Utilizing Smart Televisions as Assistive Technology to Enhance Communication and Social Lives of Older Adults: Systematic Review

Introduction

Background

Over the past decade, the proportion of the world’s population aged ≥65 years has grown exponentially. Researchers have taken an interest in this growth and have recognized the importance of exploring ways to accommodate the older adult community. The older adult population faces numerous challenges, ranging from physical decline to cognitive dysfunction. However, one of the most notable barriers that older adults face is social isolation [1]: the disconnection from friends, family, and the world around them. Loneliness is 1 of the 3 main factors leading to depression, a prominent condition among older people [2]. Social isolation and loneliness in old age have significant negative impacts on both physical and mental well-being [1]. As the world’s population of older adults grows, digital technology has increasingly and significantly influenced their daily lives. As we continue to age globally, it is critical that assistive technology is used to our advantage as a tool for ensuring that older adults age with a good quality of life. The World Health Organization defines assistive technology as an umbrella term for assistive products and their related systems and services [3]. Assistive technologies can help improve an individual’s functioning regarding cognition, communication, hearing, mobility, self-care, and vision; thus, enabling their health, well-being, inclusion, and participation. Although a large population of older adults hesitate to use technology, many of them, as well as their caregivers, benefit greatly from assistive technologies [3]. In many countries, research has shown that the number of users of assistive technologies seems to increase with age. A study in a subsample of a population aged 79 years showed that 64% of them had one or more assistive technologies, specifically for bathing [4]. Wheelchairs and stairlifts also enhance the mobility of older adults [5]. Hearing aids and automated lighting systems support older adults with both activities of daily living and independent activities of daily living [6]. At the same time, the rapid growth of the older adult population has also raised awareness of the importance of aging at home. Extending the time before older adults need to move into long-term care facilities or nursing homes can be achieved by creating a comfortable environment for aging at home. However, one of the challenges older adults face as they age is maintaining connections with friends, family, and society as a whole. Older adults who live at home are more susceptible to feelings of loneliness and depression [7]. Despite the development of information and communication technologies over the past decade, Choi and Lee [8] in their systematic literature review, found only 23 relevant studies that used information and communication technology to improve social participation among older adults and reduce their loneliness. On top of that, future research needs to look more into emerging technologies such as the Internet of Things, augmented reality, and virtual reality, as older adults are often not sufficiently addressed in the design and implementation of these technologies, as reported by Thangavel et al [9] in their scoping review. A study conducted in China on implementing smart homes to build connectivity discussed how most research and development of smart homes has actually focused on younger people, leaving little attention to older adults [10]. In addition, around 63% of older adults in Canada are either nonusers or basic users of the internet and digital technologies [11]. On average, 22.3% of the older population in Europe uses computers, and 16.8% are internet users, with large differences between age groups [12]. These disparities and usability barriers pose significant challenges in implementing assistive technology intended to enhance social interactions among older adults.

Tapia et al [13] argued that the introduction of computer-based technologies for social interactions has negatively affected the ways older adults interact with their family members. This can be attributed to a lack of technological knowledge in this demographic and to their reluctance to adopt new technologies. Rather than utilizing computer-based technologies and other touch screen devices, such as smartphones and tablets, research has shown that it can be more effective to utilize smart televisions as an assistive technology for older adults, to provide them with opportunities for social interactions. A study in Portugal has shown that integrating technology into already familiar objects can reduce this reluctance to adopt new supports [14]. Among all familiar objects, smart televisions appear to be one of the most promising. Smart televisions offer unique advantages that make them particularly suitable for enhancing accessibility and convenience in everyday life among older adults. Their widespread availability ensures that many older adults already have access to this technology, reducing the need for additional purchases or installations. The integration of smart televisions as assistive technologies into daily life has high potential, as many older adults already use televisions as a central part of their routine. This approach not only facilitates the adoption of new technology but also enriches the user experience without overwhelming them with unfamiliar devices. A study conducted by Wang et al [15] reported high television watching time among 252 older adults aged between 65 and 88 years, where approximately 25% of them spent more than 4 hours per day watching television. According to a study conducted by Alaoui and Lewkowicz [16], smart television applications to support socially oriented activities for older people have been designed. They propose that integrating smart television as an assistive device considers quality of life by improving their well-being and self-esteem [16].

