Informal carers, who provide unpaid physical, practical, and emotional care, play a particularly vital role in supporting the growing older population, of whom an increasing proportion live with multimorbidity, frailty, and other complex health and social care needs [1]. In the United Kingdom, there are an estimated 7.6 million informal carers aged >16 years, with a significant number of these aged >65 years [2]. Collectively, they form an essential part of the social care system that is estimated to save the state £132 billion every year; without it the provision of care would be unacceptably limited or unaffordable [2]. Hence, supporting the sustainability and effectiveness of informal caregiving is of major importance to individuals, families, and the wider society.

The potential of digital technologies to facilitate access to services and information to support health and well-being is becoming ever more recognized [3,4], and digital technologies are increasingly being used by carers to support their caregiving activity and responsibilities [5-7]. Indeed, digital interventions may significantly enhance the carer’s ability to quickly access information and support. However, identifying reliable, current, and easily accessible resources may be time consuming and challenging, especially for those with limited information technology (IT) literacy [8]. Although an online portal that brings together guidance from carer support organizations, information about activities, and social groups is likely to be of considerable use to carers [9], to date an easy-to-navigate program for carers that provides personalized information, resources, and support to address individual needs has been lacking.

To help address the need for individually tailored resources, we developed a Web-based platform (Care Companion) to provide profile-driven support to informal carers [10]. The platform was coproduced with older carers and utilized a theory-based approach to support resilience and sustainability and is underpinned by a biopsychosocial model of carer resilience proposed by Parkinson et al [11]. The model comprises 5 independent domains (extending social assets, strengthening psychological resources, ensuring timely availability of key external resources, maintaining physical health, and safeguarding quality of life) that can be targeted to strengthen carer resilience and coping (see Figure 1 for intervention framework) . It is recognized that digital interventions that target multiple domains and incorporate a personalized approach that is adaptive to ever-changing needs and issues are more likely to improve carers’ health outcomes [12].

Care Companion was developed with older carers in mind and includes a guided walk-through of the site, which can be accessed at any time (see Figure 2). It offers links to (1) condition-specific and generic information, local support groups, and other third-sector organizations (see Figure 3), (2) a personal journal for carers to record information, feelings, and thoughts that they deem important (see Figure 4), (3) an address book where carers can save important contacts (see Figure 5), and (4) other features to support self-monitoring (eg, mood of both the carer and the person in their care) [10] (see Figure 2). The resource library targets 3 key areas: carer needs, general information and advice, and sustaining the carer. Users can also access carers’ stories that are designed to promote self-efficacy beliefs through vicarious learning [13].

The number of older people accessing the internet and taking advantage of Web-based services is increasingly rapidly [9,10,13,14]. However, older individuals often have lower levels of confidence in using new technologies compared with younger people [9]. Applying user-centered approaches to understanding the context in which digital health technologies will be used is particularly important when developing interventions for older people [15]. As such, the coproduction of Care Companion was shaped by interviews, focus groups, and workshops with carers [10], underpinned by a theory-driven process of coproduction [16]. This informed its design, content, and implementation.

Having developed a full working version of Care Companion, there was now a need to test user acceptance with a more diverse range of users and stakeholders than those that had participated in the coproduction. User acceptance testing was undertaken to ensure Care Companion’s compatibility with different needs [15] and explore potential barriers and facilitators to its use [17].

Barriers to using Web-based technologies include issues surrounding accessibility, such as the availability of digital devices or internet connections, lack of digital skills, and lack of motivation or awareness of the potential benefits of engaging with technologies. In addition, a lack of trust in digital technologies, such as fear of crime and Web-based scams, concerns relating to privacy, and uncertainty about the credibility of sources of information, may also affect their uptake and use [18,19]. Such barriers may be particularly pertinent to older carers.

