... Running head: OLDER ADULTS AND SMARTPHONE USE 1 Exploring the Fit Between Older Adults and Smartphone Use to Inform Design and Practical Application Natalie Azzarito, Kelsey Brown, Darian Burchfield, Kaytlyn Eberly, Nicole Meert, and Molly Sears December 15th, 2017 A research project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the research advisor: Beth Ann Walker, PhD, OTR Running head: OLDER ADULTS AND SMARTPHONE USE A Research Project Entitled Exploring the Fit Between Older Adults and Smartphone Use to Inform Design and Practical Application Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By Natalie Azzarito, Kelsey Brown, Darian Burchfield, Kaytlyn Eberly, Nicole Meert, and Molly Sears Approved by: Research Advisor (1st Reader) Date 2nd Reader Date Accepted on this date by the Chair of the School of Occupational Therapy: Kate E. DeCleene Huber, OTR, MS, OTD Chair, School of Occupational Therapy Date 1 OLDER ADULTS AND SMARTPHONE USE 2 Abstract Background: Smartphones have become a valuable tool on which many rely to complete a myriad of tasks on a daily basis, and occupational therapists have begun to consider them as possible tools to support the daily occupations of older adults. While the capabilities of smartphones and available applications appear endless, older adults may not fully understand the mobile phone they are using or understand how smartphones might be used to support occupational performance. In order for occupational therapists to effectively incorporate the use of smartphone technology to support the occupational needs of the aging population, a greater understanding of older adults acceptance and use of smartphone technology is needed. Purpose: The purpose of this study was to explore older adults acceptance and use of smartphone technology and check for redundancy of Walker et al.s (2015) preliminary model. Methodology: Investigators utilized a focus group design to collect qualitative data on older adult acceptance and use of smartphone technology. Participants included eight older adults aged 60-78 who were selected through purposive, convenience, and nominative sampling. Verbatim transcription was analyzed using a constant comparative approach. Findings: Findings of this study were consistent with Walker et al.s (2015) preliminary study. Five factors contributed to participants ability to successfully operate their smartphone: physical characteristics of the device, past experience, effort expectancy, available resources, and selfefficacy. Overall, smartphone use was collectively explained by the constructs of ability, attitude, perceived need, and social influence. Conclusion: Occupational therapists can use this model to thoroughly examine and consider the fit between older adults, smartphones, and related applications in order to provide client-centered recommendations to effectively support the occupational performance of their older adult clients OLDER ADULTS AND SMARTPHONE USE using smartphone technology. Further, this model may also be used to inform the future design of smartphone technology and related applications aimed to support the needs of older adult consumers. 3 OLDER ADULTS AND SMARTPHONE USE Acknowledgements The authors would like to thank the eight participants for their time and insights on their experiences with smartphone technology. We would also like to thank Dr. Brenda Howard for taking time to provide an in-depth review of this paper prior to submission. 4 OLDER ADULTS AND SMARTPHONE USE 5 Exploring the Fit Between Older Adults and Smartphone Use to Inform Design and Practical Application Smartphones have become a valuable tool on which many rely to complete a myriad of tasks on a daily basis. They are capable of offering an endless array of options aimed to promote autonomy and independence in activities of daily living (ADLs), instrumental activities of daily living (IADLs), rest and sleep, education, work, play, leisure and social participation (American Occupational Therapy Association [AOTA], 2014). Occupational therapists can consider smartphone technology as a tool to increase independence and participation in occupation for older adults through productive aging. Productive aging refers to aging in a safe and healthy environment, while continuing to participate socially in the community regardless of living in home or a long term living facility (National Institute for Occupational Safety and Health, 2015). Occupational therapists strive to support productive aging by providing services targeted at preserving meaningful roles and occupations, such as promoting engagement in managing personal health and wellness, personal finance, transportation, community, and maintaining or increasing participation in meaningful occupations within a community context (National Aging in Place Council, n.d.). While it is evident that smartphones provide a variety of options that support productive aging, a better understanding of the factors that contribute to older adults acceptance and use of this technology is needed to inform how occupational therapists incorporate them as a tool to influence functional outcomes. It is apparent that more and more older adults are using smartphones; however, it is evident that they use their phones differently when compared to younger generations. As of 2014, 77% of older adults owned a cell phone; however, only 27% of adults 65 and older owned a smartphone (Smith, 2014 b). Older adults attitudes and use of technology, such as OLDER ADULTS AND SMARTPHONE USE 6 smartphones, are influenced by their personal, social, and physical situations (Peek et al., 2016). Individuals from different age groups utilize smartphones differently. For example, individuals ranging from 19 to 21 years of age typically used cell phones for texting, while individuals over the age of 65 primarily used them for security (Pedlow, Kasnitz, & Shuttleworth, 2010; Van Volkom, Stapley, & Amaturo, 2014). According to M. Martinez-Pecino, R. Martinez-Pecino, and Lera (2012), cell phones have helped older adults remain in communication with their families, which has brought them a sense of security. According to McLeod (2009) and Gitlow (2014), older adults reported using cell phones every day for personal calling, texting, checking voicemails, and for emergencies, whereas functions such as setting alarms, taking pictures, and checking the time were used less frequently. Most older adults did not use cell phones for playing games or using the internet as often as other features (McLeod, 2009). Smartphone technology can be utilized to support many IADLs that occupational therapists address with their clients. Instrumental activities of daily living include communication management, community mobility, home establishment and management, religious observation or spirituality, shopping, education, leisure and social participation (Lauer, 2013). Examples of applications that can assist with such IADLs for communication management include social media applications such as Easy Facebook for Seniors, which allows for communication with friends and family with less clutter compared to the basic Facebook app (18 unexpectedly innovative apps for seniors, 2017). Community mobility can be supported through apps such as Lyft, which is a user-friendly application for transportation within the community by simplifying the process of obtaining a ride (Derrick, 2017). Applications pertaining to home establishment and management such as Mint, which allows for the organization of finances to maintain a monthly budget and pay bills (18 unexpectedly OLDER ADULTS AND SMARTPHONE USE 7 innovative apps for seniors, 2017). Religious observation or spirituality can include an app called Sermon Audio, which provides audio sermons and addresses religious observations (The 25 best Bible apps, n.d.). Shopping can be supported through an application called Instacart, which assists with delivery of groceries after being ordered via the application (Mears, 2016). Education can include Goodreads, which allows the user to rate and share books online before purchasing. Leisure can include applications such as iBooks, which is an application used for educational and leisurely reading; Skype allows individuals to connect with family and friends within a virtual context (18 unexpectedly innovative apps for seniors, 2017). In addition to smartphones supporting applications for IADLS, they also support applications that enhance or adapt client factors (AOTA, 2014). Smartphone applications can be used to record body functions and send important medical readings to doctors and other health professionals such as blood sugar levels, pacemaker data, caloric intake, and even physical activity (Kim, H-S., Lee, Kim, H., & Kim, J. H., 2014; Pedlow et al., 2010). For example, the application, Blood Pressure Monitor, sends blood pressure readings and weight changes instantly to a physician (18 unexpectedly innovative apps for seniors, 2017). Smartphones may also be used to accommodate memory limitations by setting reminders for medical visits (Kim et. al., 2014). Users are also able to take notes, create voice memos, and set alarms using their smartphone to assist with their memory. Memory can be supported through apps such as Pillboxie to remind individuals to take medications at specific times (18 unexpectedly innovative apps for seniors, 2017), Evernote, an application used for creating audible reminders (Belval, 2015), and Lumosity, a memory game including over one-hundred games and puzzles (18 unexpectedly innovative apps for seniors, 2017). Vision can be supported through applications including EyeReader, which serves as a magnifying glass with a bright light for OLDER ADULTS AND SMARTPHONE USE 8 reading; and Silver Surf, which offers zoom, larger buttons, and adjustments to contrast for easier reading (Derrick, 2017; 18 unexpectedly innovative apps for seniors, 2017). Hearing can be supported by an application called BioAid, which works as a hearing aid by using a microphone to process sound