Publicatiereeks zorg en technologie, aflevering 8 engelse versie ehealth on the threshold of accepta

CARE AND TECHNOLOGY SPEARHEAD

E-HEALTH ON THE THRESHOLD OF ACCEPTANCE EUROPEAN DIFFERENCES IN THE USE OF ASSISTED LIVING TECHNOLOGIES

ABOUT THIS STUDY This study on the use of Assisted Living Technologies (ALT) in Europe is a joint project of the Verklizan Group, Utrecht University of Applied Sciences, Coventry University, Universidad Politécnica de Madrid and Beuth Hochschule für Technik Berlin. The final report on the study appeared in February 2014 under the title Acceptance of Assisted Living Technologies in Europe. The present brochure is an edited summary of that report.

CREDITS

The following publications have already

Authors: Helianthe Kort (HU) and Matti Groot

appeared in this series:

(Verklizan) on the basis of the report

• Zichtbaar beter inrichten, by M. Sinoo.

Acceptance of Assisted Living Technologies

ISBN 978-90-8928-058-9

in Europe by Roderick Udo MSc (Utrecht),

• Co-design: samen de technologie in de zorg

Nikki Holliday MSc (Coventry), Thijs van Houwelingen MSc (Utrecht) and Laura Vadillo Moreno MSc (Madrid).

verbeteren, by R. van der Lugt, F. Verhoeven and A. Cremers. ISBN 978-90-8928-061-9 • De maatschappelijke business case:

Text processing: Jolanda Keesom, Arnhem

toegevoegde waarde voor zorgtechnolo­

Editing: Jurgen Mollema and Maaike Smole

gische innovaties, by E. Huisman and

Vormgeving: Studio Vrijdag ISBN/EAN: 978-90-8928-078-7 NUR: 981

G. Lanting. ISBN 978-90-8928-062-6 • Beeldzorg bevorderen: een kwestie van

ervaring opdoen, by T. van Houwelingen and A. Barakat. ISBN 978-90-8928-0664

This is the eighth publication in a series produced by the Care and Technology Spearhead. These brochures can be downloaded from the website www.zent.hu.nl

• TASTE: het succes van zelfmanagement

ontrafelen, by Dr J. Trappenburg.

ISBN 978-90-8928-071-8 • Blijven lopen na een beroerte: Feedback

For further details, please contact

op het nachtkastje, by Dr Anita Cremers,

SpeerpuntZenT@hu.nl

Fred Montijn, Michiel Punt Msc, Dr Harriët Wittink and Marieke Zielhuis.

ISBN/EAN: 978-90-8928-0732 • Data in digitale dossiers: Wat mag en kan

er met gegevens van mensen?, by Dr Ellen Gerrits, Frank Buijs, Prof. Mia Duijnstee, Bolinda Hoeksema, Dr Johan Versendaal and Freek Zuidweg.

ISBN/EAN: 978-90-8928-078-7

CONTENTS

04

FOREWORD

05

E-HEALTH CHALLENGES

08

THE USE OF ALT IN EUROPE

10

PRACTICAL OBSTACLES TO THE USE OF ALT

15

PSYCHOLOGICAL OBSTACLES TO THE USE OF ALT

19

ALT EDUCATION

22

AN APPROPRIATE BUSINESS MODEL

24

CONCLUSIONS AND RECOMMENDATIONS

26

REFERENCES

FOREWORD Although technology applications known under the general name of ‘e-Health’ have already been widely used in the healthcare sector for several decades, they still remain somewhere between the application and the acceptance phase. In this context, the term ‘application phase’ means that the concept in question has been thoroughly tested and is widely used, but there are still all kinds of obstacles to its general acceptance.

Koert van Mensvoort gave a theoretical description of how technology evolves to a level where it is taken for granted in his lecture Pyramid of Technology, how technology becomes nature in seven steps (2013). Verklizan’s practical experience confirms the theoretical model developed by Van Mensvoort. As a supplier of an open platform for monitoring centres, Verklizan observed that technology applications in the field of Assisted Living Technologies (ALT), such as IT-based alarm systems, were used to a different extent by its various customers. It therefore asked researchers in a number of universities to look for explanations for the observed differences in the use of e-Health applications, including ALT, throughout Europe.