Objectives

To the best of our knowledge, despite the advantages offered by smart television design, its potential as an assistive technology for enhancing social communications among older adults has not been thoroughly explored. Thus, this study aimed to explore the state of the art in utilizing smart televisions as assistive technology for older adults to improve their communication and social lives.

Methods

Search Strategy

We performed the search based on the guidelines for performing a systematic literature review. A total of 6 databases were recommended: the IEEE, ACM, Google Scholar, ScienceDirect, Engineering Village by Brereton et al [17], and Springer by the Evidence-Based Software Engineering Technical Report [18]. This review was conducted without registering a protocol. The inclusion and exclusion criteria were defined before the search, as provided in Textbox 1.

Screening and Analysis

The search was conducted from February 20 to February 27, 2024. A range of keywords were used in different combinations, including “smart TV,” “older adults,” “elderly,” “communication,” “messaging,” “video call,” and “application.” The search yielded 6829 results: 169 (2.47%) from ScienceDirect, 13 (0.19%) from Engineering Village, 2 (0.03%) from the IEEE, 133 (1.95%) from the ACM, 4649 (68.08%) from Google Scholar, and 1863 (27.28%) from Springer. The screening process was conducted separately by the JL, CTC, and WKB. We removed 4158 (60.89%) duplicates and screened the remaining records. Their titles and abstracts were read for this round of screening, which resulted in the exclusion of 2610 (38.22%) records. The remaining 61 (0.89%) articles were read in full text to assess for eligibility. A total of 31 (51%) articles were excluded at this round of screening, and 30 (49%) articles were included. None of the articles were subjected to quantitative synthesis because of the significant variations in the data measured across the 30 included articles. Throughout the process, any disagreements were resolved through consensus.

On the basis of the aim of the systematic literature review, the included articles were analyzed according to the criteria described in Textbox 2.

Results

Study Selection

Figure 1 depicts the entire process using a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram [29], providing details on the reasons for excluding certain articles along with their corresponding quantities. Table 1 summarizes the details of each of the 30 included articles according to the analysis criteria. Six studies are related to the fostering social interactions for better life experience (FoSIBLE) project, which aims to provide bridging spaces to foster social interactions and experiences among older adults [16,21-25]. Despite focusing on the same project, we included all 6 studies and identified them as relevant through the search and screening process, as the objectives and reported outcomes of these articles were not exactly the same. Other than the FoSIBLE project, López et al [26], López et al [27], Tapia et al [13], and Gutierrez et al [28] were also from the same project.

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Study Characteristics

More than half of the studies explicitly focused on the context of home care. The studies that were not included in this category either did not specify a context or were conducted in geriatric care units or nursing homes. For instance, Naudé et al [47] focused on identifying enablers and barriers to the use of digital interactive television (DiTV) in nursing homes. According to Naudé et al [47], DiTV is a system that allows viewers to engage actively with content in real time. Examples of this include online shopping via television and being able to vote or comment on social posts via television, with the latter being considered a form of asynchronous communication.

More than half of the studies focused on designing or evaluating attitudes toward technology and assistive technologies, while the remainder focused on proposing concepts and frameworks. Wu and Hu [46] discussed the 3E model, known as easy and efficient for the elderly. This model was developed to better study behaviors related to the use of smart televisions among older adults. The discussion of this model was presented in a theoretical manner to analyze its framework. Although not focused on the 3E model, Gusev et al [37] proposed the stimulating intellectual activity with adaptive environment (SMILE) framework, which aims to prolong independence and improve the quality of life through cognitive stimulation, social inclusion, and personalized self-care systems. Various projects focusing on support for older adults were analyzed, including medical sensors installed in home products; the use of mobile phones and smartphones as personalized devices; and the Vital Mind project, which aims to increase the lifespan of older adults by enabling them to participate in cognitive fitness exercises actively while watching television.