and deliver to headphones for enhanced sound (Useful apps for hearing loss, n.d.). Although the capabilities of smartphones and available applications appear endless, older adults may not fully understand the mobile phone they are using (Ziefle & Bay, 2005), let alone understand how they might be used to support productive aging. Many adults do not use functions beyond personal calling and texting (McLeod, 2009). It is important to uncover barriers to smartphone use to maximize the fit between the older adult user and smartphone technology. According to McLeod (2009), ease of use is the most important feature of a cellphone among older adults. Complex phones have many different menus that may cause older adults to become lost within the menu and may seek assistance from younger users (Ziefle & Bay, 2005). Also, many of these menus may not seem necessary to the user (Plaza, Martn, Martin & Medrano, 2011). This requires that older users build a mental map of the location of the different menus, but also memorize the names of the menus (Ziefle & Bay, 2005). If the device is too small, an older adult may have difficulty holding the phone comfortably in their hand, and applications within the cell phone will be small as well (Plaza et al., 2011). It can be difficult for older adults to think of the action they are trying to do, such as calling, when many icons appear arbitrary to the task at hand (Kim et al., 2014). Small text size can hinder older adult's smartphone use if the text size is hard to read regardless of corrective lens use (Plaza et al., 2011). On the other hand, if the text size is too large, the phone many only OLDER ADULTS AND SMARTPHONE USE 9 display a few words on the screen at a time and becomes difficult to read or scroll through entire messages (Zhou, Rau & Salvendy, 2014). In an effort to better understand the factors that influence or hinder mobile phone use by older adults, Walker et al. (2015) described a preliminary comprehensive model (Appendix B) to explain the acceptance and use of mobile phone technology by older adults. The main findings of this study suggested that older adults use of mobile phones was determined by a combination of ability, social influence, perceived need, and attitude. According to this model, the factors which contributed to older adults ability to use a mobile phone included the design of the device itself, effort expectancy, experience, available resources, and self-efficacy. Effort expectancy was defined as the anticipated degree of ease associated with mobile phone use. Experience referred to the amount of previous use and knowledge an individual has with a smartphone. Available resources referred to the aid, support, or person an older adult sought out when guidance was needed to perform a function on their smartphone. Self-efficacy was defined as the participants belief in their ability to successfully perform needed tasks and functions on a smartphone device. Social influence was defined as the effect important people in an older adults life had on their acceptance and use of mobile phones and was primarily influenced by younger generations, family, friends and colleagues. Attitude was defined as older adults positive or negative feelings about using the mobile phone. Attitude was affected by the understanding, convenience, and benefit of device as well as effort expectancy and generational attitude. Perceived need was defined as the degree to which an older adult believed they needed a mobile phone and was comprised of the following constructs: communication, safety, caregiving, work and cost (Walker et al., 2015). OLDER ADULTS AND SMARTPHONE USE 10 In order for occupational therapists to effectively meet the needs of the aging population, a greater understanding of older adults acceptance and use of smartphone technology is needed to minimize the gap between the user and smartphone technology. This understanding will serve as the precipice to maximize the fit between the person and the occupational task at hand to facilitate productive aging. Research is needed to further test Walker et al.s (2015) preliminary model for redundancy over time and ever-changing smartphone technologies. In effort to inform occupational therapy practitioners on how to best optimize the fit between older adults and smartphone technology used to support occupational performance, the purpose of this study was to explore older adults acceptance and use of smartphone technology and check for redundancy of Walker et al.s (2015) preliminary model. Methodology A phenomenological approach was used to explore older adults acceptance and use of smartphones. This design was utilized to understand participants perceptions, perspectives, and experiences of a phenomenon (Lester, 1999). A focus group method was selected due to its popularity in academic qualitative studies and applicability of results for the generalization of a larger population (Cheng, 2007). The University of Indianapolis Institutional Review Board (IRB) granted approval for this study. Sampling A combination of purposive, convenience, and nominative sampling was used to recruit participants. Purposive sampling is commonly used for qualitative research and is defined as the selection of participants based on specific characteristics that relate to a certain phenomenon (Palinkas et al., 2013). According to Palinkas et al. (2013), purposive sampling is best used to uncover both differences and similarities with regards to phenomenological interest when two OLDER ADULTS AND SMARTPHONE USE 11 different types of purposive sampling are used. Convenience sampling is a method of data collection that relies on participants that are available to participate in the study due to location, availability, or personal acquaintances (Palinkas et al., 2013). Convenience sampling was used to recruit older adults within the Indianapolis and surrounding region that met the inclusion criteria. Nominative sampling occurs when participants are asked to recruit others that meet the criteria of the study (Palinkas et al., 2013). The most frequently utilized type of purposive sampling is criterion inclusion, which identifies specific, predetermined criteria that must be met before participation may occur (Palinkas et al., 2013). Inclusion criteria for participation included being between the ages of 60 and 80, own a smartphone, English speaking, living independently in the community, and ability to get to and from the focus group site on the designated date. An ideal focus group should consist of 5-12 members (Cheng, 2007). The exact number of participants varies based on the purpose of the focus group. According to Cheng (2007), focus groups with four or less participants provide fewer opinions than an eight-person group, while a large group can become too difficult to moderate thereby diminishing the opportunity for participants to provide opinions. Data Collection The focus group session was held September 2016 over a two-hour period in a private room at the University of Indianapolis. The goal of the focus group session was to investigate older adults acceptance and use of smartphone in regards to changing technologies to check for redundancy of Walker et al.s (2015) preliminary model. A semi-structured interview with openended and non directive questions was used to guide group discussion (see Appendix A). The interview guide was developed to investigate ability, social influence, perceived need, usefulness, and attitude. Question topics included participants perceptions of their ability to use OLDER ADULTS AND SMARTPHONE USE 12 their smartphone, the most influential person that impacted their decision to get a smartphone, the social effects of smartphone use, how and why participants use their smartphone, and their overall feelings and beliefs about smartphones. An explanation of the focus group procedures, including the objective and time frame, was provided to the participants. The participants selected an unidentifiable pseudonym for recording purposes in order to remain anonymous. Seven investigators were present during the focus group session. The principal investigator reframed questions, repeated items as needed, and used probing questions to increase the depth of discussion among participants to ensure complete coverage of content. The moderator of the focus group session emphasized there were no right or wrong answers and all opinions were welcome. Another investigator took notes regarding topics of conversation via computer. In order to ensure accuracy of the transcript, the remaining investigators took hand-written notes of facial expressions, body language, and any aspects not otherwise detected via audio-recording or transcription. The data was collected via a voice recorder. The voice recording was then transcribed verbatim. Data Analysis Each member of the research team listened to the audio recording individually, then read and re-read the transcripts and field notes to orient themselves to the data and took notes recording reflexive thoughts and insights (Johnson & Christensen, 2014). The research team completed an open coding process in which the researchers read through the transcripts line by line, placed the information into categories, and created tentative labels (Khandkar, n.d.). Initial codes (60) were reviewed as a group and condensed into 34 codes once a consensus was reached. Axial coding consisted of using deductive and inductive reasoning to relate the codes and identify relationships among the open codes (Bhm, 2004). Selective coding was then employed OLDER ADULTS AND SMARTPHONE USE 13 by the research team to identify the core construct of use and systematically relate it to the categories which emerged from axial coding (Bhm, 2004). Using a constant comparative technique, the data was also compared to previous data collected by Walker et al. (2015). Validity Credibility was ensured through reflexivity, investigator triangulation, member checking, peer examination, and interview technique (Krefting, 