Verklizan has studied this question in cooperation with four knowledge institutions, under the supervision of a steering committee representing a wide range of disciplines including sociology, business studies, engineering and gerontechnology. The findings are in line with Van Mensvoort’s theory of the technology pyramid. It has been found that e-Health is still regarded as a new, artificial approach that does not really belong in the healthcare sector, because it has not yet proved possible to integrate these technology applications into the fields of nursing and care as they are taught in the various training colleges. There are also cultural barriers to more extensive use of e-Health, and it is not yet clearly evident what the benefits of this approach are. A public-private partnership, like the one set up for the present study of the use of Assisted Living Technologies in various European countries, is needed to deal with these barriers to the wider use of e-Health. The study has provided input for Verklizan’s corporate strategy, and has helped the participating knowledge institutions to gain a better understanding of possible ways of improving the use of ALT. Helianthe Kort Utrecht University of Applied Sciences

M D W D V info sideeffects

take one once a day with water

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E-HEALTH CHALLENGES Technology applications in the healthcare sector intended to help people to maintain an independent lifestyle for longer – known under the general name of e-Health – are not yet widely accepted by the population as a whole. Studies have shown that insufficient attention is often paid to the user’s viewpoint during the introduction of such applications. The Care and Technology Spearhead of Utrecht University of Applied Sciences therefore sees its task in the present study as not only exploring the obstacles to greater use of e-Health by healthcare providers and their clients but also as pointing out factors that can enhance the acceptance of this approach.

THE TECHNOLOGY PYRAMID New technologies have to pass through various stages before they are widely used and accepted, from the tentative initial phase to the point when their use is taken for granted as an almost natural part of everyday life; the mobile phone is a good example of this evolution. Koert van Mensvoort from Eindhoven University of Technology developed the Pyramid of Technology in 2013 by analogy with Maslow’s hierarchy of needs. As shown in Fig. 1, Van Mensvoort distinguishes six stages in this process, from the initially envisioned concept or ‘cradle’, via the operational, application and acceptance phases to the stage when the new technology is considered to be vital, that in which it becomes invisible and finally that when it is ‘naturalized’ or completely taken for granted.

At present, e-Health has long been at the third level, the application level. There appear however still to be too many obstacles to its passage to the next level, at which it will be fully accepted by the general population.

REASONS FOR THE STAGNATION In the interests of further progress, it is important to discover why healthcare providers and their clients find it difficult to accept e-Health technologies in their work and daily life. The study by Kort and Van Hoof (2012) showed that the initial Dutch telecare projects were perceived as focusing too strongly on organizational factors while tending to neglect use factors. This was not only a matter of the differences between the ability of successive generations to use technology, but also of issues relating to regulations and legislation, education and training.

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A British study of the relationship between people’s willingness to use e-Health and the associated reduction in costs had the disappointing result that no difference was found between the group who received e-Health and the group given conventional care.

German researchers found that elderly patients were actually less willing to use e-Health after suffering cardiovascular complaints – probably because they had more need of face-to-face contact due to their more uncertain state of health.

The crucial role played by healthcare providers in determining the acceptance level of e-Health was underlined by the ‘PETZ’ study carried out in the department of Demand-driven Care at Utrecht University of Applied Sciences (Van Houwelingen and Barakat, 2013). This study showed that healthcare professionals were only willing to use e-Health technologies if their clients could handle them, derived real benefit from them and if the costs involved were not excessive. Healthcare providers were also more likely to recommend the use of e-Health if their colleagues also used these technologies. As far as the elderly patients in question were concerned, they were much more likely to use e-Health if the technologies involved motivated them to take care of themselves better and were useful in this connection.

Fig. 1: The technology pyramid proposed by Van Mensvoort, Eindhoven University of Technology, 2013.

