Review
- Jie Kie Phang1,2*, BSc, MPH ;
- Yu Heng Kwan1,2,3,4*, BSc, MD, PhD ;
- Sungwon Yoon1,2, MPH, PhD ;
- Hendra Goh2, BSc, MPH ;
- Wan Qi Yee5, BSc ;
- Chuen Seng Tan6, BSc, MSc, PhD ;
- Lian Leng Low1,5,7,8,9, MBBS, MMed, MCI
1Centre for Population Health Research and Implementation, SingHealth Regional Health System, SingHealth, Singapore, Singapore
2Health Systems and Services Research, Duke-NUS Medical School, Singapore, Singapore
3Department of Pharmacy, National University of Singapore, Singapore, Singapore
4Internal Medicine Residency, SingHealth residency, Singapore, Singapore
5Population Health & Integrated Care Office, Singapore General Hospital, Singapore, Singapore
6Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
7Department of Family Medicine & Continuing Care, Singapore General Hospital, Singapore, Singapore
8SingHealth Duke-NUS Family Medicine, Duke-NUS Medical School, Singapore, Singapore
9Outram Community Hospital, SingHealth Community Hospitals, Singapore, Singapore
*these authors contributed equally
Corresponding Author:
Yu Heng Kwan, BSc, MD, PhD
Health Systems and Services Research
Duke-NUS Medical School
8 College Rd
Singapore, 169857
Singapore
Phone: 65 90231226
Email: phakyh@nus.edu.sg
Abstract
Background: There is a compelling need for an innovative and creative approach to promote social connectedness among older adults to optimize their well-being and quality of life. One possible solution may be through a digital intergenerational program.
Objective: This realist review aimed to identify existing digital intergenerational programs that were used to reduce loneliness or social isolation among older adults and analyze them in terms of strategy, context, mechanisms, and outcomes.
Methods: We performed a realist review with an extensive search of published and gray literature. For scholarly literature, we searched PubMed, Embase, CINAHL, PsycINFO (Ovid), and Social Sciences Citation Index databases for articles published between January 2000 to August 2020. A grey literature search was performed using the Google search engine, and the search was completed in May 2021. We included programs that evaluated digital intergenerational programs for older adults, which described outcomes of loneliness or social isolation. We included quantitative, mixed methods, and qualitative studies, as well as relevant theoretical papers, policy documents, and implementation documents. The studies were appraised based on their relevance and rigor. We synthesized the available evidence from the literature into Strategy-Context-Mechanism-Outcome (S-C-M-O) configurations to better understand what, when, and how programs work.
Results: A total of 31 documents reporting 27 digital intergenerational programs were reviewed. Our final results identified 4 S-C-M-O configurations. For S-C-M-O configuration 1, we found that for community-dwelling older adults, provision of access to and training in digital technology may increase older adults’ self-efficacy in digital devices and therefore increase the use of digital communication with family. In S-C-M-O configuration 2, digital psychosocial support and educational interventions from nurses were found to be useful in reducing loneliness among community-dwelling older adults. In S-C-M-O configuration 3, a video call with a student or family was found to reduce loneliness among older adults residing in long-term residential care facilities. Finally, for S-C-M-O configuration 4, we found that behavioral activation provided through videoconferencing by a lay coach may be useful in reducing loneliness among older adults who are lonely. However, as almost half (11/27, 41%) of the included programs only reported quantitative results, this review focused on screening the discussion section of publications to identify author opinions or any qualitative information to elucidate the mechanisms of how programs work.
Conclusions: This review identified the key strategy, context, and mechanism influencing the success of programs that promote intergenerational interaction through digital means. This review revealed that different strategies should be adopted for different groups of older adults (eg, older adults who are lonely, older adults who reside in long-term residential care facilities, and community-dwelling older adults). The S-C-M-O configurations should be considered when designing and implementing digital intergenerational programs for older adults.
doi:10.2196/39848
Keywords
Introduction
Background
Driven by decreased fertility rates and increased life expectancy, worldwide population aging is expected to continue [Global Health and Aging. World Health Organization. 2011. URL: https://www.nia.nih.gov/sites/default/files/2017-06/global_health_aging.pdf [accessed 2021-06-01] 1]. The number of people aged 65 years or older is projected to grow from an estimated 524 million in 2010 to nearly 1.5 billion in 2050, representing around 16% of the total world population in 2050 [World Population Prospects 2019. United Nations. 2019. URL: https://population.un.org/wpp/Graphs/Probabilistic/PopPerc/65plus/900 [accessed 2021-05-20] 2]. Loneliness and social isolation in older adults affect a significant proportion of older adults worldwide, with current estimates of the extent of loneliness among older adults living in the community to be around 50% [Grenade L, Boldy D. Social isolation and loneliness among older people: issues and future challenges in community and residential settings. Aust Health Rev 2008 Aug;32(3):468-478. [CrossRef] [Medline]3], and around half of people aged >60 years are at risk of social isolation [Ibrahim R, Abolfathi Momtaz Y, Hamid TA. Social isolation in older Malaysians: prevalence and risk factors. Psychogeriatrics 2013 Jun;13(2):71-79 [FREE Full text] [CrossRef] [Medline]4]. Loneliness and social isolation pose serious public health risks as they are associated with adverse health outcomes [Coyle CE, Dugan E. Social isolation, loneliness and health among older adults. J Aging Health 2012 Dec;24(8):1346-1363. [CrossRef] [Medline]5,Tilvis RS, Routasalo P, Karppinen H, Strandberg TE, Kautiainen H, Pitkala KH. Social isolation, social activity and loneliness as survival indicators in old age; a nationwide survey with a 7-year follow-up. Eur Geriatr Med 2012 Feb;3(1):18-22 [FREE Full text] [CrossRef]6]. Loneliness may be associated with higher blood pressure, worse sleep, immune stress responses, and worse cognition over time in older adults [Luanaigh CO, Lawlor BA. Loneliness and the health of older people. Int J Geriatr Psychiatry 2008 Dec;23(12):1213-1221 [FREE Full text] [CrossRef] [Medline]7]. A meta-analysis demonstrated that social isolation among older adults significantly increases the likelihood of mortality, and its influence on mortality risk is comparable with well-established risk factors such as smoking, obesity, and physical inactivity [Holt-Lunstad J, Smith TB, Baker M, Harris T, Stephenson D. Loneliness and social isolation as risk factors for mortality: a meta-analytic review. Perspect Psychol Sci 2015 Mar;10(2):227-237. [CrossRef] [Medline]8].
One possible solution to mitigate loneliness and social isolation among older adults may be through an intergenerational program that leverages digital technology [Gualano MR, Voglino G, Bert F, Thomas R, Camussi E, Siliquini R. The impact of intergenerational programs on children and older adults: a review. Int Psychogeriatr 2018 Apr;30(4):451-468. [CrossRef] [Medline]9]. An intergenerational program can be defined as “vehicles for the purposeful and ongoing exchange of resources and learning among older and younger generations for individual and social benefits” [Hatton-Yeo A, Ohsako T. Intergenerational programmes: public policy and research implications--an international perspective. United Nations Educational, Scientific, and Cultural Organization. 2000. URL: https://files.eric.ed.gov/fulltext/ED458364.pdf [accessed 2021-07-01] 10]. Intergenerational programs can strengthen connections among different age groups and promote organized shared experiences, which may enhance the health of older adults by decreasing the risk of loneliness and social isolation [Weng SS. An Asian American community intergenerational response to older adult isolation and loneliness. J Intergener Relatsh 2019 Jul 31;17(3):257-272. [CrossRef]11-Giraudeau C, Bailly N. Intergenerational programs: what can school-age children and older people expect from them? A systematic review. Eur J Ageing 2019 Sep;16(3):363-376 [FREE Full text] [CrossRef] [Medline]13]. An added advantage of intergenerational interaction over peer interaction is that it provides younger generations with an opportunity to break down agist stereotypes [MacCallum J, Palmer DJ, Wright PR, Cumming-Potvin WM, Northcote J, Booker M, et al. Community Building Through Intergenerational Exchange Programs: Report to the National Youth Affairs Research Scheme (NYARS). Australia: National Youth Affairs Research Scheme; 2006.14], which will help in strengthening community cohesion [Hatton-Yeo A, Batty C. Evaluating the contribution of intergenerational practice to achieving social cohesion. In: Ratcliffe P, Newman I, editors. Promoting Social Cohesion: Implications for Policy and Evaluation. Bristol, UK: Policy Press; 2011:243-256.15]. Previous reviews have demonstrated the advantage of intergenerational interaction over peer interaction, including allowing younger counterparts to develop new communication skills and improved perceptions toward older adults [Gualano MR, Voglino G, Bert F, Thomas R, Camussi E, Siliquini R. The impact of intergenerational programs on children and older adults: a review. Int Psychogeriatr 2018 Apr;30(4):451-468. [CrossRef] [Medline]9,Giraudeau C, Bailly N. Intergenerational programs: what can school-age children and older people expect from them? A systematic review. Eur J Ageing 2019 Sep;16(3):363-376 [FREE Full text] [CrossRef] [Medline]13,Blais S, McCleary L, Garcia L, Robitaille A. Examining the benefits of intergenerational volunteering in long-term care: a review of the literature. J Intergener Relationsh 2017 Aug 11;15(3):258-272. [CrossRef]16]. In fact, the Decade of Health Ageing by the World Health Organization has emphasized the need for intergenerational solidarity [Decade of Healthy Ageing 2021-30. World Health Organization. 2020. URL: https://tinyurl.com/4ua3a4jw [accessed 2022-10-03] 17]. Intergenerational programs are usually conducted face to face, and some examples include conducting home visits or organizing large-scale events involving people from different age groups [Giraudeau C, Bailly N. Intergenerational programs: what can school-age children and older people expect from them? A systematic review. Eur J Ageing 2019 Sep;16(3):363-376 [FREE Full text] [CrossRef] [Medline]13,Galbraith B, Larkin H, Moorhouse A, Oomen T. Intergenerational programs for persons with dementia: a scoping review. J Gerontol Soc Work 2015;58(4):357-378. [CrossRef] [Medline]18]. Although there are systematic reviews available that summarize the interventions for reducing social isolation and loneliness in older persons [Chipps J, Jarvis MA, Ramlall S. The effectiveness of e-Interventions on reducing social isolation in older persons: a systematic review of systematic reviews. J Telemed Telecare 2017 Dec;23(10):817-827. [CrossRef] [Medline]19-Fakoya OA, McCorry NK, Donnelly M. Loneliness and social isolation interventions for older adults: a scoping review of reviews. BMC Public Health 2020 Feb 14;20(1):129 [FREE Full text] [CrossRef] [Medline]22], these reviews did not focus on intergenerational programs.
During the COVID-19 pandemic, social isolation among older adults intensified with the implementation of social distancing measures [Plagg B, Engl A, Piccoliori G, Eisendle K. Prolonged social isolation of the elderly during COVID-19: between benefit and damage. Arch Gerontol Geriatr 2020;89:104086 [FREE Full text] [CrossRef] [Medline]23-Cihan FG, Gökgöz Durmaz F. Evaluation of COVID-19 phobia and the feeling of loneliness in the geriatric age group. Int J Clin Pract 2021 Jun;75(6):e14089 [FREE Full text] [CrossRef] [Medline]26]. Therefore, using digital technology such as video calls to achieve intergenerational bonding becomes more compelling considering the social distancing measures implemented worldwide [Qian M, Jiang J. COVID-19 and social distancing. Z Gesundh Wiss 2022;30(1):259-261 [FREE Full text] [CrossRef] [Medline]27]. The other advantages of digital intergenerational programs in combating loneliness and social isolation among older adults are their ability to connect and reconnect people across large geographic distances, and their support for both synchronous and asynchronous forms of communication [Castells M. Globalisation, networking, urbanisation: reflections on the spatial dynamics of the information age. Urban Stud 2010 Nov 16;47(13):2737-2745 [FREE Full text] [CrossRef]28]. Current reviews of intergenerational programs are primarily based on face-to-face interventions [Canedo-García A, García-Sánchez JN, Pacheco-Sanz DI. A systematic review of the effectiveness of intergenerational programs. Front Psychol 2017 Oct 27;8:1882 [FREE Full text] [CrossRef] [Medline]29-Martins T, Midão L, Martínez Veiga S, Dequech L, Busse G, Bertram M, et al. Intergenerational programs review: study design and characteristics of intervention, outcomes, and effectiveness. J Intergener Relationsh 2019;17(1):93-109. [CrossRef]31], with a lack of emphasis on digital interventions. Although there is a scoping review by Reis et al [Reis L, Mercer K, Boger J. Technologies for fostering intergenerational connectivity and relationships: scoping review and emergent concepts. Technol Soc 2021 Feb;64:101494. [CrossRef]32] on technologies that foster intergenerational connectivity and relationships, it did not provide an analysis of program outcomes.