1991). Reflexivity was established by reviewing field notes and openly discussing the possible influence of each researchers background, interests, and perceptions on how data was interpreted (Krefting, 1991). For example, researchers identified potential biases through reflection of the generational gap between themselves and the research participants and its potential influence on perceptions of smartphone use. Investigator triangulation was ensured in this study through individual and collaborative efforts of the seven-member research team. The principal investigator, an expert in qualitative research, utilized an interview technique called member checking throughout the session to frequently ask the participants to confirm her interpretation of what was being said. Peer examination was provided by an impartial outside reviewer who is an expert in qualitative research, to ensure that the findings accurately reflect the participants experience (Birt, Scott, Cavers, Campbell, & Walter, 2016). Transferability of results was achieved through nominative sampling, which is the process of gathering participants by the use of a panel of people currently participating in the study to select additional participants that represent the phenomenon being investigated (Krefting, 1991). The gathering of dense background information about the participants served to enhance the transferability of findings. Dependability was strengthened through the coding and recoding method previously mentioned in conjunction with stepwise replication in which OLDER ADULTS AND SMARTPHONE USE 14 tasks were completed by at least two members of the research team. Dense description of research methods supported a stepwise replication. Confirmability was ensured through external reviewer, triangulation, and reflexivity. A confirmability audit was completed in which a third party individual reviewed the interview guide, field notes, raw data, data reduction and analysis procedures, and synthesis process (Krefting, 1991). Triangulation of theoretical perspectives was employed by the open and axial coding processes as well as a follow-up procedure including a priori coding using the core constructs from the Walker et. al. (2015) model to develop preliminary themes. A priori coding is used to increase methods triangulation in which codes from a previous study were identified and used to assist in writing an interview guide and preliminary codes (Stuckey, 2015). Reflexivity, already discussed in detail, also served to strengthen confirmability. OLDER ADULTS AND SMARTPHONE USE 15 Findings The participants provided information about themselves including participant type, gender, marital status, age, occupation and type of smartphone (Table 1). There were three married couples and two individuals who did not bring a partner for a total of eight participants. Table 1 Description of Participant Demographics Participant Gender Marital Status Age Occupation Smartphone Operating System 1 Male Married 75 Retired: farmer Android 2 Female Married 75 Retired: school teacher Android 3 Male Married 78 Retired: consultant Android 4 Female Married 67 Retired: homemaker iOS 5 Male Married 67 Retired: corporate manager iOS 6 Female Married 76 Retired: office worker Android 7 Male 60 Current: maintenance worker iOS 8 Female Single 67 Current: hospital insurance Android specialist Couples Individuals Married Four main factors were found to drive the use of smartphones by the older adults in this study: ability, social influence, attitude, and perceived need (Table 2). Ability was the largest and most complex of the these factors and was comprised of the following categories: smartphone device, effort expectancy, experience, available resources, and self-efficacy. Social influence was composed of categories including younger generation, family influence and peer pressure. OLDER ADULTS AND SMARTPHONE USE 16 Attitude included categories of societal concern, social acceptability, and privacy concern. Perceived need included categories of communication, safety, caregiving, work, and cost. Usefulness included categories of frequency of use, convenience, and apps used. Table 2 Factors affecting use of smartphones by older adults Theme Category Subcategory Ability Smartphone device Physical limitations Phone design Phone features Effort expectancy Ease of use Mistakes Experience Paired use Shared use Evolution of use Frequency of use Available resources Training resources Training Learning When in doubt Self-Efficacy Not smart enough Fear of misuse Decisions Training retention Social Influence Younger Generation Family Influence Peer Pressure OLDER ADULTS AND SMARTPHONE USE Attitude 17 Societal acceptability Social concern Privacy concern Perceived Need Communication Safety Caregiving Work Cost Use Frequency of use Convenience Apps used Ability Ability refers to a persons skills or competence using a smartphone given their current physical, cognitive, and psychosocial status. Ability to use a smartphone was influenced by features of the smartphone device, effort expectancy, experience, available resources, and selfefficacy. Smartphone device. The smartphone device refers to the physical features, capabilities, and complexities associated with the actual device. Features of smartphones devices, which had an influence on participants ability to use a smartphone, included the screen size, display, and icons. Features that contributed to ease of use included a stylus for easier screen selection, adequate display size, and touchscreens. While there was a consensus that phone size display may be slightly too small to clearly see and push buttons accurately, others mentioned features exist to change the keyboard settings to make letters larger or easier to select. Issues related to selecting items on the phone were due to touch screen sensitivity, size of the phone, small text size, or the complexity of the device. Participants reiterated phone size was an important feature OLDER ADULTS AND SMARTPHONE USE 18 contributing to ease of use and ability to use the smartphone. In reference to his mother, one participant stated: We tried to find something bigger with bigger keys and something she could read and theres almost nothing available. So as we get arthritis or you know, become less nimble, I think using the current phones or if they get smaller it will become more and more difficult, plus the eyesight type thing. Certain procedural tasks and functions available on smartphones were challenging to remember, such as how to access settings or contacts. Multi-step tasks often led to confusion and difficulty navigating the smartphone. The need for devices to be user friendly for all individuals became apparent with participants reports of confusion and frustration. Many participants found that the icons used to delineate functions did not make sense to them, and reported having difficulty locating the settings icon and navigating the lists of choices within it. I think for seniors the keyboard, or the symbols, it becomes harder and harder to navigate through those. I know for my mother it was difficult. The complexity of menus was not the only aspect of smartphones that caused participants difficulty. Pre-set settings such as the limit of volume a smartphone can produce and text sizes that only go so large were noted to not always be loud enough or large enough for comfortable use. One participant stated about their mother, And [we needed something] louder; it wasn't an iPhone, obviously, but you know she still couldn't hear it ring. Effort expectancy. Effort expectancy is the anticipated degree of ease associated with smartphone use. The more difficult the participant perceived the device or application, the less likely they would be to use itusing some of the applications are more difficult than theyre worth. Participants found that working toward completing a task on their smartphone could be OLDER ADULTS AND SMARTPHONE USE 19 challenging. In reference to completing a task on her smartphone, one participant stated, Well I just get frustrated sometimes and just quit. When trying to understand their smartphone and seek help, the help desks that you call sometimes are more frustrating than they are helpful. Directions to increase ease of use were not readily available or simple to follow, leading to frustration and a decrease of use. Experience. Experience is the amount of previous use and knowledge an individual has with a smartphone. The extent of experience using a smartphone had a direct influence on the participants ability to use smartphones. With more experience, participants had greater success and confidence when using their smartphones. Regarding incorrectly pressing buttons, one participant stated when asked about making mistakes when using their phone, ...I think as users, getting more experience, you kind of grow out of that. However, participants emphasized that with experience and repetitive use, they were more likely to remember how to complete the desired task. If I dont use it then I forget it. People will show me things and if I don't use it, then two weeks later I am like how did they show me that. I don't remember. But if I use it then I am fine. Available resources. Available resources refer to the aid, support, or person an older adult seeks out when guidance is needed to perform a function on their smartphone. Older adults typically asked family members or friends for assistance with their smartphone. Other common resources accessed when in need of assistance with smartphones included referring to the user manual, watching YouTube videos, contacting a help desk, attending a class, or visiting the mobile phone provider. One participant stated, If there were some instructions, I would try to read the instructions first and then go to a family member. Similar ideas were shared when OLDER ADULTS AND SMARTPHONE USE 20 seeking available resources, I might go back to the store I bought my phone, more than likely I would talk to my son-in-law. As participants encountered