Other possible barriers to adoption of Care Companion may include language, culture, and ethnicity. There are estimated to be around 600,000 ethnic minority carers in England and Wales [20], and yet the scope of the initial coproduction had largely excluded consideration of the specific needs associated with culture and ethnicity. The omission of different sociocultural perspectives might inadvertently contribute to inequalities in access to health and social care [21,22]. Hence, user acceptance testing provided an opportunity to explore how different cultural values and norms may influence the uptake and usage of Care Companion.

The aim of this study was to undertake user acceptance testing to explore the perceived usefulness (how useful the features of the platform are in everyday life) and ease of use of Care Companion and to identify refinements that might be needed before it becomes widely available.

The key objectives were to (1) explore the perceived usefulness and ease of use of Care Companion among the actual and potential users, (2) determine the barriers and facilitators that may affect its uptake and use, including the possible effects of culture and ethnicity, and (3) gather suggestions to inform plans for its wider implementation.

The study was underpinned by the principles of rapid appraisal [23]. This is a pragmatic approach to obtaining information about a specific set of questions within a time and resource-limited real-world setting and has been successfully applied to health services research [24]. It enables rapid assessment of community perspectives of needs and supports translating these findings into action [23].

We adopted a qualitative descriptive approach [25,26] to the analysis of data. Although qualitative description is the least theoretical of qualitative approaches to research [27], it is relevant for generating information about the experience of a specific phenomenon in situations where time and resources are limited [26]. It is less interpretive than other forms of qualitative enquiry as it neither requires the researcher to move far beyond the data nor requires a conceptual or highly abstract rendering of the data [27].

The Unified Theory of Acceptance and Use of Technology (UTAUT) [28] was used to help identify outcomes of interest that are relevant to the adoption and uptake of Care Companion, particularly its technical and practical aspects, as their refinement was recognized as being essential for the platform’s wider launch.

Qualitative methods including focus groups, observations, and semistructured interviews were used to explore key issues surrounding the use and implementation of Care Companion. The study aimed to recruit older carers through purposive sampling. The study was conducted iteratively, with two phases of data collection, each designed to explore different elements of the platform’s use. We aimed to recruit a diverse mix of carers, including individuals from South Asian ethnic backgrounds, from community groups within the local area.

In the first phase, semistructured interviews were undertaken while the carers tried using Care Companion to elucidate how they approached and navigated the site. The second phase involved focus group discussions and participants trialing Care Companion for up to 4 weeks, followed by a semistructured interview in which they shared their experiences of its use. The findings from both phases were used to shape subsequent technical development of Care Companion.

The study received ethical approval from the University of Warwick Biomedical Sciences Research Ethics Committee.

All interviews and focus groups were transcribed verbatim, anonymized, and managed and analyzed using NVivo [31]. Thematic analysis [32] was applied to the data, and a coding framework was developed iteratively during analysis by AT, EF, and BL. This followed a 5-step process of familiarization, identifying a thematic framework, indexing, charting, and mapping and interpretation [28]. Field notes were used to support contextualizing and interpretation of the transcripts—particularly in relation to the think-aloud interviews where participants used and pointed to different aspects of the platform. Coding was conducted inductively [33]. Once coding was complete, key themes were identified, explored, and interpreted by all authors. The analysis of each phase of the study also informed the subsequent phases of data collection and analysis. The final analysis involved synthesizing information from each phase of data collection and integrating the different themes into a broader thematic structure [34].

Participants were recruited from local carer groups organized by charities including Parkinson’s UK and a local South Asian carers’ support group. Care group facilitators were contacted through email and asked whether a researcher could join one of their weekly meetings to conduct a focus group.

Participants who took part in think-aloud interviews were recruited through local carer support groups. A total of 4 carers with differing levels of IT literacy agreed to participate. They predominantly cared for individuals with neurodegenerative diseases, such as dementia. In total, 4 focus groups were conducted involving a total of approximately 50 participants. Groups varied in size, reflecting the availability and willingness of the different carer groups’ members to participate. Of the participants, 16 expressed an interest in testing Care Companion. Of these, 2 participants declined taking part in a follow-up interview (one told us that they struggled to use the site, and the other felt that the platform did not add to the support they were already receiving). In addition, two other individuals recruited through carer groups volunteered to use Care Companion and participate in a follow-up interview. A total of 10 participants did not respond to the contact made by the research team for follow-up interviews, leaving a total of 6 interviews that were conducted with participants (see Table 2 for further details).