In addition, previous traditional reviews tend to predominantly focus on whether the intervention “worked,” often without an understanding of the complexity of the intervention in terms of for whom they may or may not work, under what context and mechanism [Wozney L, Huguet A, Bennett K, Radomski AD, Hartling L, Dyson M, et al. How do eHealth programs for adolescents with depression work? A realist review of persuasive system design components in internet-based psychological therapies. J Med Internet Res 2017 Aug 09;19(8):e266 [FREE Full text] [CrossRef] [Medline]33]. The realist review methodology used in this study seeks to provide an explanatory analysis aimed at discerning what works for whom, in what circumstances, in what respect, and how [Pawson R, Greenhalgh T, Harvey G, Walshe K. Realist review--a new method of systematic review designed for complex policy interventions. J Health Serv Res Policy 2005 Jul;10 Suppl 1:21-34. [CrossRef] [Medline]34]. The emphasis on strategies, contexts, and mechanisms in our realist review can provide an in-depth understanding of how and why interventions are successful or unsuccessful [Fakoya OA, McCorry NK, Donnelly M. Loneliness and social isolation interventions for older adults: a scoping review of reviews. BMC Public Health 2020 Feb 14;20(1):129 [FREE Full text] [CrossRef] [Medline]22,Minian N, Corrin T, Lingam M, deRuiter WK, Rodak T, Taylor VH, et al. Identifying contexts and mechanisms in multiple behavior change interventions affecting smoking cessation success: a rapid realist review. BMC Public Health 2020 Jun 12;20(1):918 [FREE Full text] [CrossRef] [Medline]35], which is lacking in existing reviews on intergenerational programs [Canedo-García A, García-Sánchez JN, Pacheco-Sanz DI. A systematic review of the effectiveness of intergenerational programs. Front Psychol 2017 Oct 27;8:1882 [FREE Full text] [CrossRef] [Medline]29,Martins T, Midão L, Martínez Veiga S, Dequech L, Busse G, Bertram M, et al. Intergenerational programs review: study design and characteristics of intervention, outcomes, and effectiveness. J Intergener Relationsh 2019;17(1):93-109. [CrossRef]31]. In addition, as studies on intergenerational programs are unlikely to be randomized controlled trials, a realistic review looking at strategy, context, mechanisms, and outcomes will be more appropriate.
Objective
This review aimed to identify existing digital intergenerational programs used to reduce loneliness or social isolation among older adults and analyze them in terms of strategy, context, mechanisms, and outcomes. The findings of this study will inform the design and implementation of digital intergenerational programs to reduce loneliness or social isolation among older adults.
Methods
Overview
Our review followed the realist synthesis principles recommended by Pawson and Tilley [Pawson R, Tilley N. Realistic Evaluation. Thousand Oaks, CA, USA: Sage Publications; 1997.36] and was anchored based on the Realist And Meta-narrative Evidence Synthesis: Evolving Standards criteria [Wong G, Greenhalgh T, Westhorp G, Buckingham J, Pawson R. RAMESES publication standards: realist syntheses. BMC Med 2013 Jan 29;11:21 [FREE Full text] [CrossRef] [Medline]37]. In this review, we used the Strategy-Context-Mechanism-Outcome (S-C-M-O) configuration (Figure 1) as this review aimed to understand which digital intergenerational program strategies have been implemented and why some of these strategies were successful [Dalkin SM, Greenhalgh J, Jones D, Cunningham B, Lhussier M. What's in a mechanism? Development of a key concept in realist evaluation. Implement Sci 2015 Apr 16;10:49 [FREE Full text] [CrossRef] [Medline]38]. Therefore, the strategies were explicitly identified, along with the context in which they were implemented, the mechanism that was triggered, and which outcome was consequently generated [van Vooren NJ, Steenkamer BM, Baan CA, Drewes HW. Transforming towards sustainable health and wellbeing systems: eight guiding principles based on the experiences of nine Dutch Population Health Management initiatives. Health Policy 2020 Jan;124(1):37-43 [FREE Full text] [CrossRef] [Medline]39]. In this review, we focus on the target population, settings, and counterparts under the context. This S-C-M-O configuration has also been adopted in other realist reviews [Shams F, Wong JS, Nikoo M, Outadi A, Moazen-Zadeh E, Kamel MM, et al. Understanding eHealth cognitive behavioral therapy targeting substance use: realist review. J Med Internet Res 2021 Jan 21;23(1):e20557 [FREE Full text] [CrossRef] [Medline]40,Brown S, Lhussier M, Dalkin SM, Eaton S. Care planning: what works, for whom, and in what circumstances? A rapid realist review. Qual Health Res 2018 Dec;28(14):2250-2266. [CrossRef] [Medline]41].

Evidence Search
We performed a systematic review of the scholarly and gray literature. We searched the PubMed, Embase, CINAHL, PsycINFO (Ovid), and Social Sciences Citation Index databases for articles published between January 2000 to August 2020. Although intergenerational programs have existed for many decades, most empirical studies assessing the influence of intergenerational interactions on health-related outcomes in older adults have been conducted since 2000 [Zhong S, Lee C, Foster MJ, Bian J. Intergenerational communities: a systematic literature review of intergenerational interactions and older adults' health-related outcomes. Soc Sci Med 2020 Nov;264:113374. [CrossRef] [Medline]30,Knight T, Skouteris H, Townsend M, Hooley M. The act of giving: a systematic review of nonfamilial intergenerational interaction. J Intergener Relationsh 2014 Aug 15;12(3):257-278. [CrossRef]42]. The search in the electronic databases was performed on September 17, 2020. A search strategy with 3 components (ie, “elderly,” “digital communication,” and “intergenerational relationships”), which was devised in collaboration with an information specialist librarian, was utilized ( Search strategies in databases.Multimedia Appendix 1
Two members of the study team (JKP and HG) independently screened all identified articles. For the scholarly literature, a 2-stage screening process was used where title and abstract were reviewed in the first stage, followed by a review of full-text articles in the second stage. The disagreement rates between the 2 reviewers were 0.14% (6/4382) and 0.9% (2/226) at the title or abstract and full-text screening stages, respectively. For gray literature, the entire document was reviewed because of a lack of executive summary or equivalent in some documents. Any discrepancies in article eligibility were discussed with a third reviewer (YHK) until consensus was reached.
Quantitative, qualitative, and mixed method studies were included. Studies met the inclusion criteria if they described 2-way digital interaction involving older adults with nonfamilial younger generations or with family, were written in English, were evaluative, and described outcomes of interests including loneliness, social isolation, or other related concepts such as social participation and social connectedness. These outcomes are selected given the lack of consistent definition of social isolation in the literature [Dickens AP, Richards SH, Greaves CJ, Campbell JL. Interventions targeting social isolation in older people: a systematic review. BMC Public Health 2011 Aug 15;11:647 [FREE Full text] [CrossRef] [Medline]43] as well as the interchangeable use of “loneliness” and “social isolation” in literature [Dickens AP, Richards SH, Greaves CJ, Campbell JL. Interventions targeting social isolation in older people: a systematic review. BMC Public Health 2011 Aug 15;11:647 [FREE Full text] [CrossRef] [Medline]43]. As there are various definitions of the age range of “older” populations [Reis L, Mercer K, Boger J. Technologies for fostering intergenerational connectivity and relationships: scoping review and emergent concepts. Technol Soc 2021 Feb;64:101494. [CrossRef]32,Sabharwal S, Wilson H, Reilly P, Gupte CM. Heterogeneity of the definition of elderly age in current orthopaedic research. Springerplus 2015 Sep 17;4:516 [FREE Full text] [CrossRef] [Medline]44], a cutoff for the lower age limit was also not specified. As such, we included programs that identified themselves as focusing on older adults or grandparents [Reis L, Mercer K, Boger J. Technologies for fostering intergenerational connectivity and relationships: scoping review and emergent concepts. Technol Soc 2021 Feb;64:101494. [CrossRef]32]. The nonfamilial younger generation was defined as either being 30 years old or younger for nonfamily members based on criteria from a previous review [Martins T, Midão L, Martínez Veiga S, Dequech L, Busse G, Bertram M, et al. Intergenerational programs review: study design and characteristics of intervention, outcomes, and effectiveness. J Intergener Relationsh 2019;17(1):93-109. [CrossRef]31]. In cases where the characteristics of the intergenerational counterparts were unclear (eg, age of the nurses or coaches involved in communicating with older adults were not clearly described), we contacted the corresponding author to clarify, and only included programs where the counterparts (eg, nurses and coaches) were aged 30 years old or younger. We excluded programs (n=3) [van der Heide LA, Willems CG, Spreeuwenberg MD, Rietman J, de Witte LP. Implementation of CareTV in care for the elderly: the effects on feelings of loneliness and safety and future challenges. Technol Disabil 2012 Dec 12;24(4):283-291. [CrossRef]45-Bond GE, Burr RL, Wolf FM, Feldt K. The effects of a web-based intervention on psychosocial well-being among adults aged 60 and older with diabetes: a randomized trial. Diabetes Educ 2010;36(3):446-456. [CrossRef] [Medline]47] where the corresponding author did not respond. However, because of the small number of programs focusing solely on digital intergenerational communication (n=1) after an initial review of the literature, we included programs that allow both intergenerational and nonintergenerational digital communication (eg, peer communication). For the familial intergenerational program, we included programs that described digital interaction with family in general, as most of the quantitative studies did not specify the types of digital familial interaction, and this allows a more comprehensive view of the programs available for digital intergenerational communication. More importantly, studies have demonstrated that similar programs are likely to increase contact with younger generations such as children and grandchildren who are well versed with digital technology [Morton TA, Wilson N, Haslam C, Birney M, Kingston R, McCloskey LG. Activating and guiding the engagement of seniors with online social networking: experimental findings from the AGES 2.0 project. J Aging Health 2018 Jan;30(1):27-51. [CrossRef] [Medline]48,Zamir S, Hennessy CH, Taylor AH, Jones RB. Video-calls to reduce loneliness and social isolation within care environments for older people: an implementation study using collaborative action research. BMC Geriatr 2018 Mar 02;18(1):62 [FREE Full text] [CrossRef] [Medline]49]. Descriptive, nonevaluative articles were also included if they were related to a program that had been formally evaluated and included in the review. Articles that were not program specific (eg, commentaries or discussion papers) were excluded.
Data Extraction and Appraisal of Studies
Relevant information from the documents was extracted using a data extraction template. The studies were appraised based on their relevance and rigor. Relevance was defined as the level of contribution to the review, and rigor was defined by the methodological quality of a study conducted on a digital intergenerational program. Relevance was assessed by reviewing the details provided for (1) context (eg, user, program features, or design components), (2) mechanism: hypotheses as to how specific strategy worked or did not work, and (3) outcome: reasons for effect or lack of effect on outcomes related to loneliness or social isolation. These details were obtained by reviewing the documentation of usability evaluation, program or study protocols, and publications related to evaluations (eg, clinical intervention studies evaluating efficacy or effectiveness). In programs where authors did not describe how they thought their program worked or did not work, this was inferred by the study team after careful reading of the description of the program. The relevance was rated as low (little or no information), medium (some information), and high (well-described information). The criteria for assessment of relevance were adopted from a previous realist review [Wozney L, Huguet A, Bennett K, Radomski AD, Hartling L, Dyson M, et al. How do eHealth programs for adolescents with depression work? A realist review of persuasive system design components in internet-based psychological therapies. J Med Internet Res 2017 Aug 09;19(8):e266 [FREE Full text] [CrossRef] [Medline]33], in which “strategy” was considered in the mechanism section. The methodological quality of evidence (rigor) around each therapy was assessed using the Mixed Methods Appraisal Tool (MMAT) [Hong QN, Fàbregues S, Bartlett G, Boardman F, Cargo M, Dagenais P, et al. The Mixed Methods Appraisal Tool (MMAT) version 2018 for information professionals and researchers. Educ Inf 2018 Dec 18;34(4):285-291. [CrossRef]50]. The MMAT assesses the quality of qualitative, quantitative, and mixed methods studies. It focuses on methodological criteria and includes five core quality criteria for each of the following five categories of study design: (1) qualitative, (2) randomized controlled, (3) nonrandomized, (4) quantitative descriptive, and (5) mixed methods.