difficulties with their smartphones, they preferred one-onone instruction and often turned to a younger family member for support. When asked who the participants turn to when they ran into difficulties using their smartphone, one participant responded with, anybody younger: students, daughter, grandkids, while another stated, We have a young guy at work and he is a techie and he does all sorts of things. He is like 25, so I have learned a lot from him actually. He has shown me how to do all sorts of things. Self-efficacy. Self-efficacy is defined as the participants belief in their ability to successfully perform needed tasks and functions on a smartphone device. Low self-efficacy negatively impacted ability to use the smartphones correctly, I hit buttons a lot for something in settings that I am trying to find and I just go through all the different choices until I find what I am looking for. Once in a while I call my son and ask him something; hell say wait a minute, this one is for the books, like its a really stupid question. Some participants felt inadequate or experienced lower levels of self-efficacy in their ability to solve problems encountered during smartphone use. These participants did not feel comfortable with open exploring on their phone when they ran into a problem, one participant did experiment some with their smartphone to figure out the intended function, I do three things. I play with it for a while and then if I dont figure it out I might Google it or call our son. Throughout the focus group, when there was a lack of confidence, there was a decreased ability to successfully use their smartphone. OLDER ADULTS AND SMARTPHONE USE 21 Another factor that contributed to self-efficacy was a fear of misusing or damaging the smartphone device during use. A fear of misuse can be defined as an individuals belief that they do not have the ability to perform certain functions on their smartphone. Thus, they believe they will perform an unintended or irreversible task, You know, Im afraid of what if I touch that and its going to do something wrong or call somebody I dont want to call. It was mentioned that performing complicated tasks such as closing out an application influenced this notion of messing something up due to not being able to reverse what was done. ...I really have a mess sometimes, I dont do things right, so then I think I have to learn how to get myself out of it because I havent ruined anything Participants mentioned they felt uncomfortable clicking icons and pushing buttons when they were unfamiliar with what the icon did. For example, I watched my little granddaughter get on my iPad and I thought she was going to crash the thing and I found out that she cant do anything to hurt it so I dont suppose I can either. Overall, in fear of making a mistake that they would be unable to fix, participants did not click icons or buttons for which they did not know the purpose. Social Influence Social influence refers to the impact other individuals have on how the participants use their smartphone. Participants felt there was a push from their children, grandchildren and peers to obtain and use smartphones. When asked about who influenced their smartphone use, one participant responded with, I think family is the biggest influence... Another agreed by saying, I guess our son-in-law is our big influence and our grandkids. I said if I could keep a grandkid with me all the time I wouldnt need a smartphone. When older adults were asked why they got their smartphones, they stated, My daughter insisted that I have a phone... Some participants did not originally believe there was a need for a smartphone, but got one to appease their family OLDER ADULTS AND SMARTPHONE USE 22 members. I think [there was] some family pressure and peer pressure to upgrade... It was expressed, if their cell phone still worked, they felt there was no need to replace it with a smartphone. One participant remarked that a phone representative stated ...if I was a vet and this is your pet, I would say its time to put it down, when her phone was taken in for maintenance. After the encounter, she was still reluctant to purchase a new phone because she did not feel there was a need, but felt she was expected to. Some participants mentioned feeling that friends and family expected them to be available to communicate at all times, but believed it was a personal choice whether they wanted to be connected or not. Participants noted social expectation to have their phones on them and be accessible at all times: Some expectation in the world and in the environment, now, that you have a smartphone and can be reached and things like that. A little bit of peer pressure, but if people need to reach us there is that expectation. Though they may not want to be reached at all times, a few participants mentioned the influence of family, friends, peers, and members of younger generations on how they use their smartphones. Attitude Attitude is defined as the participants positive or negative feelings toward smartphone use. Older adults attitudes and values influenced how they used their smartphone in everyday life. Components of attitude which emerged in this study included social acceptability, societal concern, and privacy concern. Social acceptability. Several participants conveyed that it was not socially acceptable to be on your smartphone in public; however, they did note that it is becoming more acceptable in OLDER ADULTS AND SMARTPHONE USE 23 todays society. One participant stated, Several years ago you heard a lot about people in restaurants complaining about phones, but you don't hear anything about that anymore and people are constantly on phones, and it is very rare that people complain about it anymore. However, another participant disagreed when discussing smartphone use in public by stating, It is still rude and annoying. Overall, the remaining participants agreed that the social acceptability of smartphone use has increased with the generational tide. Societal concern. Several participants noted societal concerns regarding smartphone use by younger generations. These concerns included being constantly preoccupied with smartphones, disengaged in conversations while using their devices, and a decrease in critical thinking skills due to smartphone use. Older adults felt that their generation placed less importance on smartphone use and instead, focused on other forms of communication. Participants felt that increased smartphone use has contributed to decreased social skills for individuals of younger generations. A participant supported this concept by stating, There should be mutual respect that you put down your phone and be a part of the group versus texting... One older adults agreed with younger generations having decreased social skills by saying, They go for their job interview, then they don't know how to have a conversation with a professional...my grandson doesn't know how to do that and to his detriment, because he's on his phone all the time and he's 18 years old. Another participant expressed, I think now, we as a generation, we have more conversations. The younger generations, they all have their phones. They'll be sitting in the same room, but I dont know if they are talking to each other. Another agreed with this statement, Yeah I mean they do not even pay attention to what is going on around them, let alone who they are next to or OLDER ADULTS AND SMARTPHONE USE 24 where they're at or anything. Lack of awareness. Older adults combatted this by not using their smartphones in social situations to ensure the quality of time spent with others. Older adults felt less immediacy for smartphone use compared to younger generations. One participant discussed his thoughts and frustrations about this expectation of use when he said, I think it is becoming more acceptable, just like work is texting me right now [eyebrows raised and hands thrown in air]...I think it is kind of rude that my phone is ringing right now in this atmosphere, but I think it's becoming more acceptable because that is just the way it is anymore. He continued to state his frustration about younger generations being disengaged with their surroundings and lacking social skills by intensely stating, ... I am around students a lot at [work] and its very annoying because when they walk out of class, immediately they are on the phone Students will pay absolutely no attention to what is around them. Zero. I frequently travel on the sidewalks with a pick-up truck or some kind of motorized vehicle... and I have literally had to stop on the sidewalk because there is a student coming towards me, face in the phone, and has no idea that I am sitting there with a pickup truck. They have literally gotten within 5 feet of me before they have realized that I am there. Another participant commented positively regarding this new expectation saying, I think one of the positive things about all of this is it teaches young people how to respond very quickly to things that they do see, and I know that military likes to get gamers and things like that because theyre used to getting things on screen and responding quickly. Concern was expressed over the growing dependence of younger generations on their smartphones. Participants felt their generation was not reliant on their phones as compared to OLDER ADULTS AND SMARTPHONE USE 25 younger generation smartphone use. I keep saying Im not married to my phone. I check it maybe twice a day and my family they all know if they want to get ahold of us, call. Another agreed by saying, Im not attached to my phone and I dont want to be, so if somebody really needs to get ahold of me theyll text me, or theyll leave me a message, or theyll call me." Some older adults did convey that dependence on smartphones may be necessary at some point in their lives. One participant supported this by stating, I think for seniors, if you had a medical condition, a really severe medical condition, it would probably enhance your independence by being able to