The key themes identified in the interviews related to the perceived usefulness and ease of use of Care Companion; its appearance and ease of use; the profile setup and log-in process; the safety and confidentiality of personal information; barriers to use and uptake and suggestions for overcoming them; and suggestions for improving Care Companion. Quotes that most clearly illustrated these themes were selected. These are discussed below.

This study has (1) explored the perceived usefulness and ease of use of Care Companion among older carers, (2) identified several barriers and facilitators that may affect its uptake and use, and (3) gathered suggestions for its further refinement and wider implementation. Recruiting different groups of carers to those who had participated in its coproduction [10] helped validate key themes that had been previously identified and also provided new insights. Overall, the carers who participated in our study perceived Care Companion to be a valuable and useful tool to support them in their caregiving activities.

The breadth of personalized, easily accessible, and carer-centered information on a single platform that is easy to navigate was especially celebrated by the participants. In addition to the resources section that had information relevant to supporting and informing caring roles, the journal feature within Care Companion was received with particular enthusiasm. Participants valued its ability to log events and thoughts and other important aspects of their caring role, such as medications, symptoms, and appointments. Facilitators to the uptake and the use of Care Companion were felt to include its simple and intuitive design and the breadth of personalized information. The main barriers to use included low digital literacy, access to digital technologies, the complexity of 2-factor authentication, and an inability to read English.

During the interviews and focus groups, a number of suggestions were voiced to help refine Care Companion. These included enhancing existing features (eg, the addition of tags in journal entries to enable easier retrieval of information) and ways of encouraging wider uptake and use. These included the following suggestions: running brief local training courses to support those with low technological literacy, optimizing the platform for use on devices other than computers (namely tablets and smartphones), and including more visual graphics to mitigate verbose text and the associated language barriers. Finally, suggestions emerged for a more culturally informed strategy to promote Care Companion within Indian communities by way of a community-driven approach to maximize trust in the service.

Both phases of user acceptance testing were used to drive changes to the Care Companion prototype. These changes include the following: enhancements to the journal feature to enable scheduling of appointments and tagging of entries, additional profile questions relating to ethnicity, religion, and culture to drive further personalization of resources, simplification of the 2-step authentication process, and removal of technical difficulties experienced by users.

Carers face a number of burdens, including a lack of free time for themselves [1]. Inevitably, they are a difficult population to recruit for the purposes of research. Therefore, we adopted a highly flexible and opportunistic recruitment strategy that used a range of different interview and observation methods and settings to collect data. The focus groups were based on pre-existing groupings and thus differed widely in size. The strength of this approach was the convenience to participants. However, using pre-existing groups meant that there was little possibility for collecting sociodemographic data on participants, and this inevitably raised questions about representativeness. In addition, in a large focus group, it is not possible to ensure that everyone’s views can be fully heard, and some participants may not have felt confident to express their opinions in front of such a large group.

The study had limited funding and had to be completed within a relatively short timescale to inform the planned area-wide implementation of Care Companion. Hence, it had a relatively small sample size that limits the generalizability and transferability of the findings.

The study aimed to explore how factors, such as culture and ethnicity, may influence the uptake of Care Companion. As this was a rapid and small study, we only targeted local South Asian groups, as these represent the largest ethnic minority groups in England [21,36]. Although we attempted to explore the potential of using Care Companion with South Asian carers, we experienced significant difficulties in recruiting participants. As a result, we were only able to recruit carers of Indian heritage, therefore exploring only their experiences rather than a diversity of South Asian perspectives. This may have been because the research was undertaken during summer months which coincided with holidays and religious events. Furthermore, the researcher (BL) was a male, which may have made it difficult to recruit South Asian female carers [36].