Evidence Synthesis
We examined the strategy, context, mechanism, and outcome in each program and looked for recurrent patterns of outcomes and their associated strategies, contexts, and mechanisms. We concentrated on what appeared to be recurrent patterns of contexts and outcomes in the data and then sought to explain them through the strategies and mechanisms by which they occurred. The proposed S-C-M-O configurations were analyzed at different levels of abstraction (within and across programs) to determine the most robust and plausible explanations of how, in a context, with the strategy and mechanism, the outcomes observed could be generated. The evaluation of relevance and rigor was considered when generating and revising S-C-M-O configurations. The initial list of S-C-M-O configurations was revised based on the consensus between study team members, based on the synthesis process recommended by Pawson [Pawson R. Evidence-Based Policy. Thousand Oaks, CA, USA: Sage Publications; 2006.51], including synthesis to adjudicate between rival program theories and synthesis to consider the same theory in comparative settings.
Results
Overview
List of studies excluded during full text screening.Figure 2 presents a flow diagram outlining the evidence-based search process. We retrieved 5791 records from the scholarly literature search of 5 databases (PubMed, CINAHL, PsycINFO, and Social Sciences Citation Index databases). After removing duplicates, a total of 4382 unique and potentially eligible documents were reviewed for inclusion. We excluded 4156 records and 201 documents at the title or abstract and full-text screening, respectively. The reasons for exclusion at the full-text screening stage can be found in
Multimedia Appendix 2

Structure and Delivery Features
Table 1 presents an overview of the structure and delivery features of the 27 programs. A total of 10 programs were for older adults residing in long-term residential care [Østensen E, Gjevjon ER, Øderud T, Moen A. Introducing technology for thriving in residential long-term care. J Nurs Scholarsh 2017 Jan;49(1):44-53. [CrossRef] [Medline]52] (including nursing home [Schwindenhammer TM. Videoconferencing intervention for depressive symptoms and loneliness in nursing home elders. Illinois State University. 2014.
URL: https://www.proquest.com/openview/a49fd1b55dd0416b7fcb4468a82a6475/1?pq-origsite=gscholar&cbl=18750&diss=y [accessed 2020-09-17]
53-Tsai HH, Tsai YF, Wang HH, Chang YC, Chu HH. Videoconference program enhances social support, loneliness, and depressive status of elderly nursing home residents. Aging Ment Health 2010 Nov;14(8):947-954. [CrossRef] [Medline]55], retirement homes [Barbosa Neves B, Franz R, Judges R, Beermann C, Baecker R. Can digital technology enhance social connectedness among older adults? A feasibility study. J Appl Gerontol 2019 Jan;38(1):49-72. [CrossRef] [Medline]56], aged care facilities [Loi SM, Hodson S, Huppert D, Swan J, Mazur A, Lautenschlager NT. Can a short Internet training program improve social isolation and self-esteem in older adults with psychiatric conditions? Int Psychogeriatr 2016 Oct;28(10):1737-1740. [CrossRef] [Medline]57], assisted living retirement facilities [Demiris G, Oliver DR, Hensel B, Dickey G, Rantz M, Skubic M. Use of videophones for distant caregiving: an enriching experience for families and residents in long-term care. J Gerontol Nurs 2008 Jul;34(7):50-55. [CrossRef] [Medline]58], social housing [Easton S. Digital age project evaluation report. Learning and Work Institute. 2016.
URL: https://www.linkinggenerationsni.com/portfolio-posts/digital-age-project/ [accessed 2022-05-02]
59], care homes [Zamir S. Skype on Wheels: implementation of video-calls to reduce feelings of loneliness and social isolation for older people living in care. University of Plymouth. 2020.
URL: https://pearl.plymouth.ac.uk/handle/10026.1/15790 [accessed 2020-09-17]
60], and veterans' care facility [Leone C, Lim JS, Stern A, Charles J, Black S, Baecker R. Communication technology adoption among older adult veterans: the interplay of social and cognitive factors. Aging Ment Health 2018 Dec;22(12):1666-1677. [CrossRef] [Medline]61]), 16 programs for community-dwelling older adults [Torp S, Hanson E, Hauge S, Ulstein I, Magnusson L. A pilot study of how information and communication technology may contribute to health promotion among elderly spousal carers in Norway. Health Soc Care Community 2008 Jan;16(1):75-85. [CrossRef] [Medline]62-Fokkema T, Knipscheer K. Escape loneliness by going digital: a quantitative and qualitative evaluation of a Dutch experiment in using ECT to overcome loneliness among older adults. Aging Ment Health 2007 Sep;11(5):496-504. [CrossRef] [Medline]75], and 2 programs included both community-dwelling older adults and older adults residing in long-term residential care facilities [Morton TA, Wilson N, Haslam C, Birney M, Kingston R, McCloskey LG. Activating and guiding the engagement of seniors with online social networking: experimental findings from the AGES 2.0 project. J Aging Health 2018 Jan;30(1):27-51. [CrossRef] [Medline]48,White H, McConnell E, Clipp E, Branch LG, Sloane R, Pieper C, et al. A randomized controlled trial of the psychosocial impact of providing Internet training and access to older adults. Aging Ment Health 2002 Aug;6(3):213-221. [CrossRef] [Medline]76]. Only 1 program (StoryBox) was designed for exclusive digital intergenerational interactions [Wallbaum T, Matviienko A, Ananthanarayan S, Olsson T, Heuten W, Boll S. Supporting communication between grandparents and grandchildren through tangible storytelling systems. In: Proceedings of the 2018 CHI Conference on Human Factors in Computing Systems. 2018 Apr Presented at: CHI '18; April 21-26, 2018; Montreal, Canada p. 1-12. [CrossRef]70]. Most (8/27, 30%) programs were conducted in the United States [Schwindenhammer TM. Videoconferencing intervention for depressive symptoms and loneliness in nursing home elders. Illinois State University. 2014.
URL: https://www.proquest.com/openview/a49fd1b55dd0416b7fcb4468a82a6475/1?pq-origsite=gscholar&cbl=18750&diss=y [accessed 2020-09-17]
53,Demiris G, Oliver DR, Hensel B, Dickey G, Rantz M, Skubic M. Use of videophones for distant caregiving: an enriching experience for families and residents in long-term care. J Gerontol Nurs 2008 Jul;34(7):50-55. [CrossRef] [Medline]58,Zamir S. Skype on Wheels: implementation of video-calls to reduce feelings of loneliness and social isolation for older people living in care. University of Plymouth. 2020.
URL: https://pearl.plymouth.ac.uk/handle/10026.1/15790 [accessed 2020-09-17]
60,Czaja SJ, Boot WR, Charness N, Rogers WA, Sharit J. Improving social support for older adults through technology: findings from the PRISM randomized controlled trial. Gerontologist 2018 May 08;58(3):467-477 [FREE Full text] [CrossRef] [Medline]66,Williams JM, Thyer BA, Lustria ML, Tripodi SJ, Ralston PA. Using computer-mediated communication to reduce loneliness in older adults. Florida State University. 2019.
URL: https://diginole.lib.fsu.edu/islandora/object/fsu:661182 [accessed 2020-09-17]
72,Choi NG, Pepin R, Marti CN, Stevens CJ, Bruce ML. Improving social connectedness for homebound older adults: randomized controlled trial of tele-delivered behavioral activation versus tele-delivered friendly visits. Am J Geriatr Psychiatry 2020 Jul;28(7):698-708 [FREE Full text] [CrossRef] [Medline]74,White H, McConnell E, Clipp E, Branch LG, Sloane R, Pieper C, et al. A randomized controlled trial of the psychosocial impact of providing Internet training and access to older adults. Aging Ment Health 2002 Aug;6(3):213-221. [CrossRef] [Medline]76,Fields J, Cemballi AG, Michalec C, Uchida D, Griffiths K, Cardes H, et al. In-home technology training among socially isolated older adults: findings from the tech allies program. J Appl Gerontol 2021 May;40(5):489-499. [CrossRef] [Medline]77].
Program, country | Participants | Program detail | ||||||||
Age (years) | Older adults, n | Lonely or socially isolated | Settings | Duration | Strategy | Intergenerational component | Device | Training for older adult | ||
ACTION [Torp S, Hanson E, Hauge S, Ulstein I, Magnusson L. A pilot study of how information and communication technology may contribute to health promotion among elderly spousal carers in Norway. Health Soc Care Community 2008 Jan;16(1):75-85. [CrossRef] [Medline]62], Norway | 57-85 | 19 | Not specified | Community- dwelling | 12 months | Participants received a modern broadband-linked PC, and an ICTa course consisting of three 3-hour classes dispersed over a 3-week period. | Email with grandchildren | Computer | Yes | |
ACTION (redesigned) [Savolainen L, Hanson E, Magnusson L, Gustavsson T. An Internet-based videoconferencing system for supporting frail elderly people and their carers. J Telemed Telecare 2008;14(2):79-82. [CrossRef] [Medline]63], Sweden | 66-85 | 8 | Not specified | Community- dwelling | Not specified | The app integrated a web-based multimedia system and the video communication system into a single user interface. Users could access a variety of multimedia information programs in the ACTION database and use the videoconferencing device for consultation and social purposes. | Video call with family | Computer | Yes | |
ACTIVE [Østensen E, Gjevjon ER, Øderud T, Moen A. Introducing technology for thriving in residential long-term care. J Nurs Scholarsh 2017 Jan;49(1):44-53. [CrossRef] [Medline]52], Norway | Mean 78.3 (SD 12.5) | 15 | Not specified | Long-term residential care | 1 year | Participants were provided with an internet connected tablet, free of charge, to use as they liked for an unlimited period. The iPad was set up with an individual user account, including email, Apple-ID, Skype-ID, passwords, and codes. | Messaging, video call, and email with younger generations of family, for example, grandchildren | Apple iPad | Yes | |
AGES 2.0 [Morton TA, Wilson N, Haslam C, Birney M, Kingston R, McCloskey LG. Activating and guiding the engagement of seniors with online social networking: experimental findings from the AGES 2.0 project. J Aging Health 2018 Jan;30(1):27-51. [CrossRef] [Medline]48], United Kingdom | 60-95 | 53 | Not specified | Community- dwelling and long-term residential care (care homes) | 12 months | Participants received a customized computer platform with a simplified touchscreen interface (“EasyPC”) and any necessary broadband infrastructure. “Care technologists” administered the training. | Digital interaction (email, Skype, or Facebook) with younger generations of family, for example, children and grandchildren | Customized computer platform with a simplified touchscreen interface | Yes | |
AO [Baker S, Warburton J, Hodgkin S, Pascal J. The supportive network: rural disadvantaged older people and ICT. Ageing Soc 2017;37(6):1291-1309. [CrossRef]73], Australia | 58-81 | 7 | Yes | Community- dwelling | 8 months | Participants were provided Apple iPad with cellular access, along with vouchers for data access throughout the project, and App Store card for buying apps. | Messaging with younger generations of family, for example, children | Apple iPad | Yes | |
Collage and storytelling [Vutborg R, Kjeldskov J, Paay J, Pedell S, Vetere F. Supporting young children's communication with adult relatives across time zones. In: Proceedings of the 23rd Australian Computer-Human Interaction Conference. 2011 Nov Presented at: OzCHI '11; November 28-December 2, 2011; Canberra, Australia p. 291-300. [CrossRef]71], Australia | Not specified | 3 | Not specified | Community- dwelling | 3 weeks | The system used combines the “Collage” component and the “Storytelling” component. | Digital intergenerational play and storytelling with grandchildren | Touch screen monitor | No | |
Demiris et al [Demiris G, Oliver DR, Hensel B, Dickey G, Rantz M, Skubic M. Use of videophones for distant caregiving: an enriching experience for families and residents in long-term care. J Gerontol Nurs 2008 Jul;34(7):50-55. [CrossRef] [Medline]58], United States | >65 | 4 | Not specified | Long-term residential care (assisted living retirement facility) | 3 months | The videophone can display 3 kinds of real-time images during a video call: self, other party, and a combination of both, depending on user preference. It plugs into a regular telephone and does not interfere with its use. A video call is possible only when both parties have videophone units and consent to a video call. | Video call and email with younger generations of family, for example, grandchildren | Video-telephone | No | |