Regarding the sample size of the participants, 5 articles did not report any sample size or demographics [34,36,37,40,41]. The sample sizes ranged from studies with only 5 participants to studies with more than 200 participants per sex. These variations were related to the differing methodologies of the articles. The studies that focused on assessing the accessibility of content and device platforms typically included a small number of participants, as demonstrated in the study by Alaoui et al [25], whereas studies that focused on measuring technology habits, technology skills [42], or intergenerational relationships [45] included larger sample sizes. Results from larger sample sizes were obtained through surveys as the mode of data collection. For example, Wang [44] and Cortellessa et al [32], who used surveys to measure attitudes, included between 30 and 100 participants. Geographically, all but 8 studies were conducted in Europe. Other studies were conducted in China [46], Thailand [41], Taiwan [40,44,45], Chile [13,28], and Mexico [48]. No studies from other regions, such as Africa and North America, were included.

Similarly, not all articles provided information about the participants. Most articles specified the age, gender, and demographics of their study population. The participants across all included studies ranged in age from 50 to 92 years, but most information was drawn from the participants aged 60 to 80 years. Some studies were conducted in the context of geriatric care units or nursing homes [26,27,38,44,47,48]. In these facilities, care professionals and older adults living there were interviewed regarding the DiTV system that was implemented [47]. In addition to Naudé et al [47], López et al [26] and López et al [27] also specifically mentioned the inclusion of administrative staff, ranging from health professionals to formal and informal caregivers.

The topics included in the articles covered different aspects of utilizing smart televisions as assistive technology for older adults. Most of the articles reported some form of newly developed technology, while 6 articles reported no technology development [30,37,40,43,45,47]. The technologies that were proposed and developed across all articles were various forms of interactive television. These included Android televisions and Google televisions; almost half of the included studies did not specify the type of smart television proposed or developed.

Approximately half of the articles were directly related to the social aspects of health in older age. The other half was indirectly related, addressing social health through other factors. For example, Wang [44] examined the usability of a virtual fitness platform on smart televisions for health promotion among older adults. This was indirectly related to social health because older adults were given the opportunity to interact with others via the virtual fitness platform, even though its purpose was to improve physical health.

Discussion

Principal Findings

To the best of our knowledge, this review is the first to summarize the state-of-the-art research on the use of smart televisions as assistive technologies for communications and social life among older adults. Andreadis and Zambon [49] in their survey, provided an overview of compelling studies that used television devices as the primary user interface to address the social exclusion and digital barriers encountered by older adults. However, almost all studies included in their review involved the use of traditional televisions, rather than smart televisions. In many other studies, smart televisions have been used to collect data to assist with everyday life activities (eg, reminders, health status monitoring, and calendar management) [50,51]; as smart decision support systems to support healthy aging [52]; and as rehabilitation tools [53]. Although some of these studies incorporated certain social elements, such as shared training and gaming activities, their primary focus was not on fostering social communications among older adults to reduce exclusion and loneliness. Wong et al [54] published a scoping review protocol to provide an overview of existing research findings on factors that aid or hinder the use of smart televisions by older adults in care settings. However, at the time of writing this review in November 2024, their scoping review remained unpublished. Another review conducted by Carvalho et al [55] reported solely on television remote controls and their use by older adults. Their findings included usability issues faced by this user group when using television remote controls and proposed solutions to address these issues.