go out and if you had an episode you could contact someone. That doesnt apply to use now but eventually it may. Participants were adamant that they did not want to be tied to their phones and did not feel the urgency of smartphone use as compared to younger generations. Older adults also explained that younger generations lacked critical thinking skills and expected immediate gratification due to instant access to information at all times through smartphones. Regarding societal concerns, one participant contributed, I think it creates lack of critical thinking. You know, instead of having to figure something out they just Google it. They get the information just like that. They don't have to ponder and think this was like this, and this was like that, then what would be the result. They just get the answer instead of figuring something out. One participant challenged this notion of people being tied to their phones and engaging less in conversations by stating, I think it depends on the situation. I could see that sometimes in a conversation it would be helpful to know and Google something and there could be other times when it's not; the urgency is not there. OLDER ADULTS AND SMARTPHONE USE 26 Privacy concern. Participants expressed they did not store sensitive information on their smartphones due to having concerns about privacy. We dont put anything on the phone thats sensitive, we dont store passwords, and we dont store accounts. Participants provided advice about storing information on smartphones, Dont put things on there that are that critical. I mean if its that critical you dont put it on there because I dont think it is private. I mean I think that if somebody wants to find out what is going on, some people have capabilities...I mean who knows for sure who has access to our information. Perceived Need Perceived need can be defined as the degree to which the older adult participants perceived they needed to use a smartphone. The factors that influenced perceived need included communication, safety, caregiving, work, and cost. Communication. Communication refers to the need participants have to connect with others through the use of their smartphone. Communication was a popular reason for smartphone use. The main reasons that communication was important included the need of being reachable away from home, by work, family, or friends in case of emergencies and for socialization purposes. All participants expressed the importance of having a phone for safety. One participant stated, Its really nice when you are out there working on the tractor and something goes wrong and you can just [call] right then and say I need help. Participants discussed the need to communicate during medical emergencies. One participant expressed this by stating I think for seniors, if you had a medical condition...it would probably enhance your independence by being able to go out and if you had an episode you could contact someone. That doesnt apply to us now but eventually it may. OLDER ADULTS AND SMARTPHONE USE 27 Safety. A popular thread when discussing the necessity of a smartphone was the aspect of driving. Three participants stated they got their phone for safety while driving, including being able to contact someone in case of car trouble or emergencies. One participant stated, I just mainly have it with me for actually safety, if I was driving and I need to call... Three participants discussed they used their phones for navigation while driving, since it updates traffic conditions including accidents and a standard navigation system does not. Regarding the navigation system, one participant said, We can put the app in and it really almost tells you your location and theres especially the traffic, and if theres accidents or traffic and its helpful when you are traveling. Caregiving. Another theme which emerged as a reason participants needed a smartphone was tied to the role of caregiver. One participant expressed her need for continuous accessibility while others are providing care for her adult daughter with special needs, We also have a special needs daughter and it was nice to be able to be available. They could reach me if they ever had a problem at her program so its still that way. The participant explained that games were also important to have on her smartphone as a source of entertainment for her daughter, stating, She [daughter with special needs] likes to do matching games and all that and she has an iPad, but if we are out some place, then she can do it on my phone. So, I have a few of them loaded on here so she can play some of the matching games. Gives her something to do. Another participant expanded on the use of smartphones within the role of caregiver for an aging parent, I think for family support, emergencies, for medical reasons, I know I mentioned my mother, when she was living, you know, to make sure we could be contacted if she needed help. OLDER ADULTS AND SMARTPHONE USE 28 Work. Many participants were influenced by their current or previous employment to have a smartphone. Two participants stated that they first received their phones through work. One man stated that while he was employed, You had to try to find an internet connection to get to do some of the work that I had. And a laptop and a lot of times a paid telephone booth so I got a phone to start out with and then you know just the flip phone and then went to the smart. An additional participant explained, I probably got mine in the late 80s, mid 80s, and it was really because of my work at the time and the company provided the phones to me or to all of our managers. For the remaining participants, work was not a driving force on their decision to purchase a smartphone. One participant still currently working, explained she was unable to use her smartphone within her profession, One of the reasons I dont use mine at work is because of the MRI machine just eats up the life of the battery, so I keep it in my purse tucked away and it doesnt go away quite so quickly. But, inside of a hospital is not a good place to use a cell phone. Cost. The cost associated with purchasing and maintaining use of a smartphone appeared to influence use. When discussing the process of purchasing a smartphone, cost was found to be a substantial factor. Half of the participants noted that the only reason they got a smartphone was either that it was free through work, or that a family member pays for their phone and phone service. One participant explained, Well because my daughter insisted that I have a phone and she pays for it, so thats even better. Other participants stated that store deals allowed them to upgrade for free, or other specials were available which helped them when making the decision to purchase a smartphone. One deal was described as, ...it said if you have a workable smartphone and you want to come in we will give you $200 for it and you can get an S7 and all it OLDER ADULTS AND SMARTPHONE USE 29 costs you is sales tax for a new phone. Additionally, one participant commented on the rising costs of smartphones, yet he continues his services. He stated, The expense of it too, I mean it can start adding up you know what I mean I can remember back when we spent 30-40 dollars a month for phone and thats all we did. Now we spend you know its easy to spend 200-300-400 a month on phone service of all kinds. Use Use is defined as the way in which a smartphone is utilized. Collectively, the participants discussed their use of smartphones including: frequency of use, convenience, and apps used. Frequency of use. The participants frequency of smartphone use was inconsistent and varied between each individual. When asked how frequently participants used their smartphones throughout the day, some participants conveyed that they used their smartphones frequently, and others expressed using their smartphone only minimally. When asked how often participants used their phone, one participant replied, Constantly. From the time I get up in the morning, about 6-6:30, I check it to see if I have any messages, like from our daughters driver, or what the news is of the day. I have an app for one of the local stations and it gives me breaking news. I use it all day long; if I get a bill in the mail, I pull up our bank and pay a bill, and go shopping. I text everybody back and forth instead of calling them, I google things. I use it all day until I go to bed at night. In contrast, another participant stated, I have my phone with me in case someone needs to get a hold of me, but Im not attached to my phone and I dont want to be. Participants expressed a general consensus of a desire to not use their phones constantly. OLDER ADULTS AND SMARTPHONE USE 30 I use [my smartphone] throughout the day probably hourly or half hourly but I havent become addicted to it like I think some people have and I dont play games I probably only use 10-15% of its capacity because you know I dont want to become tied to it. I use it for the basics, I dont use it, very rarely, when I drive so there are times of the day when I dont depend on it and dont use it and resist the temptation to use it. Convenience. Convenience refers to the reduction in effort to carry out various functions. Every participant alluded to the convenience that is created by owning a smartphone. One participant stated, You go to the grocery store and somebody forgot to tell you to get something, you get back home and [they say] we needed this too. And I mean that really does come in handy a lot of times. And then work, I just use it, I use it all the time for work. Participants discussed several positives aspects of the convenience provided by using a smartphone. One opinion was, Yeah to be available at any time. Thats been probably the best thing about having one, again, I just I use it for everything. Another participant stated, If we are going somewhere, you used to get out the atlas and look at it, and spend a half an hour mapping out a route. Now you punch it up on your phone and it tells you exactly where