Digital age [Easton S. Digital age project evaluation report. Learning and Work Institute. 2016. URL: https://www.linkinggenerationsni.com/portfolio-posts/digital-age-project/ [accessed 2022-05-02] 59], Northern Ireland | Not specified | 82 | Not specified | Long-term residential care (social housing) | 10 weeks | Digital Age consisted of a free, in-house, 10-week IT course for residents. The program also provided free IT hardware for each participating housing scheme, free web-based digital toolkits for older learners and their supporters, and a series of intergenerational digital projects to encourage links between older and younger people, further develop residents’ digital capabilities and help to sustain the program beyond the program lifetime. | Video call with family | Not specified | Yes | |
Esc@pe [Fokkema T, Knipscheer K. Escape loneliness by going digital: a quantitative and qualitative evaluation of a Dutch experiment in using ECT to overcome loneliness among older adults. Aging Ment Health 2007 Sep;11(5):496-504. [CrossRef] [Medline]75], Netherlands | Mean 66 | 12 | Yes | Community- dwelling | 3 years | At the start of the project, participants were given five 2-hour lessons at home by experienced teachers. During these lessons, the participants learned how to email and how to use the internet. During the rest of the project, the participants were supported and coached by visiting volunteers who had also paid home visits to the participants once every 2 or 3 weeks before the start of the pilot project. | Using internet and email to communicate with family | Computer | Yes | |
InTouch [Leone C, Lim JS, Stern A, Charles J, Black S, Baecker R. Communication technology adoption among older adult veterans: the interplay of social and cognitive factors. Aging Ment Health 2018 Dec;22(12):1666-1677. [CrossRef] [Medline]61], Canada | Mean 92.2 (SD 3.0) | 11 | Not specified | Long-term residential care | 12 weeks | Veteran and volunteer participants were each given an iPad with the InTouch app on it, as well as a detailed instructions manual. | Using InTouch app to communicate with family | Apple iPad | Yes | |
LINE [Tsai HH, Cheng CY, Shieh WY, Chang YC. Effects of a smartphone-based videoconferencing program for older nursing home residents on depression, loneliness, and quality of life: a quasi-experimental study. BMC Geriatr 2020 Jan 28;20(1):27 [FREE Full text] [CrossRef] [Medline]54], Taiwan | Mean 81.1 (SD 8.5) | 32 | Not specified | Long-term residential care (nursing home) | 6 months | Participants interacted with their family members once a week for 6 months using a smartphone and the “LINE” app. Discussion topics were provided to nurses and the participants, such as their meals, organized activities, and “news” on nursing home life. | Video call with family | Smartphone | No | |
Loi et al [Loi SM, Hodson S, Huppert D, Swan J, Mazur A, Lautenschlager NT. Can a short Internet training program improve social isolation and self-esteem in older adults with psychiatric conditions? Int Psychogeriatr 2016 Oct;28(10):1737-1740. [CrossRef] [Medline]57], Australia | Mean 69.9 | 5 | Not specified | Long-term residential care (aged care facility) | 6 weeks | Structured 6-week, twice weekly program of 45-minute duration based on a local program was used for older adults (internet for Seniors). Apple iPads were used. | Digital interaction with family | Apple iPad | Yes | |
Media Parcels [Zaine I, Frohlich DM, Rodrigues KR, Cunha BC, Orlando AF, Scalco LF, et al. Promoting social connection and deepening relations among older adults: design and qualitative evaluation of media parcels. J Med Internet Res 2019 Oct 03;21(10):e14112 [FREE Full text] [CrossRef] [Medline]64], United Kingdom | 82 | 1 | Not specified | Community- dwelling | Not specified | A facilitator, upon specific requests to participants, collects media and wraps them in text commentary, bringing out their memories and meaning. Next, the facilitator passes the wrapped media parcel to a target person, who in turn unwraps them. | Digital interaction with children | Not specified | Not specified | |
MSNb or Skype [Tsai HH, Tsai YF, Wang HH, Chang YC, Chu HH. Videoconference program enhances social support, loneliness, and depressive status of elderly nursing home residents. Aging Ment Health 2010 Nov;14(8):947-954. [CrossRef] [Medline]55],Taiwan | Mean 74.4 (SD 10.2) | 24 | Not specified | Long-term residential care (nursing home) | 3 months | The videoconference program was designed for once a week (the in-person visiting frequency for most families) and to last for 3 months to provide time for adjustment to a new program. The residents were helped to use the videoconference technology by a trained research assistant, who spent at least 5 minutes per week with the residents at the appointment time. | Video call with family | Computer | No | |
Neves et al [Barbosa Neves B, Franz R, Judges R, Beermann C, Baecker R. Can digital technology enhance social connectedness among older adults? A feasibility study. J Appl Gerontol 2019 Jan;38(1):49-72. [CrossRef] [Medline]56], Canada | 74-95 | 12 | Not specified | Long-term residential care (retirement home) | 3 months | The app allowed residents to send and receive photos, audio, video, and text messages with sent messages being predefined to increase simplicity. The residents’ contacts could respond using their own emails and devices. | Using app to communicate with younger generations of family, for example, children | Apple iPad | Yes | |
Plymouth SeniorNet [Jones RB, Ashurst EJ, Atkey J, Duffy B. Older people going online: its value and before-after evaluation of volunteer support. J Med Internet Res 2015 May 18;17(5):e122 [FREE Full text] [CrossRef] [Medline]65], United Kingdom | One-to-one help: mean 79.0 (SD 7.5); group help: mean 74.3 (SD 8.2) | 144 | Not specified | Community- dwelling | Depends | Sessions by volunteers covered basic computer use, how to get on the web and search the internet, shopping, email, Skype or FaceTime, and web-based news and entertainment. | Digital interaction with family | Computer | Yes | |
PRISM [Czaja SJ, Boot WR, Charness N, Rogers WA, Sharit J. Improving social support for older adults through technology: findings from the PRISM randomized controlled trial. Gerontologist 2018 May 08;58(3):467-477 [FREE Full text] [CrossRef] [Medline]66], United States | Mean 76.9 (SD 7.3) | 300 | Not specified | Community- dwelling | 12 months | PRISM software app included internet access, an annotated resource guide, a dynamic classroom feature, a calendar, a photo feature, email, games, and web-based help. | Digital interaction with family | Computer | Yes | |
Skype [Schwindenhammer TM. Videoconferencing intervention for depressive symptoms and loneliness in nursing home elders. Illinois State University. 2014. URL: https://www.proquest.com/openview/a49fd1b55dd0416b7fcb4468a82a6475/1?pq-origsite=gscholar&cbl=18750&diss=y [accessed 2020-09-17] 53], United States | 71-97 | 40 | Not specified | Long-term residential care (nursing home) | 14 weeks | The Skype videoconferencing intervention took place on a weekly for a total of 10 sessions over a 14-week period in a private room at the nursing home. | Video call with family | Computer | No | |
Skype on Wheel [Zamir S. Skype on Wheels: implementation of video-calls to reduce feelings of loneliness and social isolation for older people living in care. University of Plymouth. 2020. URL: https://pearl.plymouth.ac.uk/handle/10026.1/15790 [accessed 2020-09-17] 60], United States | Not specified | 20 | Not specified | Long-term residential care (care home) | 6 weeks | Students from local school and older adults across 3 care homes in engaged in Skype video calls over a 6-week study. Residents were supported by care staff; students accessed Skype from school laptops. A conversational aid was trialed with students to assist their conversation with an older generation. | Video call with students | Wheeled device that could hold an iPad and handset | No | |
StoryBox [Wallbaum T, Matviienko A, Ananthanarayan S, Olsson T, Heuten W, Boll S. Supporting communication between grandparents and grandchildren through tangible storytelling systems. In: Proceedings of the 2018 CHI Conference on Human Factors in Computing Systems. 2018 Apr Presented at: CHI '18; April 21-26, 2018; Montreal, Canada p. 1-12. [CrossRef]70], country not specified | 63-76 | 8 | Not specified | Community- dwelling | 2-4 weeks | StoryBox alleviates the barriers of communication between different generations. For young grandchildren, this often means the sharing of crafts, drawings, stickers, and short exclamations. For grandparents, the device provides a way to digitize analog memories and use handwriting for communication. | Digital sharing of photos and audio recordings with grandchildren | Smartphone and tablet | No | |
Tech Allies [Fields J, Cemballi AG, Michalec C, Uchida D, Griffiths K, Cardes H, et al. In-home technology training among socially isolated older adults: findings from the tech allies program. J Appl Gerontol 2021 May;40(5):489-499. [CrossRef] [Medline]77], United States | Mean 75 (SD 7.9) | 83 | Yes | Community- dwelling | 2 months | Participants took part in 8 weekly, 1:1 digital training sessions. Participants each received a tablet, a tablet case, a stylus, broadband access or a hot spot device, and a certificate of completion at the end of the program. | Digital interaction with family | Tablet | Yes | |
Tele-BA [Choi NG, Pepin R, Marti CN, Stevens CJ, Bruce ML. Improving social connectedness for homebound older adults: randomized controlled trial of tele-delivered behavioral activation versus tele-delivered friendly visits. Am J Geriatr Psychiatry 2020 Jul;28(7):698-708 [FREE Full text] [CrossRef] [Medline]74], United States | Mean 74.4 (SD 8.2) | 43 | Yes | Community- dwelling | 12 weeks | Lay counselors delivered videoconference behavioral activation | Videoconference behavioral activation by lay counselors | Computer | No | |
Telesenior [Arnaert A, Delesie L. Effectiveness of video-telephone nursing care for the homebound elderly. Can J Nurs Res 2007 Mar;39(1):20-36. [Medline]67], Belgium | Mean 72 (SD 9.3) | 71 | Not specified | Community- dwelling | Not specified | The telenurses delivered psychosocial support and educational interventions based on 3 principles: contact and communication, safety and protection, and care mediation. | Video call with nurse | Video-telephone | No | |
Tlatoque [Cornejo R, Tentori M, Favela J. Enriching in-person encounters through social media: a study on family connectedness for the elderly. Int J Human Comput Stud 2013 Sep;71(9):889-899. [CrossRef]68], Mexico | Not specified | 2 | Not specified | Community- dwelling | 21 weeks | Tlatoque communicates to Facebook site to expose photographs in the participant’s home and provides means of reciprocating information into Facebook. | Digital interaction with younger generations of family, for example, children and grandchildren | Digital picture frame with wireless capabilities or PC with multitouch screen | Yes | |
White et al [White H, McConnell E, Clipp E, Branch LG, Sloane R, Pieper C, et al. A randomized controlled trial of the psychosocial impact of providing Internet training and access to older adults. Aging Ment Health 2002 Aug;6(3):213-221. [CrossRef] [Medline]76], United States | Mean 71 (SD 12) | 48 | Not specified | Community- dwelling and long-term residential care (nursing facility) | 5 months | Participants received 9 hours of small group training in 6 sessions over 2 weeks. Computers were available for continued use over 5 months and the trainer was available 2 hours per week for questions. | Digital interaction with family | Computer | Yes | |
Williams et al [Williams JM, Thyer BA, Lustria ML, Tripodi SJ, Ralston PA. Using computer-mediated communication to reduce loneliness in older adults. Florida State University. 2019. URL: https://diginole.lib.fsu.edu/islandora/object/fsu:661182 [accessed 2020-09-17] 72], United States | Phase 1: 59-86; phase 2 54-82 | Phase 1: 16; phase 2: 29 | Yes | Community- dwelling | 2 weeks | The course on computer-mediated communication lasted for six 2- hour classes. Each course followed the same module: introduction to computer-mediated communication, email and instant messaging, microblogging: Twitter, social networking sites: Facebook, video chat, and web-based safety. | Digital interaction with family | Computer | Yes | |
You, me and television [Coelho J, Rito F, Duarte C. “You, me and TV” — fighting social isolation of older adults with Facebook, TV and multimodality. Int J Hum Comput Stud 2017 Feb;98:38-50. [CrossRef]69], Portugal | 65-73 | 3 | Not specified | Community- dwelling | 3-6 weeks | The system has three main features: (1) user feed; (2) managing groups of friends; and (3) photo viewing and sharing. | Digital interaction with family | Television | Yes |
aICT: information and communications technology.
bMSN: Microsoft Network.