Level 7 Naturalized Level 6 Invisible Level 5 Vital Level 4 Accepted Level 3 Applied Level 2 Operational Level 1 Envisioned

THE ROAD TO ACCEPTANCE Important factors for stimulating the acceptance of e-Health in the healthcare sector are that potential users know what e-Health is and can recognize an e-Health application when they see one; that the design is self-explanatory so that people can easily use the application in question; and that training in use of the application is available. This applies in principle to all potential users throughout the world.

Nevertheless, the developers and suppliers of e-Health technology in Europe report large differences in the use of this technology throughout the continent.

In order to discover the reasons for these differences, Verklizan commissioned a study of the acceptance of e-Health in various European countries.

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THE USE OF ALT IN EUROPE Wide differences in the use of Assisted Living Technologies (ALT), as e-Health technologies are often called, have been found across Europe (Kubitschke, 2010).

Only 3 per cent of potential users in the 65+ age group in Germany and the Netherlands are found to use these technologies, as compared with 6 to 10 per cent in the Scandinavian countries and 15 per cent in the UK. The reasons for these differences are unclear. Are people not being given enough information about these technologies, do they distrust them, do healthcare professionals discourage their use, or do the technologies fail to meet the needs of people with disabilities?

FACTORS THAT ENCOURAGE AND DISCOURAGE THE USE OF ALT This uncertainty led Verklizan, supplier of software for monitoring centres, to commission researchers from various disciplines and various European countries to carry out a study of the factors encouraging and discouraging the use of ALT in order to gain a better insight into the overall low acceptance of these technologies.

Verklizan hopes that the results of this study will enhance its cooperation with clients and trading partners in marketing their products and services, so as to be able to offer more elderly patients the ALT services they need.

STUDY DESIGN AND STUDY METHODS This exploratory study was performed in the UK, the Netherlands, Germany and Spain, with the objective of generating new ideas and pointers for researchers, companies and government bodies at various levels about relevant factors that need further investigation. First of all, a literature survey relating to the following four points was carried out: • practical aspects of ALT of importance to users; • psychological aspects of ALT of importance to users; • training in the use of ALT; • business models used by ALT companies.

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The researchers then drew up a questionnaire, translated it into the relevant languages and sent it to 2460 experts in four different stakeholder groups (companies producing ALT technology, companies providing ALT services, educational institutions and healthcare institutions). A total of 361 persons filled in the questionnaire and returned it to the researchers. The results were analysed by a descriptive method, and the outcomes for the various countries were then compared.

Due to the width of the topic studied, the low response rate and the limited funds and time available for the study, it was not possible to investigate the four points mentioned above in depth, to set up case studies or to prove specific hypotheses. The investigation did, however, yield sufficient data to be regarded as a pilot study.

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PRACTICAL OBSTACLES TO THE USE OF ALT Use of ALT in Europe is still limited, despite the enormous advances in the technological possibilities offered by such systems and the beneficial effect they can have on the quality of life. Even in the UK, where the government subsidizes the use of ALT more than in other European countries, no more than 15 per cent of potential users actually use such systems. This is why one of the topics dealt with in this study was the existence of practical obstacles to the use of ALT.

LITERATURE SURVEY It is assumed on the basis of a review of the international scientific literature in this field that the practical obstacles to the use of ALT by the elderly or by people with a physical disability may be related to: • the extent to which products adequately meet the needs of the elderly; • user involvement in the development of the product or service; • the accessibility of the technology (in this report, the term ‘accessibility’ is used to refer to problems potential users may have in actually using the product or service in question because of visual, auditory, physical, intellectual or cognitive disabilities); • the availability of user training facilities; • the attitude of the user’s social environment; • the perceived utility; • the user’s own attitude to the product or service in general.

DECISIVE FACTORS The study carried out on behalf of Verklizan shows that the factor that is most decisive for acceptance of ALT by users in all four countries is the perceived safety, followed by reduction in anxiety (see Fig. 2). In all countries, unfamiliarity with the potential utility of ALT is found to be the greatest obstacle to its use.