to go. And if it's somebodys birthday next week, its one of my grandkids birthday next week, what day is it on, oh it's this day.... It's just, it's more convenient to have the information. It was also beneficial for the participants to be able to take their smartphones with them wherever they went: It is convenient, it is light, it is a nice size. Apps used. Participants discussed the various apps they used for communication, navigation, time management, data storage, social media, shopping, financial management, OLDER ADULTS AND SMARTPHONE USE 31 information exploration, and entertainment apps. Apps commonly used for communication management included text messages, video calls, voice calls, voicemails, and emails. Participants discussed using these apps to communicate with family, friends, and work. One participant enjoys the benefits of video calls, Now its nice to be able to FaceTime and see what the kids are doing the grandkids and if they have done something special in school theyll send you a picture of what theyve done or you know theyll call you and tell you something. Its nice. Another participant discussed managing his emails via smartphone, I get a lot of emails and Im always checking my computer and I just scan down and if they look like something I had to respond to I would; otherwise, I would just leave them on there...One thing I found on the cell phone when they come in, they are easy to delete and I keep much more up to date on that now. Navigation was another app discussed for use while traveling: We can put the app in and it really almost tells you your location and theres especially the traffic, and if theres accidents or traffic and its helpful when you are traveling. One application that was discussed, which would be in considered in the occupation of time management, was the calendar app. In reference to this app, one participant expressed, I keep things in it that I need to keep track of. Participants also discussed using their phone apps for data storage like the photo album for picture storage, and storing documents and recipes via cloud storage apps. One participant expressed using cloud storage: ...some of the clouds and the store information back and forth and we follow those apps. It was expressed by another participant that she desired to learn how to specifically save her recipes via Dropbox. The only app discussed relating to social media was OLDER ADULTS AND SMARTPHONE USE 32 Facebook. One participant mentioned social networking as a way for sharing information by stating, No one has mentioned Facebook...people send stuff all the time and you can see the pictures and things. Several participants discussed using their smartphones for shopping, with apps like Costco, JoAnn Fabrics, Cartwheel (Target), Michael's. One participant stated, hmm I cant think of what else, but I have a lot. A few participants reported using banking and stocks apps for financial management. One participant stated, I use a lot of it for like your stock the PNC apps for grain markets and oil, so on and so forth what the current standing is. Google, weather apps, and news apps were heavily used by the participants to access information and keep up with current events. One participant expressed his feelings towards the app stating, Google is really handy though, if I want to know something its fast and I cant believe how fast it is. Three participants indicated that they use their phones for entertainment with games. One participant expressed, I play games occasionally, but my granddaughter is on hers all the time. In reference to the perceived use of smartphones for entertainment, one participant stated, As parents, when all of our kids were little you know, we would park them in front of the TV at times to entertain them... and now I think they have all these other things that the parents use...theres just so much more available than when our kids were little and entertainment. Many participants used and liked the applications, however, one participant expressed negative feelings and felt that many of the apps were not beneficial to him, ...theres no benefit to a lot of the applications in my opinion. Discussion The purpose of this study was to explore older adults acceptance and use of smartphone technology to check for redundancy of the Walker et al. (2015) preliminary model in order for OLDER ADULTS AND SMARTPHONE USE 33 occupational therapists to optimize the fit between older adults and smartphones used to support daily occupations. The preliminary model created from the previous study consisted of four constructs which included ability, attitude, perceived need, and social influence. Factors within the Walker et al. (2015) model found to influence an individuals ability to use a smartphone included physical aspects of the device, available resources, effort expectancy, and self-efficacy. Findings confirm the primary constructs of the original model (Walker et al., 2015); however, investigators found inconsistencies among contributing factors. Ability Ability was found to have a substantial impact on smartphone use. The participants ability to use their smartphone was influenced by physical features of the device, effort expectancy, experience, available resources, and self-efficacy. Smartphone device. Participants preferred smartphones that had a large display screen, were lightweight, and could easily fit into pockets or purses. Participants in this study also reported a desire for smartphones to be durable, have the capability to take clear pictures, and allow easy access to their important information stored on the device. Plaza, Martn, Martin and Medrano (2011), found that older adults experienced difficulties operating phones with small screens due to the decreased size of the information presented on the screen. Plaza, Martn, Martin and Medrano (2011), support the findings of this study, as it is recommended that smartphones continue to be designed with larger screens, simple menus, and universally representative icons to promote use by users of all ages. Occupational therapists are positioned well to provide educational resources to assist older adult consumers in selecting appropriate smartphones to reduce effort expectancy with smartphone use as well as increase independence while using this as a tool within their daily life (Fletcher & Jensen, 2015). Occupational OLDER ADULTS AND SMARTPHONE USE 34 therapists can also recommend adaptations to smartphone settings to increase size of onscreen buttons and inform clients of shortcuts for use of menus and icons to assist with older adults integrating use of their smartphone device into their daily routines. By providing recommendations, occupational therapists can reduce the impact of many barriers between physical design and productive use of smartphones. Effort expectancy. Findings indicated older adults were less likely to use their smartphone devices if viewed as difficult or unfamiliar. Participants noted they were less likely to use an app or smartphone feature if they perceived the associated steps were difficult to remember or if menus were too complex and confusing. The participants discussed challenges associated with various apps and functions Participants reported they would start a task on their smartphone then becoming frustrated and quit the task entirely. A study conducted by Zhou, Rau, and Salvendy (2014), identified a strong correlation between perceived ease of use and an older adults ability to operate their smartphone successfully, whereas the amount of effort needed to complete a task on the participants smartphone directly influenced the likelihood of completing the task successfully. Nagle and Schmidt (2012), found that older adults accepted technology when the system gave the impression it was easy to master, provided immediate technical support, and allowed for simple communication between family and friends. Older adults often experience an increase in effort with smartphone use due to possible changing in their physical, cognitive, or sensory functions as well as, acceptance of use or the advanced design of the smartphone (Fletcher & Jensen, 2015). When an occupational therapist makes recommendations, which require smartphone use, hands-on, repetitive training, with opportunities for practice should be incorporated into the treatment plan as well as follow-up to OLDER ADULTS AND SMARTPHONE USE 35 ensure carry-over of skill in order to increase confidence in hopes to also decrease anxiety and effort expectancy. Experience. Participants relayed that the more experience they had, the greater success and confidence they experienced when using their smartphones, therefore enhancing their ability to use their smartphone with less mistakes. According to Grindrod, Li, and Gates (2014), older adults were more likely to become frustrated and make more mistakes when they were first time smartphone users. As older adults experiment and use their smartphones more often they can manipulate their phone successfully. According to Mori and Harada (2010), older adults who lived with a grandchild were more likely to be able to perform complicated tasks on their smartphone due to more opportunities for older adults to have supervised practice with their grandchild, enhancing their overall experience with smartphone use (Mori & Harada, 2010). As a result of these findings, it is evident that within occupational therapy practice we have a role to not only provide recommendations to assist with smartphone use but also assist with step by step practice with clients in order to ensure carryover. It is also important for the occupational therapist to encourage family and friends to guide older adults through procedures rather than completing the tasks for them. Having the individual complete tasks themselves will ensure greater learning retention. Available resources. When seeking support or assistance using their smartphone, participants reported use of the internet or a training manual on occasion, but did not find these methods to be