Level of Contribution and Methodological Quality
An overview of the level of contribution and methodological quality of the documents elaborating the 27 programs is presented in Mixed Methods Appraisal Tool appraisal for documents evaluating digital intergenerational program.Table 2. On the basis of the level of contribution assessment, 20 programs were rated as having a high level of contribution to the context, mechanism, and outcome. Across the programs, descriptions of mechanisms and outcomes were less developed than descriptions of contexts. All studies met at least 2 of the 5 MMAT criteria. The detailed MMAT appraisal of documents evaluating the digital intergenerational program is shown in
Multimedia Appendix 3
Program | Quality appraisal | Associated MMATa scores | |||
Context | Mechanismb | Outcome | |||
ACTION | High | Low | Low | 5 [Torp S, Hanson E, Hauge S, Ulstein I, Magnusson L. A pilot study of how information and communication technology may contribute to health promotion among elderly spousal carers in Norway. Health Soc Care Community 2008 Jan;16(1):75-85. [CrossRef] [Medline]62] | |
ACTION (redesigned) | High | Low | Low | 2 [Savolainen L, Hanson E, Magnusson L, Gustavsson T. An Internet-based videoconferencing system for supporting frail elderly people and their carers. J Telemed Telecare 2008;14(2):79-82. [CrossRef] [Medline]63] | |
ACTIVE | High | Medium | Low | 5 [Østensen E, Gjevjon ER, Øderud T, Moen A. Introducing technology for thriving in residential long-term care. J Nurs Scholarsh 2017 Jan;49(1):44-53. [CrossRef] [Medline]52] | |
AGES 2.0 | High | High | High | 3 [Morton TA, Wilson N, Haslam C, Birney M, Kingston R, McCloskey LG. Activating and guiding the engagement of seniors with online social networking: experimental findings from the AGES 2.0 project. J Aging Health 2018 Jan;30(1):27-51. [CrossRef] [Medline]48] | |
AO | High | High | Medium | 5 [Baker S, Warburton J, Hodgkin S, Pascal J. The supportive network: rural disadvantaged older people and ICT. Ageing Soc 2017;37(6):1291-1309. [CrossRef]73] | |
Collage and storytelling | High | High | High | 4 [Vutborg R, Kjeldskov J, Paay J, Pedell S, Vetere F. Supporting young children's communication with adult relatives across time zones. In: Proceedings of the 23rd Australian Computer-Human Interaction Conference. 2011 Nov Presented at: OzCHI '11; November 28-December 2, 2011; Canberra, Australia p. 291-300. [CrossRef]71] | |
Demiris et al | High | Medium | Low | 4 [Demiris G, Oliver DR, Hensel B, Dickey G, Rantz M, Skubic M. Use of videophones for distant caregiving: an enriching experience for families and residents in long-term care. J Gerontol Nurs 2008 Jul;34(7):50-55. [CrossRef] [Medline]58] | |
Digital age | High | High | Low | 5 [Easton S. Digital age project evaluation report. Learning and Work Institute. 2016. URL: https://www.linkinggenerationsni.com/portfolio-posts/digital-age-project/ [accessed 2022-05-02] 59], 5 [The Digital Age Project 2014 -2017. Linking Generations Northern Ireland. 2018. URL: https://www.linkinggenerationsni.com/project/the-digital-age-project-2014-2017/ [accessed 2022-12-06] 78] | |
Esc@pe | High | High | High | 5 [Fokkema T, Knipscheer K. Escape loneliness by going digital: a quantitative and qualitative evaluation of a Dutch experiment in using ECT to overcome loneliness among older adults. Aging Ment Health 2007 Sep;11(5):496-504. [CrossRef] [Medline]75] | |
InTouch | High | High | High | 5 [Leone C, Lim JS, Stern A, Charles J, Black S, Baecker R. Communication technology adoption among older adult veterans: the interplay of social and cognitive factors. Aging Ment Health 2018 Dec;22(12):1666-1677. [CrossRef] [Medline]61] | |
LINE | High | High | High | 5 [Tsai HH, Cheng CY, Shieh WY, Chang YC. Effects of a smartphone-based videoconferencing program for older nursing home residents on depression, loneliness, and quality of life: a quasi-experimental study. BMC Geriatr 2020 Jan 28;20(1):27 [FREE Full text] [CrossRef] [Medline]54] | |
Loi et al | High | High | Low | 4 [Loi SM, Hodson S, Huppert D, Swan J, Mazur A, Lautenschlager NT. Can a short Internet training program improve social isolation and self-esteem in older adults with psychiatric conditions? Int Psychogeriatr 2016 Oct;28(10):1737-1740. [CrossRef] [Medline]57] | |
Media parcels | High | High | High | 5 [Zaine I, Frohlich DM, Rodrigues KR, Cunha BC, Orlando AF, Scalco LF, et al. Promoting social connection and deepening relations among older adults: design and qualitative evaluation of media parcels. J Med Internet Res 2019 Oct 03;21(10):e14112 [FREE Full text] [CrossRef] [Medline]64] | |
MSNc or Skype | High | High | High | 5 [Tsai HH, Tsai YF, Wang HH, Chang YC, Chu HH. Videoconference program enhances social support, loneliness, and depressive status of elderly nursing home residents. Aging Ment Health 2010 Nov;14(8):947-954. [CrossRef] [Medline]55], 5 [Tsai HH, Tsai YF. Changes in depressive symptoms, social support, and loneliness over 1 year after a minimum 3-month videoconference program for older nursing home residents. J Med Internet Res 2011 Nov 15;13(4):e93 [FREE Full text] [CrossRef] [Medline]79] | |
Neves et al | High | High | High | 5 [Barbosa Neves B, Franz R, Judges R, Beermann C, Baecker R. Can digital technology enhance social connectedness among older adults? A feasibility study. J Appl Gerontol 2019 Jan;38(1):49-72. [CrossRef] [Medline]56] | |
Skype | High | High | High | 5 [Schwindenhammer TM. Videoconferencing intervention for depressive symptoms and loneliness in nursing home elders. Illinois State University. 2014. URL: https://www.proquest.com/openview/a49fd1b55dd0416b7fcb4468a82a6475/1?pq-origsite=gscholar&cbl=18750&diss=y [accessed 2020-09-17] 53] | |
Skype on Wheel | High | High | High | 5 [Zamir S. Skype on Wheels: implementation of video-calls to reduce feelings of loneliness and social isolation for older people living in care. University of Plymouth. 2020. URL: https://pearl.plymouth.ac.uk/handle/10026.1/15790 [accessed 2020-09-17] 60], 5 [Zamir S, Hennessy CH, Taylor AH, Jones RB. Video-calls to reduce loneliness and social isolation within care environments for older people: an implementation study using collaborative action research. BMC Geriatr 2018 Mar 02;18(1):62 [FREE Full text] [CrossRef] [Medline]49] | |
StoryBox | High | High | High | 2 [Wallbaum T, Matviienko A, Ananthanarayan S, Olsson T, Heuten W, Boll S. Supporting communication between grandparents and grandchildren through tangible storytelling systems. In: Proceedings of the 2018 CHI Conference on Human Factors in Computing Systems. 2018 Apr Presented at: CHI '18; April 21-26, 2018; Montreal, Canada p. 1-12. [CrossRef]70] | |
Tech Allies | High | High | High | 3 [Fields J, Cemballi AG, Michalec C, Uchida D, Griffiths K, Cardes H, et al. In-home technology training among socially isolated older adults: findings from the tech allies program. J Appl Gerontol 2021 May;40(5):489-499. [CrossRef] [Medline]77] | |
Tele-BA | High | High | High | 3 [Choi NG, Pepin R, Marti CN, Stevens CJ, Bruce ML. Improving social connectedness for homebound older adults: randomized controlled trial of tele-delivered behavioral activation versus tele-delivered friendly visits. Am J Geriatr Psychiatry 2020 Jul;28(7):698-708 [FREE Full text] [CrossRef] [Medline]74], 3 [Choi NG, Marti CN, Wilson NL, Chen GJ, Sirrianni L, Hegel MT, et al. Effect of telehealth treatment by lay counselors vs by clinicians on depressive symptoms among older adults who are homebound: a randomized clinical trial. JAMA Netw Open 2020 Aug 03;3(8):e2015648 [FREE Full text] [CrossRef] [Medline]80] | |
Telesenior | High | High | High | 4 [Arnaert A, Delesie L. Effectiveness of video-telephone nursing care for the homebound elderly. Can J Nurs Res 2007 Mar;39(1):20-36. [Medline]67] | |
Tlatoque | High | High | High | 5 [Cornejo R, Tentori M, Favela J. Enriching in-person encounters through social media: a study on family connectedness for the elderly. Int J Human Comput Stud 2013 Sep;71(9):889-899. [CrossRef]68] | |
PRISM | High | High | High | 4 [Czaja SJ, Boot WR, Charness N, Rogers WA, Sharit J. Improving social support for older adults through technology: findings from the PRISM randomized controlled trial. Gerontologist 2018 May 08;58(3):467-477 [FREE Full text] [CrossRef] [Medline]66] | |
White et al | High | High | High | 3 [White H, McConnell E, Clipp E, Branch LG, Sloane R, Pieper C, et al. A randomized controlled trial of the psychosocial impact of providing Internet training and access to older adults. Aging Ment Health 2002 Aug;6(3):213-221. [CrossRef] [Medline]76] | |
Williams et al | High | High | High | 5 [Williams JM, Thyer BA, Lustria ML, Tripodi SJ, Ralston PA. Using computer-mediated communication to reduce loneliness in older adults. Florida State University. 2019. URL: https://diginole.lib.fsu.edu/islandora/object/fsu:661182 [accessed 2020-09-17] 72] | |
Plymouth SeniorNet | High | High | High | 5 [Jones RB, Ashurst EJ, Atkey J, Duffy B. Older people going online: its value and before-after evaluation of volunteer support. J Med Internet Res 2015 May 18;17(5):e122 [FREE Full text] [CrossRef] [Medline]65] | |
You, me and television | High | High | High | 2 [Coelho J, Rito F, Duarte C. “You, me and TV” — fighting social isolation of older adults with Facebook, TV and multimodality. Int J Hum Comput Stud 2017 Feb;98:38-50. [CrossRef]69] |
aMMAT: Mixed Methods Appraisal Tool.
bConsists of strategy and mechanism.
cMSN: Microsoft Network.
S-C-M-O Configurations
Of the candidate S-C-M-O configurations based on the authors’ description ( Candidate Strategy-Context-Mechanism-Outcome configurations for digital intergenerational programs based on the authors’ description.Multimedia Appendix 4
Figures 3-Tilvis RS, Routasalo P, Karppinen H, Strandberg TE, Kautiainen H, Pitkala KH. Social isolation, social activity and loneliness as survival indicators in old age; a nationwide survey with a 7-year follow-up. Eur Geriatr Med 2012 Feb;3(1):18-22 [FREE Full text] [CrossRef]6). We present the configurations with key examples of strategies, contexts, mechanisms, and outcomes from the reviewed documents. S-C-M-O configurations 1 and 2 focused on community-dwelling older adults, S-C-M-O configuration 3 focused on older adults residing in long-term residential care facilities, and S-C-M-O configuration 4 focused on older adults who are lonely.




S-C-M-O Configuration 1
A total of 4 programs contributed to this S-C-M-O configuration: ACTION [Torp S, Hanson E, Hauge S, Ulstein I, Magnusson L. A pilot study of how information and communication technology may contribute to health promotion among elderly spousal carers in Norway. Health Soc Care Community 2008 Jan;16(1):75-85. [CrossRef] [Medline]62], Plymouth SeniorNet [Jones RB, Ashurst EJ, Atkey J, Duffy B. Older people going online: its value and before-after evaluation of volunteer support. J Med Internet Res 2015 May 18;17(5):e122 [FREE Full text] [CrossRef] [Medline]65], PRISM [Czaja SJ, Boot WR, Charness N, Rogers WA, Sharit J. Improving social support for older adults through technology: findings from the PRISM randomized controlled trial. Gerontologist 2018 May 08;58(3):467-477 [FREE Full text] [CrossRef] [Medline]66], and Tlatoque [Cornejo R, Tentori M, Favela J. Enriching in-person encounters through social media: a study on family connectedness for the elderly. Int J Human Comput Stud 2013 Sep;71(9):889-899. [CrossRef]68]. For community-dwelling older adults, provision of access to and training in digital technology may increase their self-efficacy in digital devices, thereby increasing the use of digital-based communication with family (Figure 3). The outcomes observed for the 4 programs included reduced loneliness [Jones RB, Ashurst EJ, Atkey J, Duffy B. Older people going online: its value and before-after evaluation of volunteer support. J Med Internet Res 2015 May 18;17(5):e122 [FREE Full text] [CrossRef] [Medline]65,Czaja SJ, Boot WR, Charness N, Rogers WA, Sharit J. Improving social support for older adults through technology: findings from the PRISM randomized controlled trial. Gerontologist 2018 May 08;58(3):467-477 [FREE Full text] [CrossRef] [Medline]66], reduced social isolation [Czaja SJ, Boot WR, Charness N, Rogers WA, Sharit J. Improving social support for older adults through technology: findings from the PRISM randomized controlled trial. Gerontologist 2018 May 08;58(3):467-477 [FREE Full text] [CrossRef] [Medline]66], and increased frequency of contact [Torp S, Hanson E, Hauge S, Ulstein I, Magnusson L. A pilot study of how information and communication technology may contribute to health promotion among elderly spousal carers in Norway. Health Soc Care Community 2008 Jan;16(1):75-85. [CrossRef] [Medline]62,Cornejo R, Tentori M, Favela J. Enriching in-person encounters through social media: a study on family connectedness for the elderly. Int J Human Comput Stud 2013 Sep;71(9):889-899. [CrossRef]68].
