy,
definitions and procedure. International Journal of Qualitative
Methods 2009;8:4.
[54] Maxwel JA. Understanding the validity in qualitative research.
Havard Educational Review 1992;62(3):279–300.
[55] Pedersen K, Emblemsvag J, Bailey R, Allen JK, Mistree F,
editors. Validating Design Methods and Research_ The Valida-
tion Square. DETC 2000; 2000; Baltimore Maryland: ASME
Design Engineering Conferences.
[56] Guba EG. Lincoln Ys. Fourth Generation Evaluation. California:
Sage Publications; 1989.
[57] Bandura A. Self-efficacy mechanism in human agency. Amer-
ican Psychologist 1982;37(2):122–47.