near as helpful as training from friends or family members. The most commonly used resource for technological support shared by participants were friends and family members, specifically those of younger generations. Individuals who received smartphone assistance from their grandchildren were more likely to be advanced in using their device when compared to OLDER ADULTS AND SMARTPHONE USE 36 others (Mori & Harada, 2010). According to Loorbach, Karreman, and Steehouder (2013), older adults prefer learning how to use their device from other users personal stories rather than using a training manual. Given the frequent reliance on family and friends for technological support, when learning how to use applications on a smartphone, it is essential for occupational therapy practitioners to collaborate with key friends and family and include them in aspects of training. Self-efficacy. Self-efficacy was found to have a significant contribution to the participants ability to successfully use their smartphones. Most participants indicated a fear of misusing or breaking the device, or not being able to properly close specific applications. Participants also expressed that feelings of incompetence with operation, which negatively impacted their overall ability. Previous evidence from Zhou et al. (2014), found that when older adults were unsure how to use a new smartphone application they experienced a fear of breaking the device. Research from Grindrod, Li, and Gates (2014), related to these findings by conveying that older adults did not feel comfortable using their smartphones to integrate use of specific applications until after a period of training. It is evident that older adults often experience lack of confidence using their smartphones which negatively impacts on the way they use their smartphones. Occupational therapists can promote self-efficacy for smartphone use through stepby-step training while older adults are learning to use novel applications. Occupational therapists can also use graded practice opportunities, support, and education to facilitate carryover and confidence with use. Social Influence Findings indicated participants children, grandchildren, younger generations, and peers/friends were the main reasons for acquiring and using smartphone technology. Purchasing and using smartphone technology was connected to being pressured to be available at all times OLDER ADULTS AND SMARTPHONE USE 37 from family members. Participants relied on friends and family for input on purchasing a mobile phone, but also upgrading to smartphones. Zhou et al. (2014) noted that family members frequently advised older adults to obtain cell phones so they could be conveniently and that older adults rarely made their own decisions when buying smartphones. It is important for occupational therapists to understand the importance of the role of family within the social context when recommending applications for older adults. Recommending smartphones and applications already used by multiple family members or easily accessed and understood by family members will enhance carryover and provide a source of available support as needed. Attitude Participants felt that younger generations spend an excessive amount of time using smartphone technology, affecting their social skills and critical thinking. Participants conveyed more accepting attitudes toward smartphone use than demonstrated in previous literature. According to Mitzner et al. (2010), older adults believed the positives of using technology outweighed the negatives, especially when the technology encouraged independence and continued socialization. While some older adults have positive perceptions of smartphone technologies, others worried that it may replace human interaction (Harrefors, Axelsson, & Savenstedt, 2010). Older adults have had positive attitudes toward smartphones used for cases of emergency (Zhou et al., 2014). Attitude, as a factor that influences use, can be influenced by occupational therapists to support client occupations using smartphone technology. It is important for occupational therapists to assess older adults attitudes on smartphone technology that may influence use. For older adults who have negative attitudes toward smartphone technology, occupational therapists need to educate clients on the benefits of use, importance of improved occupational performance, weigh pros and cons related to use, address possible OLDER ADULTS AND SMARTPHONE USE 38 barriers to use. It is also essential for practitioners to understand that smartphone technology may not be the best tool to enhance occupational performance and should consider alternative means to facilitate optimal outcomes. Social acceptability. While the expectation from society was to constantly have smartphones on hand and readily available, participants were able to discuss related positive and negative outcomes. Regardless of positive or negative perceptions of the way society views smartphone use, participants recognized the use of smartphones becoming progressively more accepted, especially for younger generations. There was still a general consensus that smartphones were heavily used by the younger population and that use in public was considered rude, but becoming more accepted by society. Forma and Kaplowitz (2012) agreed that cell phone conversations were perceived as being more rude than face-to-face conversations, thus confirming negative stigma of use. Therefore, it is important for occupational therapists to consider how clients view the acceptability of smartphone technology when recommending applications, as acceptance may influence use. Societal concern. The older adults in this study believed that the increase of smartphone use has decreased social skills in younger generations. There was also a less perceived immediacy for smartphone usage as compared to younger generations. Older adults also expressed the lack of critical thinking skills in younger generations due to using smartphones and the sense of instant gratification that is produced from smartphone use. These findings are similar to a study that by van Deursen, Colle, Hegner, and Kommers (2015), that found older adults are less likely to become dependent on cell phone use as young people. In this study, compared to younger generations, older adults felt they placed less significance and experienced less dependency on using smartphones. There was limited research regarding older adults OLDER ADULTS AND SMARTPHONE USE 39 societal concern regarding smartphone use of younger generations. Occupational therapists can utilize this information to increase their awareness of how differently older adults may view smartphone technology and allow them to validate older adults societal concerns related to use. Privacy concern. Older adults did not store sensitive information on their smartphones, so they were not concerned about unintended dispersion of sensitive information. However, older adults would be concerned with sensitive information if they had it stored on their phones. McLeod (2009) also found that found older adults felt distressed and had negative feelings toward smartphones when storing personal information. McLeod (2009), found that smartphone capability of storing personal or sensitive information may cause older adults to worry that unauthorized distribution of their information may occur. Thus, occupational therapists need to consider and respect this generation's privacy of personal and sensitive information to better recommend applications and promote aging in place. Occupational therapists can also use this information to reduce barriers in order to increase positive attitudes toward smartphone use. Perceived Need Perceived need was a main theme consisting of the following categories: communication, safety, caregiving, work, and cost. Peek et al. (2016), determined that older adults do not use technology unless they see a need for it, and identified one of the three major attitudes of older adults that influence their use of technology as the perceived need for technology. All participants in this study confirmed that smartphones are useful, and they perceived a need to own one. Previous research showed that older adults will only adopt smartphones after they have perceived that it was useful (Reneau, 2013). Mobile technology allows individuals to monitor their overall well-being, retrieve up to date information, and seek out ongoing support for their health or chronic disease management (Joe & Demiris, 2013). Due to the convenience and access OLDER ADULTS AND SMARTPHONE USE 40 to medical information, mobile technology has become more frequently used by older adults (Joe & Demiris, 2013). Health professionals, including occupational therapists, may influence the perceived need of older adults to use smartphones, through providing education on the benefit of tracking medications and medical appointments electronically (Fletcher & Jensen, 2015). It is important to emphasize to older adults how smartphones can be used to support occupation (Fletcher & Jensen, 2015). Communication. Participants described the perceived need of smartphone use for communication purposes. They explained that the appeal of a smartphone in regard to communication is the ability to be reached by family, friends, and work while away from landlines. These findings agree with Gitlow (2014), who determined social communication was one of the most common reasons older adults use cell phones. While participants felt that communication was more convenient with use of a smartphone, they also expressed the expectation to constantly be available. According to McLeod (2009) and Gitlow (2014), most older adults use their cell phone every day for socialization including personal calling, texting, checking voicemails, and emergencies. As participants engaged in socialization through the use of smartphones occurred through video/voice calling, texting, and social media, it is important for practitioners to highlight the benefits of older adults remaining