In all 4 programs, the devices were provided free of charge for older adults. Of the 4 programs, 2 (PRISM [Czaja SJ, Boot WR, Charness N, Rogers WA, Sharit J. Improving social support for older adults through technology: findings from the PRISM randomized controlled trial. Gerontologist 2018 May 08;58(3):467-477 [FREE Full text] [CrossRef] [Medline]66] and Tlatoque [Cornejo R, Tentori M, Favela J. Enriching in-person encounters through social media: a study on family connectedness for the elderly. Int J Human Comput Stud 2013 Sep;71(9):889-899. [CrossRef]68]) used apps or systems specially designed for older adults, which may have “eased the adoption of the technology” [Cornejo R, Tentori M, Favela J. Enriching in-person encounters through social media: a study on family connectedness for the elderly. Int J Human Comput Stud 2013 Sep;71(9):889-899. [CrossRef]68]. The other programs used commercially available digital communication modes, for example, email (n=2) [Torp S, Hanson E, Hauge S, Ulstein I, Magnusson L. A pilot study of how information and communication technology may contribute to health promotion among elderly spousal carers in Norway. Health Soc Care Community 2008 Jan;16(1):75-85. [CrossRef] [Medline]62,Jones RB, Ashurst EJ, Atkey J, Duffy B. Older people going online: its value and before-after evaluation of volunteer support. J Med Internet Res 2015 May 18;17(5):e122 [FREE Full text] [CrossRef] [Medline]65] and Skype (n=1) [Jones RB, Ashurst EJ, Atkey J, Duffy B. Older people going online: its value and before-after evaluation of volunteer support. J Med Internet Res 2015 May 18;17(5):e122 [FREE Full text] [CrossRef] [Medline]65].
The mode of training included one-to-one, group, and a combination of one-to-one and group training. In the Plymouth SeniorNet program, older adults attending group sessions appeared to have a greater reduction in loneliness as compared with those in one-to-one sessions, although the results from the two modes of training may not be comparable, as the allocation was not random [Jones RB, Ashurst EJ, Atkey J, Duffy B. Older people going online: its value and before-after evaluation of volunteer support. J Med Internet Res 2015 May 18;17(5):e122 [FREE Full text] [CrossRef] [Medline]65]. Participants in the Plymouth SeniorNet program also mentioned that training conducted by someone closer to their age was important [Jones RB, Ashurst EJ, Atkey J, Duffy B. Older people going online: its value and before-after evaluation of volunteer support. J Med Internet Res 2015 May 18;17(5):e122 [FREE Full text] [CrossRef] [Medline]65].
S-C-M-O Configuration 2
One program (Telesenior [Arnaert A, Delesie L. Effectiveness of video-telephone nursing care for the homebound elderly. Can J Nurs Res 2007 Mar;39(1):20-36. [Medline]67]) contributed to the S-C-M-O configuration. For community-dwelling older adults, digital psychosocial support and educational interventions from nurses were useful in reducing loneliness (Figure 4). In the Telesenior program, digital psychosocial support and educational interventions were delivered through video-telephone to homebound older adults based on 3 principles: contact and communication, safety and protection, and care mediation [Arnaert A, Delesie L. Effectiveness of video-telephone nursing care for the homebound elderly. Can J Nurs Res 2007 Mar;39(1):20-36. [Medline]67]. The digital psychosocial support and educational interventions from nurses can provide “a network of relationships which the older adults felt accepted, had common interests and concerns, and found help, advice, and support” [Arnaert A, Delesie L. Effectiveness of video-telephone nursing care for the homebound elderly. Can J Nurs Res 2007 Mar;39(1):20-36. [Medline]67]. In the Telesenior program, older adults who were older (>66 years old), were widowed, lived alone, had financial problems, and used several health and social services showed improvement in feelings of social loneliness after participating in the program [Arnaert A, Delesie L. Effectiveness of video-telephone nursing care for the homebound elderly. Can J Nurs Res 2007 Mar;39(1):20-36. [Medline]67].
S-C-M-O Configuration 3
A total of 7 programs—ACTIVE [Østensen E, Gjevjon ER, Øderud T, Moen A. Introducing technology for thriving in residential long-term care. J Nurs Scholarsh 2017 Jan;49(1):44-53. [CrossRef] [Medline]52], Demiris et al [Demiris G, Oliver DR, Hensel B, Dickey G, Rantz M, Skubic M. Use of videophones for distant caregiving: an enriching experience for families and residents in long-term care. J Gerontol Nurs 2008 Jul;34(7):50-55. [CrossRef] [Medline]58], Digital Age [Easton S. Digital age project evaluation report. Learning and Work Institute. 2016.
URL: https://www.linkinggenerationsni.com/portfolio-posts/digital-age-project/ [accessed 2022-05-02]
59], LINE [Tsai HH, Cheng CY, Shieh WY, Chang YC. Effects of a smartphone-based videoconferencing program for older nursing home residents on depression, loneliness, and quality of life: a quasi-experimental study. BMC Geriatr 2020 Jan 28;20(1):27 [FREE Full text] [CrossRef] [Medline]54], Microsoft Network (MSN) or Skype [Tsai HH, Tsai YF, Wang HH, Chang YC, Chu HH. Videoconference program enhances social support, loneliness, and depressive status of elderly nursing home residents. Aging Ment Health 2010 Nov;14(8):947-954. [CrossRef] [Medline]55], Skype [Schwindenhammer TM. Videoconferencing intervention for depressive symptoms and loneliness in nursing home elders. Illinois State University. 2014.
URL: https://www.proquest.com/openview/a49fd1b55dd0416b7fcb4468a82a6475/1?pq-origsite=gscholar&cbl=18750&diss=y [accessed 2020-09-17]
53], and Skype on Wheel [Zamir S. Skype on Wheels: implementation of video-calls to reduce feelings of loneliness and social isolation for older people living in care. University of Plymouth. 2020.
URL: https://pearl.plymouth.ac.uk/handle/10026.1/15790 [accessed 2020-09-17]
60]—contributed to this S-C-M-O configuration. In this review, we found that video calls with students or families may be useful in reducing loneliness among older adults residing in long-term residential care facilities (Figure 5). Only 1 program (Skype on Wheel [Zamir S. Skype on Wheels: implementation of video-calls to reduce feelings of loneliness and social isolation for older people living in care. University of Plymouth. 2020.
URL: https://pearl.plymouth.ac.uk/handle/10026.1/15790 [accessed 2020-09-17]
60]) evaluated intergenerational communication with students from a local school, whereas the other 6 programs (LINE [Tsai HH, Cheng CY, Shieh WY, Chang YC. Effects of a smartphone-based videoconferencing program for older nursing home residents on depression, loneliness, and quality of life: a quasi-experimental study. BMC Geriatr 2020 Jan 28;20(1):27 [FREE Full text] [CrossRef] [Medline]54], MSN or Skype [Tsai HH, Tsai YF, Wang HH, Chang YC, Chu HH. Videoconference program enhances social support, loneliness, and depressive status of elderly nursing home residents. Aging Ment Health 2010 Nov;14(8):947-954. [CrossRef] [Medline]55], Skype [Schwindenhammer TM. Videoconferencing intervention for depressive symptoms and loneliness in nursing home elders. Illinois State University. 2014.
URL: https://www.proquest.com/openview/a49fd1b55dd0416b7fcb4468a82a6475/1?pq-origsite=gscholar&cbl=18750&diss=y [accessed 2020-09-17]
53], ACTIVE [Østensen E, Gjevjon ER, Øderud T, Moen A. Introducing technology for thriving in residential long-term care. J Nurs Scholarsh 2017 Jan;49(1):44-53. [CrossRef] [Medline]52], Demiris et al [Demiris G, Oliver DR, Hensel B, Dickey G, Rantz M, Skubic M. Use of videophones for distant caregiving: an enriching experience for families and residents in long-term care. J Gerontol Nurs 2008 Jul;34(7):50-55. [CrossRef] [Medline]58], and Digital Age [Easton S. Digital age project evaluation report. Learning and Work Institute. 2016.
URL: https://www.linkinggenerationsni.com/portfolio-posts/digital-age-project/ [accessed 2022-05-02]
59]) were designed to facilitate communication with family members or friends of older adults in long-term residential care facilities. It has been hypothesized that a video call helps in language interaction as well as verbal and nonverbal elements of communication. Video calls may also aid in promoting a social presence for older adults and family members [Demiris G, Oliver DR, Hensel B, Dickey G, Rantz M, Skubic M. Use of videophones for distant caregiving: an enriching experience for families and residents in long-term care. J Gerontol Nurs 2008 Jul;34(7):50-55. [CrossRef] [Medline]58]. The outcomes observed for the 7 programs included reduced loneliness [Schwindenhammer TM. Videoconferencing intervention for depressive symptoms and loneliness in nursing home elders. Illinois State University. 2014.
URL: https://www.proquest.com/openview/a49fd1b55dd0416b7fcb4468a82a6475/1?pq-origsite=gscholar&cbl=18750&diss=y [accessed 2020-09-17]
53,Tsai HH, Cheng CY, Shieh WY, Chang YC. Effects of a smartphone-based videoconferencing program for older nursing home residents on depression, loneliness, and quality of life: a quasi-experimental study. BMC Geriatr 2020 Jan 28;20(1):27 [FREE Full text] [CrossRef] [Medline]54,Demiris G, Oliver DR, Hensel B, Dickey G, Rantz M, Skubic M. Use of videophones for distant caregiving: an enriching experience for families and residents in long-term care. J Gerontol Nurs 2008 Jul;34(7):50-55. [CrossRef] [Medline]58,Tsai HH, Tsai YF. Changes in depressive symptoms, social support, and loneliness over 1 year after a minimum 3-month videoconference program for older nursing home residents. J Med Internet Res 2011 Nov 15;13(4):e93 [FREE Full text] [CrossRef] [Medline]79], reduced social isolation [Demiris G, Oliver DR, Hensel B, Dickey G, Rantz M, Skubic M. Use of videophones for distant caregiving: an enriching experience for families and residents in long-term care. J Gerontol Nurs 2008 Jul;34(7):50-55. [CrossRef] [Medline]58], and improved social participation [Østensen E, Gjevjon ER, Øderud T, Moen A. Introducing technology for thriving in residential long-term care. J Nurs Scholarsh 2017 Jan;49(1):44-53. [CrossRef] [Medline]52,Easton S. Digital age project evaluation report. Learning and Work Institute. 2016.
URL: https://www.linkinggenerationsni.com/portfolio-posts/digital-age-project/ [accessed 2022-05-02]
59,Zamir S. Skype on Wheels: implementation of video-calls to reduce feelings of loneliness and social isolation for older people living in care. University of Plymouth. 2020.
URL: https://pearl.plymouth.ac.uk/handle/10026.1/15790 [accessed 2020-09-17]
60].