Recommendations by family were seen in all countries to be the most important trigger for acceptance. In addition, suggestions by social services were found to play an important role in influencing acceptance of ALT in the UK and the Netherlands, while healthcare professionals only play a significant role in the UK.

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greater safety

seeing others successfully use ALT services

greater safety

feeling alone

recommended by family

seeing others successfully use ALT services

feeling less anxious

feeling alone

recommended by family

UK

THE NETHERLANDS

greater safety

seeing others successfully use ALT services

greater safety

feeling alone

recommended by family

feeling less anxious

seeing others successfully use ALT services

feeling less anxious

feeling alone

recommended by family

SPAIN

feeling less anxious GERMANY

Fig. 2: Summary of the relevance of the reasons for end-users to use ALT in various countries, according to service providers and healthcare institutions.

As regards information about ALT products and training in their use, such information and training was found to reach producers, suppliers and users’ relatives more easily than the users themselves. It follows that information and training should be aimed not only at end-users but in particular at relatives, social workers and healthcare professionals.

The acquisition and service costs for ALT services were found to be one of the most significant obstacles to the introduction of ALT in healthcare institutions in the Netherlands and the UK.

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LACK OF QUALITY STANDARDS It is clear that there needs to be more information about the utility of ALT in society in general. A multidisciplinary approach to the development of new ALT solutions that takes this factor into account is desirable. Dutch ALT producers are found to be more likely to involve users in the improvement of products and services than those in the UK (see Fig. 3). No conclusions about the actual quality of these products and services may be drawn from this fact. It may however be stated that the lack of standards and procedures for involving users in the development process and the lack of service quality models are obstacles

% answers by stakeholders

to the improvement of products and services.

100 90 80 70 60 50 40 30 20 10 0

producers

providers UK

Annual user satisfaction survey

providers

NETHERLANDS System for dealing with complaints and comments

Fig. 3: What do ALT producers and providers do to improve the quality of their products and services?

12

producers

User testing

Internal quality standards

% answers by stakeholders

40 35 30

INFORMATION AND TRAINING

25

The relative importance of unawareness of

20

the potential benefits of ALT and fear of

15

technology as reasons for not using ALT

10

varies from country to country among the

80-100%

60-80%

30-60%

appears to be the least relevant in the

10-30%

countries surveyed. Fear of technology

0 0-10%

5

% of users

% answers by stakeholders

Training by producer/provider

Netherlands. Particularly in Spain, contact with others who know about ALT appears to make a difference to the extent to which the technology is used. This is an argument for improving the supply of information about

40

ALT.

35

According to ALT producers and providers,

30

users need to be trained to use the technolo-

25

gy. This is particularly true in Spain. Opinions

20

are divided on this subject in the UK; in

15

Germany, only a small proportion of users

10

are considered to need training, while

5

opinions are evenly spread over the whole

0

spectrum in the Netherlands (see Fig. 4).

80-100%

60-80%

30-60%

10-30%

0-10%

% of users

Explanation by family/friends

These differences may be due, for example, to the ease with which the technology can be used and the varying roles played by relatives and healthcare professionals in

% answers by stakeholders

encouraging use of ALT. Training becomes 60

more important the more the user is

50

expected to master the technology.

40

Providing more examples of use of ALT

30

and sharing experience may help in this

20

connection.

10 80-100%

60-80%

% of users

30-60%

10-30%

0-10%

0

Fig. 4: Relative importance of various ways for users to learn how to use ALT products and services, according to healthcare institutions.

Own efforts UK

NETHERLANDS

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People may also be more willing to undergo training if they are given information about the equipment in advance and have the opportunity to try out a product or service before buying it.

ACCESSIBILITY The importance attached to accessibility by the various stakeholders has been found to vary quite considerably (see Fig. 5). Healthcare institutions regard this factor as very important, producers and suppliers less so. This may influence their views on the ease of use of products and services.

The fact that ALT producers and providers pay relatively little attention to accessibility may perhaps be explained by the fact that many people are unable to use ALT as a result of being disabled. If more work were done on modifying the equipment to take their specific needs into account, that could improve the

% answers by stakeholders

accessibility for people who at the moment do not use ALT.