Comparison With Prior Work

Evidence and the Number of Included Studies

Although 30 relevant studies were included in this review, this number indicates that smart televisions have been seldom utilized as assistive technologies to enhance communication and social lives among older adults. Despite several of the included publications stemming from the same or larger studies, it is notable that these publications involved participants from multiple countries. Conversely, some publications that were not part of larger studies also included participants from different countries. For example, Alaoui et al [22] conducted interviews with participants living in France, Austria, and Germany, while Müller et al [23] included participants from both France and Germany. In addition, Gusev et al [37] involved users from Macedonia, the United Kingdom, and Slovenia when proposing a socially interactive television–based self-care system tailored for older adults to support independent living and aid in the prevention or delay of dementia. These studies show that the same technology developed has potential for use across diverse geographical areas.

When considering the countries involved in the included studies, the majority were conducted in European countries or other technologically advanced countries. This geographic concentration may limit the generalizability of the findings, particularly in non-Western or resource-limited settings where cultural, economic, and technological factors differ significantly. Our findings indicate that no studies from Africa or North America were represented. This is unsurprising, as research on more advanced technologies has historically been concentrated in regions with greater access to resources, infrastructure, and technological expertise. This aligns with the work of Ondiek and Onyango [56] and Bosch and Currin [57], who highlight both the challenges and efforts involved in engaging user groups from these underrepresented regions. Therefore, when generalizing these findings, it is crucial to consider the unique challenges and needs of such regions, as the effectiveness and applicability of the technology may vary.

As most studies focused on designing, developing, and evaluating prototypes, many also proposed some design guidelines [27,44]. These guidelines may be useful not only for researchers and policy makers, but also for designers working in this field. Almost all articles reporting on prototypes indicated that the technology had been developed by the researchers themselves. By contrast, Carvalho et al [55] was one of the few studies to include a smart television application, e-lioTV [58], which was developed by a private start-up named Technosens [59]. Costa et al [33] also involved an engineering group responsible for technical design in their study. These findings indicate that there may be a lack of collaboration between the public and private sectors, which could potentially limit the use of smart televisions as assistive technologies for enhancing social interaction among older adults.

Finally, it is worth mentioning that some of the included articles did not prioritize social communication as the main aspect of their functionalities. However, they highlighted the impacts such functionalities had on influencing the social lives of older adults. For instance, Wang [44] proposed a virtual fitness platform on smart television with multiple users, and Gusev et al [37] and Lee [40] proposed self-care interactive smart television applications that incorporated social interactions as one of their features. We acknowledge that social interactions can occur in various forms—both synchronous and asynchronous—and with different people, including peers, family members, and formal and informal caregivers. For this reason, these articles were included in this review.

User Involvement

Older adults often face unique challenges related to mobility, sensory perception, and cognitive function, which can vary significantly from person to person [60,61]. Involving older adults in the design of assistive technologies is essential for creating effective and user-friendly solutions tailored to their specific needs. By including them in the design process, developers can gain valuable insights into their preferences, limitations, and everyday experiences, ensuring that these technologies are relevant and accessible. Research has shown that user involvement of older adults has been low in the design of assistive technologies intended for this user group [62]. However, our findings indicate that user involvement has been high regarding the utilization of smart televisions as communication-type assistive technologies for this group. Among the 30 included studies, almost all involved users during the design and/or evaluation phases. A few articles specifically mentioned that they adopted a user-centered design approach [22,28,34,35,48]. From these studies, it was evident that feedback from older users contributed to identifying potential usability issues and informing design features that truly accommodate their capabilities and needs. It is worth noting that involving older adults can promote a sense of ownership [63] and acceptance of the proposed technology [62]. This may also contribute to the scalability of the use of technology [64].

These articles not only demonstrate user involvement, but also show careful considerations when involving older adults. One of the reasons for utilizing smart televisions as social communication–type assistive technologies is because of their familiarity. Hence, older adults with low technology use have been one of the main target groups. Gutierrez et al [28] and Tapia et al [13], in their studies, specifically targeted older adults with low technology use. In addition to this primary group of end users, some studies also involved secondary end users. Cortellessa et al [32] conducted initial internal testing to gather feedback from experts, caregivers, and health care professionals. This internal testing aimed to inform iterative technological refinements before engaging end users, which could enhance the prototype’s technical stability, usability, and design quality before involving older adults and proceeding to a feasibility study. When the proposed technologies were intended for use by older adults with dementia, health care personnel and caregivers (formal or informal) were involved as well [27,32].