in contact with family and friends to reduce depression and loneliness (Fletcher & Jensen, 2015). Safety. Findings indicated that older adults value the security provided by owning a smartphone in case of emergencies. Finding are in agreement with Kubik (2009) and Zhou et al. (2014), who recognized that older adults typically valued the usefulness of cell phones during emergencies. Another aspect of safety that was discussed was the need for a smartphone while driving for safety and navigation. Participants expressed the convenience of utilizing navigation OLDER ADULTS AND SMARTPHONE USE 41 features of their smartphone for traveling purposes. Lin and Da Young (2015) stated that more and more drivers are using navigation applications on their smartphones even if there is an invehicle system available. Participants discussed how smartphone use while driving can impact safety and emphasized that smartphones could decrease safety if used while operating a vehicle. This idea was heavily supported by the National Safety Council, and known as driver distraction while forcing the brain to multitask. Occupational therapists can present the benefits of using a smartphone by framing it as a tool to increase Older adults safety due to their ability to contact someone in an emergency or find a route when traveling in unfamiliar areas (Fletcher & Jensen, 2015). Caregiving. Participants described the importance of communication in the role of caregiver, whether caring for parents, children with disabilities, or grandchildren. There are an estimated 29.2 million people that are currently caring for a family member over 18 years of age with a disability or chronic illness (Family Caregiver Alliance, 2010). Family caregivers are the largest source of long-term care services and it is predicted that the number of family caregivers will increase to 37 million by 2050 (Family Caregiver Alliance, 2010). The need for caregivers is increasing as the baby boomer population ages. When occupational therapists are discussing the role of being a caregiver, a smartphone can be a useful solution for caregivers when they need to be away from home to run errands. Caregivers can also use smartphones to communicate with the person they are caring for through text messages or video calls to monitor how the person is doing. Work. This study determined that two of the eight participants adopted smartphones because of work requirements. According to Mcleod (2009), sometimes, older adults decided to purchase a cell phone specifically used for employment. As the baby boomer population OLDER ADULTS AND SMARTPHONE USE 42 continues to age, work may become a more predominant factor in smartphone adoption. Since work is considered a main occupation (AOTA, 2014), it is important for occupational therapists to discuss technology use at work and the benefits of similar technology that can be used at home to assist in the productive aging process. Cost. During this study, when discussing the factors, the participants considered when purchasing a smartphone, cost was the most common consideration. One participant alluded to the rising costs of smartphones and service, yet still purchased and used a smartphone. Mallenius, Rossi, and Tuunainen (2007) stated the current baby boomer generation is concerned with high prices of technology. An interesting aspect of this study was that most of the participants received their smartphones at little to no cost due to various sources (i.e., work, family, or store deals), these findings may indicate a need for further research on the topic of how older adults afford smartphones. It is important for practitioners to make feasible and affordable recommendations for smartphones and applications, given many older adults consider cost as a barrier to smartphone adoption/use (Wallace, Graham, & Saraceno, 2013). Use While the frequency of use varied from minimum to maximum use between participants, reasons for use included personal use, communication management, navigation, time management, data storage, accessing social media, shopping, financial management, information exploration, and entertainment. Depending on how a client uses his or her smartphone may depict how well it might work as a tool to support occupational performance. Although sample size is not a limitation for a qualitative study, the generalizability of these findings is limited. Researchers interpretations of findings may be influenced by the generational gap between the participants and the researchers. Another limitation includes OLDER ADULTS AND SMARTPHONE USE 43 researchers prior exposure to Walker et al. (2015) study and preliminary model depicting a similar topic. Participants also may have been hesitant to fully express their thoughts as they were in front of a group of people. In the context of this study, the Walker et al. (2015) preliminary model is a practice framework that can also be applied to implement client-centered occupational therapy services with regards to smartphone technology. According to AOTA (2014), holistic occupational therapy interventions address virtual environments, functional communication, and the ability to access information as related to participation in occupations. Holistic occupational therapy services include overarching instrumental activities of daily living (AOTA, 2014). Through this evidence, occupational therapists could advocate for change in practice regarding technology and promote holistic care. Continued research to investigate the applicability and implications of smartphone technology use by older adults is crucial for occupational therapists to effectively support productive aging. To advance the future of smartphone design to assist with independence for older adults, there is a need for more research in global applications to capture both the needs of older adults and standard smartphones users in order assist with ADLs. This will facilitate the introduction of a global design, so that smartphone applications are simple enough to comprehend for users across the lifespan. A cross-generational design would eliminate the need to design applications specifically for older adult users as all applications would encompass this approach. Research should also include efforts to test the Walker et al. (2015) model on a large population to ensure redundancy of the model. Researchers should also aim to investigate comparisons in applications designed for use across the lifespan utilizing universal design versus OLDER ADULTS AND SMARTPHONE USE 44 applications designed specifically for older adults in order to assess the strengths and limitations of both designs. Conclusion Five factors contributed to participants ability to successfully operate their smartphone: physical characteristics of the device, past experience, effort expectancy, available resources, and self-efficacy. Smartphone use was collectively explained by the constructs of ability, attitude, perceived need, and social influence. Occupational therapists can use this model to thoroughly examine and consider the fit between older adults, smartphones, and related applications in order to provide client-centered recommendations to effectively support the occupational performance of their older adult clients using smartphone technology. Further, this model may also be used to inform the future design of smartphone technology and related applications aimed to support the needs of older adult consumers. OLDER ADULTS AND SMARTPHONE USE 45 References American Occupational Therapy Association. (2008). Occupational therapy practice framework: Domain and process. (2nd ed.). American Journal of Occupational Therapy, 62, 625 683. doi:10.5014/ajot.62.6.625 American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). 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Older adults use of smartphones: An investigation of the factors influencing the acceptance of new functions. Behaviour & Information Technology, 33(6), 552-560. doi:10.1080/0144929X.2013.780637 Ziefle, M., & Bay, S. (2005). How older adults meet complexity: Aging effects on the usability of different mobile phones. Behaviour & Information Technology, 24(5), 375-389. OLDER ADULTS AND SMARTPHONE USE Appendix A Interview Guide 1. Please share with the group when and why you got your first mobile phone a. Prompt what type of phone was that? 2. Why did you decide to convert to upgrade to a smartphone? 3. What did you take into consideration before getting a smartphone? 4. Who was the most influential person in your decision to get a smartphone and why? 5. How often do you use your smartphone? 6. What do you typically use your smartphone for? 7. What apps do you use and why? 8. For those of you who still have a landline, what do you use each phone for? 9. What are the benefits of having a smartphone? 10. How did you learn to operate your current phone? a. Did anyone show you how to use any of the features? 11. What do you like about the design of your smartphone? 12. What do you not like about your current phone? a. Is there anything hard to do? b. Any features you do not understand? c. Do you avoid any features on your phone? 13. If you could wave a magic wand, what would you change about the design of your smartphone? 14. For those of you who have had multiple phones, what did you like better about your old phone over your new phone? 53 OLDER ADULTS AND SMARTPHONE USE 15. What do you do when you dont know how to use a feature on your phone? a. Who helps you the most 16. In what ways do you rely on your phone on a day to day basis? 17. How do you feel your mobile phone contributes to your independence? 18. Do you have any privacy concerns regarding the information on your phone? 19. What is the difference between how you use your phone versus younger generations? a. Do you feel you use your phone as intended? b. Why do you think this gap exists? 20. Do you have any other suggestions or comments regarding your experience with mobile phone technology? 54 OLDER ADULTS AND SMARTPHONE USE Appendix B 55 ...