50 45 40 35 30 25 20 15 10 5 0

0-10% UK (63)

10-30% NETHERLANDS (30)

30-60% SPAIN (11)

60-80%

GERMANY (10)

Fig. 5: Influence of “accessibility� (user problems in using technology due to visual, auditory, physical, intellectual or cognitive disabilities) as a reason for rejecting the product (according to providers of products and services).

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PSYCHOLOGICAL OBSTACLES TO THE USE OF ALT The decision whether to use ALT can depend on whether it is perceived as matching the user’s identity and as a source of support or a threat. In the case of elderly people, their tendency to regard modern technology as too complicated in general may withhold them from using it. The attitude of healthcare professionals can also influence the extent to which ALT is used – especially when they see it as a threat to their own role and are afraid that they may lose face-to-face contact with clients if ALT is introduced. There were no striking differences between the countries involved in the study as far as psychological issues are concerned.

IMPACT ON USER IDENTITY Healthcare professionals and companies engaged in the production and provision of ALT in the UK and the Netherlands agree that people who want to remain independent and who have a positive attitude to the aging process are more likely to use ALT. This is in line with the finding from the literature survey that there is a greater likelihood that people who value independence and autonomy will use ALT to maintain their identity. The various stakeholders further agreed that the provision of information about health and positive aging can encourage people to use ALT, possibly because it can focus attention on the benefits of these technologies in helping them to keep their independence.

ALT may help them to stay in their own home for longer, which is important because one’s identity and self-image are closely linked with one’s own home and the surroundings one is used to (see Fig. 6).

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Percentage response of healthcare professionals to the statement that clients who have a positive view of aging are more likely to use ALT 50

UK

45

NETHERLANDS

40

SPAIN

35

GERMANY

30 25 20 15 10 5 0 Strongly agree

Agree

Neither agree nor disagree

Disagree

Strongly disagree

Fig. 6: Percentage response of healthcare professionals to the statement that clients who have a positive view of aging are more likely to use ALT. (UK: n=76; NL: n=17; D: n=13; Sp: n=5.)

Percentage response of ALT service providers to the statement that the perceived stigma attached to the use of ALT may be an obstacle to successful use

65

UK

60

NETHERLANDS

55

SPAIN

50

GERMANY

45 40 35 30 25 20 15 10 5 0 Strongly agree

Agree

Neither agree nor disagree

Disagree

Strongly Disagree

Fig. 7: Percentage response of ALT service providers to the statement that the perceived stigma attached to the use of ALT may be an obstacle to successful use. (UK: n=54; NL: n=25; D: n=3; Sp: n=11.)

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STIGMATIZING EFFECT Not all stakeholders agree that providing more information about use of ALT will increase the extent to which these technologies are used – for example because use of such equipment may be seen as stigmatizing and the design of the equipment may be regarded as too unattractive (see Fig. 7).

THREAT TO PROFESSIONALS? The response to the statement that healthcare professionals regard ALT as a threat to their professional identity varies from one stakeholder group to the other. Companies that provide ALT services tend to agree with this statement more than the healthcare professionals themselves, who predominantly do not regard ALT as a threat (see Fig. 8).

Percentage response of healthcare professions to the statement that they worry that ALT may threaten their professional identity

60

UK

55

NETHERLANDS

50

SPAIN

45

GERMANY

40 35 30 25 20 15 10 5 0 Strongly agree

Agree

Neither agree nor disagree

Disagree

Strongly Disagree

Fig. 8: Percentage response of healthcare professions to the statement that they worry that ALT may threaten their professional identity.

(UK: n=76; NL: n=17; D: n=13; Sp: n=5.)

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Educational institutions, especially those in the Netherlands and the UK, indicate their belief that healthcare professionals are concerned that increasing use of ALT will lead to loss of face-to-face contact with their clients, which they regard as important (see Fig. 9).