Attitudes in Using Smart TVs for Communications

Older adults often hold diverse attitudes toward using smart televisions as a means of communication, shaped by factors, such as familiarity with technology, perceived usefulness, and social needs. Depending on their backgrounds, some older adults have more proficient digital literacy than others. Age has been shown to be one of the strongest predictors in online participation, but race, gender, and education play a role as well [65]. In Finland, 80% of people aged between 65 and 74 years have used the internet, and 57% use it daily [66]. However, these numbers drop to approximately 41% of internet use and 23% of daily use among adults aged between 75 and 89 years. This difference in internet use highlights discrepancies in digital literacy and varying attitudes toward technology based on age. In addition, a study found that females were more likely to show lower global and technical confidence and to have lower operational and less positive attitudes toward technology compared with males [67]. Generally, older adults tend to feel more comfortable operating a television with a remote control than a smartphone or tablet. Therefore, we believe that many older adults will hold more positive attitudes toward a smart television interface as a means of improving social connection.

Limitations

Although this study contributes to the understanding of the state of the art in using smart televisions to improve social connectivity among older adults, several limitations must be acknowledged when interpreting the findings. First, the study only included literature published in English. By only reviewing articles written and published in English, important findings from studies conducted in other languages may have been missed. Second, articles published more than 10 to 12 years ago were excluded. As mentioned in our inclusion and exclusion criteria, the concept of smart televisions is relatively new. While this ensures that the review focuses on recent advancements, it may also limit the inclusion of foundational research that could provide context for the transition of smart televisions into assistive technologies. Third, only peer-reviewed literature was included. The exclusion of gray literature may result in missing valuable information that is not traditionally found in academic publications. While this study focused on peer-reviewed literature, future studies could incorporate gray literature, such as patents, white papers, ongoing research, and dissertations, to gain a broader understanding of the real-world applications of smart televisions as an assistive technology [68].

The next limitation of this study is the potential exclusion of relevant studies because of the search strategy. Although we carefully selected search terms to capture both the direct and indirect impacts of smart televisions on the social lives of older adults, there may still be relevant articles that used different terminology. Consequently, some studies that explored the social implications of smart televisions in alternative ways may not have been included. Expanding the search strategy in future reviews by incorporating a broader range of keywords and synonyms could help address this limitation and provide a more comprehensive understanding of the topic. Regarding the generalizability of the findings, it is important to note that the geographic concentration may have affected the results, particularly concerning the non-Western or resource-limited settings. As mentioned earlier, most of the included articles were from Europe, and European contexts often differ culturally, economically, and technologically from other regions. Therefore, the applicability of the findings to diverse global populations may be limited. Finally, this review was conducted without registering the protocol. While this practice is not mandatory, we acknowledge this as a limitation.

Conclusions

With people in today’s society living longer, the shift toward an aging population is undeniable. As people age, significant declines in both physical and cognitive health are common and are often accompanied by an increased risk of social isolation, which can further impact well-being. Because depression or the onset of depressive symptoms is a prevalent issue among older adults, introducing assistive technologies to enhance their communications and social life is crucial for supporting holistic well-being. While numerous assistive technologies present usability challenges for older adults, smart televisions stand out as one of the most familiar and frequently used technologies within this demographic. Thus, this research is essential for understanding the potential of smart televisions as an assistive technology to enhance social connections and communication among older adults, thereby addressing the challenges of exclusion and loneliness.