A total of 4 programs used existing software programs, including LINE [Tsai HH, Cheng CY, Shieh WY, Chang YC. Effects of a smartphone-based videoconferencing program for older nursing home residents on depression, loneliness, and quality of life: a quasi-experimental study. BMC Geriatr 2020 Jan 28;20(1):27 [FREE Full text] [CrossRef] [Medline]54], MSN [Tsai HH, Tsai YF, Wang HH, Chang YC, Chu HH. Videoconference program enhances social support, loneliness, and depressive status of elderly nursing home residents. Aging Ment Health 2010 Nov;14(8):947-954. [CrossRef] [Medline]55], and Skype [Østensen E, Gjevjon ER, Øderud T, Moen A. Introducing technology for thriving in residential long-term care. J Nurs Scholarsh 2017 Jan;49(1):44-53. [CrossRef] [Medline]52,Schwindenhammer TM. Videoconferencing intervention for depressive symptoms and loneliness in nursing home elders. Illinois State University. 2014. URL: https://www.proquest.com/openview/a49fd1b55dd0416b7fcb4468a82a6475/1?pq-origsite=gscholar&cbl=18750&diss=y [accessed 2020-09-17] 53,Tsai HH, Tsai YF, Wang HH, Chang YC, Chu HH. Videoconference program enhances social support, loneliness, and depressive status of elderly nursing home residents. Aging Ment Health 2010 Nov;14(8):947-954. [CrossRef] [Medline]55] for video calls, whereas 1 program used videophones [Demiris G, Oliver DR, Hensel B, Dickey G, Rantz M, Skubic M. Use of videophones for distant caregiving: an enriching experience for families and residents in long-term care. J Gerontol Nurs 2008 Jul;34(7):50-55. [CrossRef] [Medline]58]. For programs using commercially available software, smartphone [Tsai HH, Cheng CY, Shieh WY, Chang YC. Effects of a smartphone-based videoconferencing program for older nursing home residents on depression, loneliness, and quality of life: a quasi-experimental study. BMC Geriatr 2020 Jan 28;20(1):27 [FREE Full text] [CrossRef] [Medline]54], tablet [Østensen E, Gjevjon ER, Øderud T, Moen A. Introducing technology for thriving in residential long-term care. J Nurs Scholarsh 2017 Jan;49(1):44-53. [CrossRef] [Medline]52,Zamir S. Skype on Wheels: implementation of video-calls to reduce feelings of loneliness and social isolation for older people living in care. University of Plymouth. 2020. URL: https://pearl.plymouth.ac.uk/handle/10026.1/15790 [accessed 2020-09-17] 60] and laptop [Tsai HH, Tsai YF, Wang HH, Chang YC, Chu HH. Videoconference program enhances social support, loneliness, and depressive status of elderly nursing home residents. Aging Ment Health 2010 Nov;14(8):947-954. [CrossRef] [Medline]55] have been used. The frequency of contact between older adults and their families was designed to be once per week in 4 programs—LINE [Tsai HH, Cheng CY, Shieh WY, Chang YC. Effects of a smartphone-based videoconferencing program for older nursing home residents on depression, loneliness, and quality of life: a quasi-experimental study. BMC Geriatr 2020 Jan 28;20(1):27 [FREE Full text] [CrossRef] [Medline]54], MSN or Skype [Tsai HH, Tsai YF, Wang HH, Chang YC, Chu HH. Videoconference program enhances social support, loneliness, and depressive status of elderly nursing home residents. Aging Ment Health 2010 Nov;14(8):947-954. [CrossRef] [Medline]55], Skype [Schwindenhammer TM. Videoconferencing intervention for depressive symptoms and loneliness in nursing home elders. Illinois State University. 2014. URL: https://www.proquest.com/openview/a49fd1b55dd0416b7fcb4468a82a6475/1?pq-origsite=gscholar&cbl=18750&diss=y [accessed 2020-09-17] 53], and Demiris et al [Demiris G, Oliver DR, Hensel B, Dickey G, Rantz M, Skubic M. Use of videophones for distant caregiving: an enriching experience for families and residents in long-term care. J Gerontol Nurs 2008 Jul;34(7):50-55. [CrossRef] [Medline]58].
As highlighted in the Skype on Wheel [Zamir S. Skype on Wheels: implementation of video-calls to reduce feelings of loneliness and social isolation for older people living in care. University of Plymouth. 2020. URL: https://pearl.plymouth.ac.uk/handle/10026.1/15790 [accessed 2020-09-17] 60] program, “younger generations (grandchildren) may not be sure of how to communicate with their elderly relatives”; therefore, it may be helpful to provide conversational aid to facilitate intergenerational communication, such as a list of possible conversational topics as seen in 2 programs (Skype on Wheel [Zamir S. Skype on Wheels: implementation of video-calls to reduce feelings of loneliness and social isolation for older people living in care. University of Plymouth. 2020. URL: https://pearl.plymouth.ac.uk/handle/10026.1/15790 [accessed 2020-09-17] 60] and LINE [Tsai HH, Cheng CY, Shieh WY, Chang YC. Effects of a smartphone-based videoconferencing program for older nursing home residents on depression, loneliness, and quality of life: a quasi-experimental study. BMC Geriatr 2020 Jan 28;20(1):27 [FREE Full text] [CrossRef] [Medline]54]). Although not developed for older adults residing in long-term residential care facilities, other programs have investigated digital storytelling [Wallbaum T, Matviienko A, Ananthanarayan S, Olsson T, Heuten W, Boll S. Supporting communication between grandparents and grandchildren through tangible storytelling systems. In: Proceedings of the 2018 CHI Conference on Human Factors in Computing Systems. 2018 Apr Presented at: CHI '18; April 21-26, 2018; Montreal, Canada p. 1-12. [CrossRef]70] and exposure to photographs in the older adults’ environment [Cornejo R, Tentori M, Favela J. Enriching in-person encounters through social media: a study on family connectedness for the elderly. Int J Human Comput Stud 2013 Sep;71(9):889-899. [CrossRef]68] as ways to facilitate intergenerational conversation.
A total of 2 programs (ACTIVE [Østensen E, Gjevjon ER, Øderud T, Moen A. Introducing technology for thriving in residential long-term care. J Nurs Scholarsh 2017 Jan;49(1):44-53. [CrossRef] [Medline]52] and Digital Age [Easton S. Digital age project evaluation report. Learning and Work Institute. 2016. URL: https://www.linkinggenerationsni.com/portfolio-posts/digital-age-project/ [accessed 2022-05-02] 59]) explicitly included training on using digital technology for older adults residing in long-term residential care facilities. In the ACTIVE program, the authors highlighted that “a carefully selected, smaller set of basic apps was installed when the intervention started” to avoid overwhelming the older adults [Østensen E, Gjevjon ER, Øderud T, Moen A. Introducing technology for thriving in residential long-term care. J Nurs Scholarsh 2017 Jan;49(1):44-53. [CrossRef] [Medline]52]. The content of the training is well described in the Digital Age program [Easton S. Digital age project evaluation report. Learning and Work Institute. 2016. URL: https://www.linkinggenerationsni.com/portfolio-posts/digital-age-project/ [accessed 2022-05-02] 59], which includes the following core subjects: learning how to use a tablet, browsing the internet, staying safe on the internet, emailing, using an App Store, and video calling. The content of the training sessions was flexible and tailored to the needs of older adults in the Digital Age program [Easton S. Digital age project evaluation report. Learning and Work Institute. 2016. URL: https://www.linkinggenerationsni.com/portfolio-posts/digital-age-project/ [accessed 2022-05-02] 59].
S-C-M-O Configuration 4
One program, Tele-Behavioral Activation (BA) [Choi NG, Pepin R, Marti CN, Stevens CJ, Bruce ML. Improving social connectedness for homebound older adults: randomized controlled trial of tele-delivered behavioral activation versus tele-delivered friendly visits. Am J Geriatr Psychiatry 2020 Jul;28(7):698-708 [FREE Full text] [CrossRef] [Medline]74], contributed to this S-C-M-O configuration. We found that behavioral activation provided through videoconferencing by a lay coach may be useful in reducing loneliness among older adults who are lonely (Figure 6). Several studies have evaluated the effectiveness of digital training courses [Williams JM, Thyer BA, Lustria ML, Tripodi SJ, Ralston PA. Using computer-mediated communication to reduce loneliness in older adults. Florida State University. 2019.
URL: https://diginole.lib.fsu.edu/islandora/object/fsu:661182 [accessed 2020-09-17]
72,Baker S, Warburton J, Hodgkin S, Pascal J. The supportive network: rural disadvantaged older people and ICT. Ageing Soc 2017;37(6):1291-1309. [CrossRef]73,Fokkema T, Knipscheer K. Escape loneliness by going digital: a quantitative and qualitative evaluation of a Dutch experiment in using ECT to overcome loneliness among older adults. Aging Ment Health 2007 Sep;11(5):496-504. [CrossRef] [Medline]75,Fields J, Cemballi AG, Michalec C, Uchida D, Griffiths K, Cardes H, et al. In-home technology training among socially isolated older adults: findings from the tech allies program. J Appl Gerontol 2021 May;40(5):489-499. [CrossRef] [Medline]77] in reducing loneliness or social isolation for older adults who were lonely or socially isolated. However, as highlighted in the Assertive Outreach (AO) program, establishing “even a small web-based social network proved very difficult in many cases” for older adults who were socially isolated, which may have resulted in the lack of improvement in the outcomes in most of these studies [Baker S, Warburton J, Hodgkin S, Pascal J. The supportive network: rural disadvantaged older people and ICT. Ageing Soc 2017;37(6):1291-1309. [CrossRef]73]. BA is a brief, structured behavioral approach that aims to increase and reinforce wellness-promoting behaviors that can be conducted by lay coaches [Choi NG, Pepin R, Marti CN, Stevens CJ, Bruce ML. Improving social connectedness for homebound older adults: randomized controlled trial of tele-delivered behavioral activation versus tele-delivered friendly visits. Am J Geriatr Psychiatry 2020 Jul;28(7):698-708 [FREE Full text] [CrossRef] [Medline]74]. In the Tele-BA program, lay coach “worked with participants to identify and schedule value-based activities, rewarding social engagement and activities, and using strategies to reduce and solve barriers to social connectedness [Choi NG, Pepin R, Marti CN, Stevens CJ, Bruce ML. Improving social connectedness for homebound older adults: randomized controlled trial of tele-delivered behavioral activation versus tele-delivered friendly visits. Am J Geriatr Psychiatry 2020 Jul;28(7):698-708 [FREE Full text] [CrossRef] [Medline]74]. Participants first reviewed their daily activity patterns, then chose activity goals, worked on specific implementation plans, and reviewed their successes and areas for improvement” [Choi NG, Pepin R, Marti CN, Stevens CJ, Bruce ML. Improving social connectedness for homebound older adults: randomized controlled trial of tele-delivered behavioral activation versus tele-delivered friendly visits. Am J Geriatr Psychiatry 2020 Jul;28(7):698-708 [FREE Full text] [CrossRef] [Medline]74]. This may have enabled older adults to learn to overcome barriers to social connectedness and to use skills for maintaining social connectedness over time, leading to reduced levels of loneliness that were sustained beyond the 5 sessions of tele-BA.
Discussion
Principal Findings
In this review, we sought to answer the following question: “How do different digital intergenerational programs interact with different contexts to produce certain outcomes?” This review revealed that different strategies should be adopted for different groups of older adults (eg, older adults who are lonely, older adults who reside in long-term residential care facilities, and community-dwelling older adults). For example, providing training and access to digital technology may be useful in reducing loneliness among community-dwelling older adults but not for older adults who are already lonely or socially isolated. This may be because establishing “even a small web-based social network proved very difficult in many cases” for older adults who are socially isolated as discussed in the AO program [Baker S, Warburton J, Hodgkin S, Pascal J. The supportive network: rural disadvantaged older people and ICT. Ageing Soc 2017;37(6):1291-1309. [CrossRef]73]. Similar to AO, Tech Allies program also pointed out the older adults “were already facing many contextual factors in their daily lives, such as physical disability and a lack of close friends and living relatives” would make “their loneliness more systemic and harder to change” [Fields J, Cemballi AG, Michalec C, Uchida D, Griffiths K, Cardes H, et al. In-home technology training among socially isolated older adults: findings from the tech allies program. J Appl Gerontol 2021 May;40(5):489-499. [CrossRef] [Medline]77]. Although tele-BA by lay coaches may be helpful for lonely older adults, future studies should explore different program strategies for this subgroup of older adults with more complex needs. A possibility is to entail young volunteers to befriend older adults who lack existing social support [Airola E, Rasi P, Outila M. Older people as users and non-users of a video conferencing service for promoting social connectedness and well-being – a case study from Finnish Lapland. Educ Gerontol 2020 Mar 29;46(5):258-269. [CrossRef]81]. Williams [Williams JM, Thyer BA, Lustria ML, Tripodi SJ, Ralston PA. Using computer-mediated communication to reduce loneliness in older adults. Florida State University. 2019. URL: https://diginole.lib.fsu.edu/islandora/object/fsu:661182 [accessed 2020-09-17] 72] investigated the effect of a 2-week computer-mediated communication course for lonely older adults and found “no significant difference in loneliness between pre-test and post-test” [Williams JM, Thyer BA, Lustria ML, Tripodi SJ, Ralston PA. Using computer-mediated communication to reduce loneliness in older adults. Florida State University. 2019. URL: https://diginole.lib.fsu.edu/islandora/object/fsu:661182 [accessed 2020-09-17] 72]. However, as explained by the author, the lack of observed differences after the intervention was not unexpected with the short duration of the intervention (2 weeks) [Williams JM, Thyer BA, Lustria ML, Tripodi SJ, Ralston PA. Using computer-mediated communication to reduce loneliness in older adults. Florida State University. 2019. URL: https://diginole.lib.fsu.edu/islandora/object/fsu:661182 [accessed 2020-09-17] 72]. Therefore, the duration of intergenerational programs should be considered before implementation.