FURTHER RESEARCH IS NEEDED Although the present study confirms the main psychological factors influencing the use of ALT as reported in the literature at a qualitative level, further quantitative research is needed to permit measurement of the effect of such factors and determination of the relationships between them.

Percentage of respondents from educational institutions who believe that nurses are worried that more use of ALT will cause them to lose face-to-face contact with their patients

60 55 50 45 40 35 30 25 20 15 10 5 0 UK

Netherlands

Germany

Spain

Fig. 9: Percentage of respondents from educational institutions who believe that nurses are worried that more use of ALT will cause them to lose face-to-face contact with their patients. (UK: n=39; NL: n=12; D: n=11; Sp: n=10.)

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ALT EDUCATION Healthcare professionals can play an important role in optimizing the use of ALT, but they can only do this if they have knowledge of the way these technologies can be implemented in the healthcare sector. Far from all healthcare professionals are found to be motivated to acquire such knowledge, however. One contributing factor in this context may be the lack of adequate educational resources in this field.

LACK OF A COMPLETE CURRICULUM There are no universities in any of the four countries surveyed that offer students complete courses in the use of ALT. In fact, rapid technological advances in this field mean that the existing courses are at risk of lagging behind day-to-day practice (see Fig. 10).

RESPONSIBILITY There are considerable differences of opinion in all countries surveyed about who is responsible for training healthcare professionals in the use of ALT. Educational institutions want to make such training compulsory, but believe that the healthcare organizations should share the responsibility. It would seem to be an obvious solution that healthcare professionals who have already completed their professional training should be trained in the use of ALT by their employers. It is however uncertain how often this actually occurs in practice. Significant differences have been found between the UK, the Netherlands and Germany on this point (see Fig. 11).

Providers of ALT technologies also train healthcare professionals in the use of ALT. This occurs slightly less in the UK than in the other countries surveyed (see Fig. 12).

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Percentage of nursing colleges 80

Already offer courses on personal alarm systems

75 70

Courses on personal alarm systems offered or planned for the future

65 60

Already offer courses on screen-to-screen telecare systems

55 50 45

Courses on screen-toscreen telecare systems offered or planned for the future

40 35 30 25 20 15 10 5 0

UK

Netherlands

Germany

Spain

Fig. 10: Percentage of nursing colleges in the four countries surveyed already offering or planning to offer courses on personal alarm systems and/or screen-to-screen telecare systems.

3.50 3.00 2.50 2.00 1.50 1.00 0.50 0

UK

Netherlands

Germany

Note: The reported scores range from 1 (rarely, 0–10% of staff) to 5 (always, 81–100% of staff) * The results for Spain were not included, because of the low response rate for this country Fig. 11: Self-reported scores of healthcare organizations for the extent to which they train their healthcare professionals in the use of ALT.

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3.50 3.00 2.50 2.00 1.50 1.00 0.50 0

UK

Netherlands

Germany

Spain

Note: The reported scores range from 1 (rarely, 0–10% of staff) to 5 (always, 81–100% of staff)

Fig. 12: Self-reported scores of ALT providers for the extent to which they train healthcare professionals in the use of ALT.

COOPERATION AS A SOLUTION Cooperation with regard to ALT education that also involves the ALT providers would seem to be the best option. After all, all parties have an interest in providing proper training: it will allow producers to sell more products, educational institutions to improve their curricula and healthcare organizations to promote the use of ALT. In addition, cooperation in the field of training could yield extra benefits in other directions: • it could help ALT providers and healthcare organizations to make the benefits of ALT more clear; • it could motivate healthcare organizations to look at things from the client’s perspective rather than that of technological efficiency; • it could help healthcare organizations to promote the use of ALT and to let end users make recommendations; • it could give suppliers and healthcare organizations practical awareness of ALT, to be embedded in care pathways; • it could help ALT technology providers to improve their relationships with experts and specialists; • it could help ALT service providers to improve the technical support they offer; • it could improve ALT providers’ basic knowledge about how ALT works and what its benefits are; • it could help nursing colleges and healthcare organizations to understand their own role better.