This review reveals that smart televisions hold significant promise as an assistive technology to enhance social connections and communication for older adults. The number of articles included in this study is 30, which is relatively low considering that smart televisions have been on the market for more than 10 years. Of these 30 studies, 6 were associated with the same project, that is, the FoSIBLE project [16,21-25]. In addition, López et al [26], López et al [27], Tapia et al [13], and Gutierrez et al [28] were from the same respective studies. Many studies examined the use of smart televisions for social connectivity in home settings; however, some also explored their application in senior housing facilities, care centers, hospitals, and nursing homes, highlighting their potential across diverse environments.

Most of the articles focused on user attitudes toward the design and evaluation of the technology, while others focused on conceptual and framework proposals. Of the 30 articles, 24 either proposed or developed interactive smart television applications and platforms that used a variety of smart televisions, including Google and Android. A wide range in participant sample sizes was observed, varying from 5 to more than 200 participants, depending on the research methodology. In addition, not all articles provided detailed information about the participants. User involvement emerged as a key factor in the development and evaluation of the proposed technologies. Although research has traditionally shown low user involvement in designing assistive technologies for older adults, this review indicates that most studies integrated older users at various stages of the design and evaluation. Finally, the review highlights the distinction between the direct and indirect contributions of smart televisions to the social lives of older adults.

While this review provides valuable insight into the role of smart televisions as assistive technologies for enhancing the social connectivity of older adults, several research gaps remain. First, most of the studies focused on short-term usability and initial user experience. There is little research on how smart televisions can impact and change the trajectory of the social well-being of older adults over time. Future studies should conduct longitudinal research to assess the long-term impact of smart televisions on the social well-being of older adults. This includes examining whether smart televisions can be used sustainably over extended periods and whether their sustained use can foster social engagement and improve quality of life over time. Second, 22 studies were conducted in Europe, 5 in Asia [40,41,44-46], and 3 in South America [13,28,48], with no representation from North America and Africa. This underscores the need for future research to engage participants from underrepresented regions to ensure that findings are more globally applicable and inclusive of varying needs, preferences, and challenges. To address this knowledge gap, cross-cultural research should also be conducted. Future studies should focus on these underrepresented regions to understand how different cultural attitudes toward technology and access to smart televisions may influence the adoption of assistive technologies for older adults.

Third, while some studies have explored how smart televisions can be used as assistive technologies for social connection among older adults with specific health conditions, such as Parkinson disease, dementia, and other health-related challenges, research on adaptation for these users remains limited. There is limited information on long-term adaptation for improving their social connectivity. Future research should explore adaptive accessibility solutions and features in smart televisions that evolve with users’ changing abilities and assess the long-term impacts of smart televisions on social engagement and quality of life for older adults with diverse needs. These solutions and features may include voice commands, improved remote control design, and other innovative interaction methods and modalities for interacting with smart televisions. By prioritizing these solutions and features, researchers may better address the diverse health conditions of older adults. In addition, bridging these research gaps to reduce barriers to adoption is essential for developing a more comprehensive understanding of how smart televisions can support long-term social engagement, be adopted across diverse cultural contexts, assess their actual impact on the social well-being of older adults, and adapt to the progressive needs of older adults with health conditions. In addition, future research should explore how smart televisions could serve as more accessible assistive technologies for older adults with disabilities. Smart televisions may be easier to interact with compared with smaller touchscreen devices. For instance, a remote control with larger buttons may be more manageable for older adults with disabilities than small touch-sensitive devices such as smartphones and tablets.

We hope that our review will inspire others and pave the way for future research exploring the potential of smart televisions as assistive technologies. These technologies hold promise for fostering meaningful social interactions, reducing social isolation, and enhancing the health, well-being, and overall quality of life of the aging population. Stakeholders, such as policy makers, decision makers, and designers, can also refer to our work, as it provides a comprehensive summary of the state of the art in this field. By understanding the current advancements and gaps highlighted in our review, they can develop strategies and design solutions that are better aligned with the needs and preferences of older adults.