Furthermore, caregiving is understood as an intrinsic part of family duty among many South Asian communities [21,37], meaning that members of these communities may not identify as carers because they locate their caregiving within broader religious and cultural norms [37]. South Asian caregivers may, therefore, better recognize themselves as persons who are fulfilling their duty to the family and community, rather than as carers. Although the problem of identifying as a carer is not unique to South Asian communities, it can hinder access to vital support and resources [38] and may be particularly pertinent to these communities.

Although we were not able to recruit participants from a diverse range of ethnic and cultural groups, the insights that emerged from those that did participate illustrated the need for further, more detailed exploration of the role culture and ethnicity may play in the uptake of such technologies.

Although the sample size was relatively small, it is worth acknowledging that there was a high level of coherence and conformity among the data that were collected through a variety of techniques. Data saturation was reached in discussions about the usefulness of the platform.

Although the use of digital technologies is increasing throughout all age groups across the population, there remains greater fear and anxiety among older adults toward using them, as well as a lack of confidence in their own skills and abilities to do so [39]. Our study suggests that older carers recognize that online technologies are potentially valuable and relevant. Our findings demonstrate that members of this this group are willing to learn how to navigate through a well-designed and tailored platform, such as Care Companion. This is in line with the model of technology acceptance proposed by Barnard et al [40].

Participants in our study indicated that an in-person introduction to Care Companion, such as through brief individual or group training sessions, could help increase the understanding and uptake among older carers. Studies have shown that supportive environments can have a powerful role for encouraging the use of digital technologies, whether through step-by-step guidance, offering a friendly space to use trial and error methods, or through providing an instruction manual [40]. Preferably, this should involve a user-centered model where an individual’s unique characteristics and needs are taken into consideration [41].

Concerns about online security and confidentiality are reported in other studies [42,43], where older adults report fear that their personal data may be misused and manipulated [42]. Our study shows that older carers are aware of these risks and are eager to understand how their personal information is being stored and used. They were concerned that if they uploaded personal information this would compromise their safety and there might be the possibility of other people reading and accessing their private notes. This highlights how important it is for platforms, such as Care Companion, to be unambiguous and transparent about how information is stored and that this is presented clearly in simple language. Although 2-factor authentication is in place to help protect users’ information, for Care Companion, this entailed users receiving a phone call with a 4-digit pin code whenever they logged in from a different internet protocol address; this verification process was seen as cumbersome and off-putting. There is a need for authentication mechanisms to be accessible and inclusively designed for a broad range of users [44]. As a result, Care Companion’s 2-factor authentication process has now been modified to include a number of changes to make it easier to hear and understand the automatic call back. The introduction of an I’m ready button to allow users time to find their telephone or a pen and paper on which they could write down the code, has also been added.

The journal feature of Care Companion was widely considered to be the most useful aspect of the platform and which would encourage the site’s continuous use. Writing expressively about emotionally triggering events is recognized as having positive effects on physical and mental well-being [45,46]. This may help the carers to understand, regulate, and process difficult emotions and so shape affective and cognitive state, as well as serve as an aide-memoire when explaining issues to a health or social care provider [46].

Exploring the acceptability and aspects of use of Care Companion has been an informative and important step between the coproduction process and the wider realization and evaluation of the platform. A number of insightful lessons emerged, illustrating the importance of careful user acceptance testing [15].

The key findings identified during the coproduction phase of Care Companion’s development were reinforced by this study. These include the need for resources aimed specifically at carers (instead of care recipients); importance of personalized information; and the value of having a journal. This acceptance testing further highlighted issues that had not previously been identified during the coproduction phase, which include the importance of transparency for security and data usage; minimizing barriers to initial registration; and offering demonstrations to support a wider uptake by people with low technological literacy. In addition, this study underscores the need to develop a culturally sensitive approach to promoting Care Companion that works in partnership with and reflects the diversity of the local population.

The evidence from our study is relevant to the wider development of digital interventions for carers and is now informing the strategy for a full area-wide implementation of Care Companion.