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AN APPROPRIATE BUSINESS MODEL The results of this exploratory study of the factors promoting and hindering the use of ALT can best be translated into a dynamic business model that takes the roles of both users and healthcare professionals into account.

INFORMATION ABOUT USERS Since insufficient data are available for Spain and Germany, only the details of the business models for technology producers and technology service providers from the UK and the Netherlands are compared with one another (see Fig. 13).

In the UK, where 15% of people aged 65 or over use ALT – five times as much as the 3% found in the Netherlands – many companies admit that they do not know who uses their products or services. All the Dutch companies surveyed believe that they do know who their users are. At the same time, British companies regard doctors as more of an obstacle to the use of ALT than Dutch companies.

100

UK Producers

90

NL Producers

80

UK Services

70

NL Services

60 50 40 30 20 10 0 %

User satisfaction survey

Complaints & comments handling system

User testing

Fig. 13: Percentage of Dutch and British companies with an operative quality management system.

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Quality standards

It may be asked whether there is a link between these differences and the extent to which the business models used by the companies involved take ALT users into account.

LEAN LAUNCH PAD The Lean Launch Pad is a good business model for companies providing ALT products and services because it can combine the different aspects considered in this study – the practical and psychological user perspectives and the need for training in the use of ALT. This model allows companies to make use of an iterative design process, using both feedback from customers and trials. This may result in a market-based approach that is appreciated by end-users and their relatives, healthcare professionals and doctors, thus leading to increased use of ALT.

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CONCLUSIONS AND RECOMMENDATIONS It is no easy matter, to put it mildly, to indicate all the factors that could explain the differences in the use of ALT that may be observed between various countries. The data collected within the restraints of this multidisciplinary study were not enough to prove or disprove the hypotheses formulated on the basis of the literature survey.

It was possible, however, to determine which factors came into consideration for further research.

THE ROLE OF HEALTHCARE PROFESSIONALS Comparison of the Dutch results with those for the UK shows that healthcare professionals play a bigger role in initiating the use of ALT technologies in the UK. In the Netherlands, potential users and their family are more likely to be the first to raise this topic. This difference may be explained by the differences between the healthcare systems in the two countries. The government plays a much greater role on the healthcare market in the UK, via the National Health Service (NHS). In the Netherlands, on the other hand, the healthcare market is privatized and individualized.

WORTH INVESTIGATION There are differences of opinion between the various stakeholders on the value of providing information about ALT. It may be useful to study in greater depth the reasons why some do not think this is such a good idea.

Another topic on which respondents in the various countries surveyed disagreed was the extent to which the stigmatizing effect of use of the equipment, or even ugly design of the equipment, could discourage people from using ALT solutions. Such factors seems to have less of a deterrent effect in the Netherlands than in the UK. This might also be an interesting topic for further research.

A third possible theme for future research is the influence of concerns that healthcare professionals may have about the impact of ALT on their professional roles. The present study did not indicate any marked differences between the various countries surveyed in this respect.

WORKING TOGETHER TO PROVIDE ADEQUATE TRAINING It was clear from the study that educational institutions in the UK pay most attention to ALT in training courses for healthcare personnel. The Netherlands

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comes a good second: Dutch nursing colleges hope that all nurses will be trained in the use of ALT by 2020. Germany clearly lags behind, while not enough data were collected for Spain to make it possible to draw conclusions.

It is recommended that companies, healthcare organizations and institutions, nursing colleges and government bodies at various levels work together to improve education and training in the use of ALT.

FOCUS ON USERS Further research on business models should concentrate on the extent to which users play a key role. Why, for example, do English companies sell more ALT, while they themselves state that they do not always really know who their customers are?

The Lean Launch Pad approach could inspire companies to change the way they do things, thus finding ways of winning more customers for their services and technologies.

RECIPE FOR SUCCESSFUL CORPORATE STRATEGIES This study has yielded important insights into possible obstacles to the use of ALT. Verklizan and its trading partners can make use of these insights to maintain a competitive edge and at the same time to help to improve the quality of life of potential users.