Among the digital intergenerational programs included in this realist review, 2 programs (AGES 2.0 [Morton TA, Wilson N, Haslam C, Birney M, Kingston R, McCloskey LG. Activating and guiding the engagement of seniors with online social networking: experimental findings from the AGES 2.0 project. J Aging Health 2018 Jan;30(1):27-51. [CrossRef] [Medline]48] and White et al [White H, McConnell E, Clipp E, Branch LG, Sloane R, Pieper C, et al. A randomized controlled trial of the psychosocial impact of providing Internet training and access to older adults. Aging Ment Health 2002 Aug;6(3):213-221. [CrossRef] [Medline]76]) targeted both community-dwelling older adults and older adults residing in long-term care facilities by providing training in digital technology. However, both the programs demonstrated unsuccessful outcomes [Morton TA, Wilson N, Haslam C, Birney M, Kingston R, McCloskey LG. Activating and guiding the engagement of seniors with online social networking: experimental findings from the AGES 2.0 project. J Aging Health 2018 Jan;30(1):27-51. [CrossRef] [Medline]48,White H, McConnell E, Clipp E, Branch LG, Sloane R, Pieper C, et al. A randomized controlled trial of the psychosocial impact of providing Internet training and access to older adults. Aging Ment Health 2002 Aug;6(3):213-221. [CrossRef] [Medline]76]. A possible reason for the unsuccessful outcome from these 2 programs may be that although providing training in digital technology may be useful to reduce loneliness among community-dwelling older adults based on S-C-M-O configuration 1 (all 4 programs in S-C-M-O configuration 1 achieved successful outcomes), this program strategy may not be useful for older adults in long-term residential care facilities. This further supports the importance of designing targeted digital intergenerational programs for different groups of older people (eg, older adults residing in long-term residential care facilities and community-dwelling older adults). The AGES 2.0 study also found that “feelings of self-competence, social engagement, and maintenance of identity were critical to the intervention’s success” [Morton TA, Wilson N, Haslam C, Birney M, Kingston R, McCloskey LG. Activating and guiding the engagement of seniors with online social networking: experimental findings from the AGES 2.0 project. J Aging Health 2018 Jan;30(1):27-51. [CrossRef] [Medline]48]. Future research should explore whether interventions that enhance these aspects are useful in promoting social connectedness among older adults.
Comparison With Prior Work
In a previous realistic review exploring the use of technology to engage hospitalized patients, the authors found that a user-centered design may increase the engagement level [Roberts S, Chaboyer W, Gonzalez R, Marshall A. Using technology to engage hospitalised patients in their care: a realist review. BMC Health Serv Res 2017 Jun 06;17(1):388 [FREE Full text] [CrossRef] [Medline]82]. However, in our realistic review of digital intergenerational programs based on digital technology, only 3 programs designed for community-dwelling older adults incorporated a user-centered design [Savolainen L, Hanson E, Magnusson L, Gustavsson T. An Internet-based videoconferencing system for supporting frail elderly people and their carers. J Telemed Telecare 2008;14(2):79-82. [CrossRef] [Medline]63,Czaja SJ, Boot WR, Charness N, Rogers WA, Sharit J. Improving social support for older adults through technology: findings from the PRISM randomized controlled trial. Gerontologist 2018 May 08;58(3):467-477 [FREE Full text] [CrossRef] [Medline]66,Coelho J, Rito F, Duarte C. “You, me and TV” — fighting social isolation of older adults with Facebook, TV and multimodality. Int J Hum Comput Stud 2017 Feb;98:38-50. [CrossRef]69], and 2 programs were evaluated in a small sample (n<10) [Savolainen L, Hanson E, Magnusson L, Gustavsson T. An Internet-based videoconferencing system for supporting frail elderly people and their carers. J Telemed Telecare 2008;14(2):79-82. [CrossRef] [Medline]63,Coelho J, Rito F, Duarte C. “You, me and TV” — fighting social isolation of older adults with Facebook, TV and multimodality. Int J Hum Comput Stud 2017 Feb;98:38-50. [CrossRef]69]. Studies in long-term residential care facilities using existing digital communication tools such as LINE and Skype demonstrated beneficial effects on reducing loneliness [Tsai HH, Cheng CY, Shieh WY, Chang YC. Effects of a smartphone-based videoconferencing program for older nursing home residents on depression, loneliness, and quality of life: a quasi-experimental study. BMC Geriatr 2020 Jan 28;20(1):27 [FREE Full text] [CrossRef] [Medline]54,Tsai HH, Tsai YF, Wang HH, Chang YC, Chu HH. Videoconference program enhances social support, loneliness, and depressive status of elderly nursing home residents. Aging Ment Health 2010 Nov;14(8):947-954. [CrossRef] [Medline]55], which implies that user-centered design may not be critical for the success of digital intergenerational design. However, this could be because staff are available at long-term residential care facilities to assist with the set-up of the video call tools in these programs, which facilitates intergenerational communication with family members or students [Tsai HH, Cheng CY, Shieh WY, Chang YC. Effects of a smartphone-based videoconferencing program for older nursing home residents on depression, loneliness, and quality of life: a quasi-experimental study. BMC Geriatr 2020 Jan 28;20(1):27 [FREE Full text] [CrossRef] [Medline]54,Tsai HH, Tsai YF, Wang HH, Chang YC, Chu HH. Videoconference program enhances social support, loneliness, and depressive status of elderly nursing home residents. Aging Ment Health 2010 Nov;14(8):947-954. [CrossRef] [Medline]55,Zamir S. Skype on Wheels: implementation of video-calls to reduce feelings of loneliness and social isolation for older people living in care. University of Plymouth. 2020. URL: https://pearl.plymouth.ac.uk/handle/10026.1/15790 [accessed 2020-09-17] 60] and mitigates the potential problem of digital illiteracy among older adults [Neves BB, Amaro F, Fonseca JR. Coming of (old) age in the digital age: ICT usage and non-usage among older adults. Sociol Res Online 2013 Jun 06;18(2):22-35. [CrossRef]83,Terp R, Kayser L, Lindhardt T. Older patients' competence, preferences, and attitudes toward digital technology use: explorative study. JMIR Hum Factors 2021 May 14;8(2):e27005 [FREE Full text] [CrossRef] [Medline]84]. Future research should be conducted to examine whether a user-centered design may have contributed to a reduction in loneliness or social isolation among specific groups of older adults.
Strengths and Limitations
This review is the first to use a realist framework to study digital intergenerational programs for older adults. The realist framework allowed us to consider empirical findings and theories together to understand how these programs worked. Previous reviews on the effectiveness of intergenerational programs have focused primarily on scholarly literature [Canedo-García A, García-Sánchez JN, Pacheco-Sanz DI. A systematic review of the effectiveness of intergenerational programs. Front Psychol 2017 Oct 27;8:1882 [FREE Full text] [CrossRef] [Medline]29-Martins T, Midão L, Martínez Veiga S, Dequech L, Busse G, Bertram M, et al. Intergenerational programs review: study design and characteristics of intervention, outcomes, and effectiveness. J Intergener Relationsh 2019;17(1):93-109. [CrossRef]31] and, therefore, have provided limited insight into the complex causal pathways that may underpin the efficacy or effectiveness of intergenerational programs. The inclusion of diverse research designs, such as quantitative, qualitative, and mixed methods studies, enabled this review to leverage the strengths of each approach. From a realistic perspective, this diversity has huge explanatory value and can help uncover contexts and mechanisms not typically captured in traditional systematic reviews and meta-analyses [Wozney L, Huguet A, Bennett K, Radomski AD, Hartling L, Dyson M, et al. How do eHealth programs for adolescents with depression work? A realist review of persuasive system design components in internet-based psychological therapies. J Med Internet Res 2017 Aug 09;19(8):e266 [FREE Full text] [CrossRef] [Medline]33].
However, a limitation of this realist review is that nearly half (11/27, 41%) of the programs reported only quantitative results. A problem with conducting a realist review of quantitative studies is that their primary emphasis is on quantitative results; thus, there may be fewer descriptions and explanations of the mechanisms [Jagosh J. Realist synthesis for public health: building an ontologically deep understanding of how programs work, for whom, and in which contexts. Annu Rev Public Health 2019 Apr 01;40:361-372. [CrossRef] [Medline]85]. Thus, our realist review generally focuses on screening the discussion section of publications to identify author opinions or any qualitative information that may provide information on the mechanisms of how certain programs work. As we inferred most of the information regarding the mechanism from the authors’ comments and discussions in the quantitative studies, we acknowledge the subjectivity of these inferences. Nevertheless, the S-C-M-O configurations derived from this study may serve as a basis for further studies to corroborate the proposed theory and mechanisms that drive program outcomes in different contexts.
Second, we acknowledge that for some programs, the outcome observed may not be solely attributable to intergenerational interaction, as the participants may interact with their peers or spouses using digital technology. We decided to include these studies, as there was only 1 study [Wallbaum T, Matviienko A, Ananthanarayan S, Olsson T, Heuten W, Boll S. Supporting communication between grandparents and grandchildren through tangible storytelling systems. In: Proceedings of the 2018 CHI Conference on Human Factors in Computing Systems. 2018 Apr Presented at: CHI '18; April 21-26, 2018; Montreal, Canada p. 1-12. [CrossRef]70] focusing solely on intergenerational interaction using digital technology. However, the inclusion of programs that accommodate both nonintergenerational and intergenerational communication provides a more comprehensive list of programs available for intergenerational communication. As such, some programs in this review may need to be adapted for intergenerational interactions only, and their effectiveness in addressing isolation and loneliness may require investigation in future studies.
Third, as the search in the scholarly literature was restricted to articles published before August 2020, our review may have excluded studies published after the cutoff date. Nevertheless, the findings of this review can serve as a foundation for future research on digital intergenerational programs.
Finally, another limitation of this study was the inclusion of only English-language documents, which may have potentially led to the omission of relevant programs from English-speaking countries. Among the 27 programs included in this review, only 2 (7%) programs were conducted in Asian countries [Tsai HH, Cheng CY, Shieh WY, Chang YC. Effects of a smartphone-based videoconferencing program for older nursing home residents on depression, loneliness, and quality of life: a quasi-experimental study. BMC Geriatr 2020 Jan 28;20(1):27 [FREE Full text] [CrossRef] [Medline]54,Tsai HH, Tsai YF. Changes in depressive symptoms, social support, and loneliness over 1 year after a minimum 3-month videoconference program for older nursing home residents. J Med Internet Res 2011 Nov 15;13(4):e93 [FREE Full text] [CrossRef] [Medline]79]. However, the inclusion of only English-language documents minimizes potential information loss during translation.
Conclusions
This review identifies the key strategy, context, and mechanism that influence the success of programs in reducing loneliness or isolation among older adults by potentially promoting intergenerational interaction through digital means. Digital interventions are becoming increasingly popular to tackle social problems, such as loneliness and social isolation. We identified 4 S-C-M-O configurations to consider when developing intergenerational programs for older adults. Future studies, especially quantitative studies, should consider clearly describing the components of the program and their corresponding contexts and mechanisms driving the improvement of outcomes in digital intergenerational programs. With a better understanding of the components and mechanisms of digital intergenerational programs, well-informed decisions can be made when planning or developing digital intergenerational programs.
Acknowledgments
This research is supported by the Singapore Ministry of Health’s National Medical Research Council under the SingHealth Regional Health System, Population-based, Unified, Learning System for Enhanced and Sustainable Health Centre Grant (NMRC/CG/C027/2017_SHS) and SingHealth Duke-NUS Healthy Empowered and Active Living Fund.
Data Availability
The data sets generated during and/or analyzed during this study are available from the corresponding author upon reasonable request.
Conflicts of Interest
None declared.
Multimedia Appendix 3
Mixed Methods Appraisal Tool appraisal for documents evaluating digital intergenerational program.
DOCX File , 19 KB
Multimedia Appendix 4
Candidate Strategy-Context-Mechanism-Outcome configurations for digital intergenerational programs based on the authors’ description.
DOCX File , 27 KBReferences
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Abbreviations
AO: Assertive Outreach |
BA: Behavioral Activation |
MMAT: Mixed Methods Appraisal Tool |
MSN: Microsoft Network |
S-C-M-O: Strategy-Context-Mechanism-Outcome |
Edited by T Leung; submitted 25.05.22; peer-reviewed by H Motahari-Nezhad, M Choi; comments to author 14.09.22; revised version received 03.10.22; accepted 28.10.22; published 04.01.23
Copyright©Jie Kie Phang, Yu Heng Kwan, Sungwon Yoon, Hendra Goh, Wan Qi Yee, Chuen Seng Tan, Lian Leng Low. Originally published in JMIR Aging (https://aging.jmir.org), 04.01.2023.
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