It may be concluded that a successful corporate strategy for ALT will include the following elements: • asking yourself whether you really know your customers; • promoting a positive view of aging and independence; • bearing in mind that ALT equipment design that has a stigmatizing effect can put potential users off; • working together with other stakeholders to improve ALT education and training; • describing your corporate strategy and business model from the viewpoint of users and their families; • drawing inspiration from the Lean Launch Pad approach, which uses an iterative design process to market technologies or services.

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REFERENCES Houwelingen, Thijs van, and A. Barakat (2013) Beeldzorg Bevorderen. Utrecht: Utrecht University of Applied Sciences.

Kort, H. and J. van Hoof (2012) Telehomecare in The Netherlands: Barriers to Implementation.

International Journal of Ambient Computing and Intelligence, 64-73.

Kubitschke, L. and K.Cullen (2010) ICT&Aging: European study on users, markets and technologies – Final Report. European Commission, Directorate General for Information Society and Media.

Mensvoort, K.van (2013) Pyramid of Technology. How technology becomes nature in seven steps. Eindhoven University lectures, NR.3, (2012 -2013) Eindhoven: Platform for Academic Education (Eindhoven University of Technology).

Verklizan (2014) Acceptance of Assisted Living Technologies in Europe. Analysis of the major differences in the adoption rates of Assisted Living Technologies across Europe. Sliedrecht.

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UTRECHT UNIVERSITY OF APPLIED SCIENCES Utrecht University of Applied Sciences (HU) delivers high-quality teaching and research in the service of innovation and professionalization in professional practice. This fast-growing, dynamic educational establishment is located in Utrecht Science Park, near its knowledge-intensive strategic partners the University of Utrecht (UU) and the Utrecht University Medical Centre (UMCU).

HU regards the development and dissemination of knowledge as among its core tasks. As a result, it invests in demand-oriented applied research and the dissemination and valorization of knowledge, and as a University of Applied Sciences it makes a substantial contribution through teaching and research to innovation in professional practice, and hence to the social and economic development of the Utrecht/Amersfoort innovation hub.

HU research centres HU has six research centres. Various groups within a given research domain, each headed by a Reader, combine to form a research centre. A single research centre performs research on specific themes in consultation with professionals from the field. Each research centre at HU has its own website, which provides information about the individual fields of research, studies and projects together with profiles of the Readers within the centre. An overview of the research centres at HU may be found at www.onderzoek.hu.nl.

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Care and Technology Spearhead The Care and Technology Spearhead at HU focuses on research relating to two current trends: the rapid aging of society and the rapid advances in technology.

The prevailing view in the field of healthcare and technology is that technology applications can improve the quality of life of people who need healthcare services. The other side of the coin is that technology, in particular IT, can actually restrict the quality of life of such people. The problem is then how to design and use such technology applications so as to get rid of practically all impediments. In general, it is mainly older people and those with a chronic disease need some form of healthcare. The Care and Technology Spearhead focuses in particular on how the right combination of healthcare and technology can be used to help people with a medical problem as well enhance prevention.

The Care and Technology Spearhead considers the following questions in particular: • How can the right combination of healthcare and technology minimize restrictions on functioning in daily life and/or social interaction due to biological aging or a chronic disease?

• How can the right combination of healthcare and technology improve support for the client system when providing care for one’s fellow human beings?

• How can the right combination of healthcare and technology alleviate the work of healthcare professionals and thus help them to provide healthcare services matching the need?

• How can the right combination of healthcare and technology be implemented in housing or residential environments so as to provide people who have a need for healthcare with maximum support in making the most of their abilities?

Contacts Prof. Helianthe Kort, Director of the Care and Technology Programme Healthcare Innovation Research Centre, Utrecht University of Applied Sciences For further information, please E-mail SpeerpuntZenT@hu.nl or visit the website www.zent.hu.nl Verklizan B.V., Stationspark 500, 3364 DA Sliedrecht P.O. Box 284, 3360 AG Sliedrecht T: +31 (0)184 42 18 18

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Maaike Smole, Care and Technology Manager