Agency and the Limits of Responsibility: Co-Management of Technology-Enabled Care in Supported Housing

Round 1

Reviewer 1 Report

I do think the article has potential, but needs revisions.

The title is Health, Wellbeing and the Limits of Responsibility: Understanding the Role of Technology in Supported Housing. The case is four supported housing schemes with residents with diagnosed/suspected dementia. The aim was to examine the impact of health technologies.

The examples of health technology introduced are smart phones, tablets and voice recognition devices, tin or jar openers and hot water dispensers. The empirical evidence concerns facebook, skype, online banking, hobbies, fitbit and passwords.

Overall I find that the paper contains three different discussions. One in the theory section concerning welfare state retrenchment. Another in the empirical section concerning attitudes towards smartphones and online banking, and a third in the conclusion regarding housing associations responsibilities for potential unwanted consequences of technology. They are all interesting discussions. I suggest that the authors think carefully about which discussion they wish to contribute to, and narrow the scope of the article.

Specifically

1. An ideology should be applied at the system level. As responsibilisation is presented as a neoliberal ideology, it is possible to state that it has limited value at the individual level. One understanding of responsibilisation, the one presented, is welfare retrenchment. However, responsibilisation can also be understood as the necessity to prevent care needs and to prioritise between citizens. When applied at the individual level, it is hard to discern the difference between responsibilisation on one hand and empowerment and other words and concepts used to describe how a person’s care/health/assistance needs are met, on the other.

In the empirical section the is a description of individual attitudes towards receiving assistance in the form of technology. The result is that responsibilisation, explained as service retrenchment and the not-rendering of services, is opposed to attitudes toward a specific service received.

If the authors still want to use responsibilisation as the theoretical frame, I suggest that you explore more ways to understand the concept, and in the conclusion discuss your findings against the different meanings.

2. The empirical section describes attitudes towards technology in general. Neither smartphones nor tin openers are prime examples of ‘telecare’, ‘telemedicine’, ‘telehealth’ ‘digital health technologies’ or devices to self-manage healthcare, although they can be used for that purpose. I would have expected the study to comprise technology such as safety alarms, fall monitors, medicine dispensers etc. as the paper is repeatedly pointing towards health care and health technologies.

For that reason, I do not reach the same conclusion as the authors; that there is a resistance to managing health via technology support. To me, the empirical section has not given evidence that the focus of the study was the impact of health technologies, but attitudes toward technology used by most people every day.

3. The conclusion problematises whether housing associations should provide interventions. I wish that question was better linked to the theoretical section. It is not intuitive how the author places the housing associations responsibilities to the concept of responsibilisation – on the part of those responsibilising the individual, or as an entity aiding individuals in assuming responsibility and thus being empowered.

Housing associations were not introduced as object of study until the concluding section, in which they were given much attention.

4. The study presents 3 questions: 1. What role can technology play in improving health outcomes and bridging health inequalities among residents in supported housing schemes? 2. How was the introduction of technology perceived within supported housing schemes? 3. How effective is responsibilisation in improving health outcomes amongst older supported housing residents?

I can only find that the second question is adequately responded.

Author Response

Thank you for taking the time to review our article, please find our letter outlining how we have addressed your comments. 

Author Response File: Author Response.pdf

Reviewer 2 Report

I found this text interesting and clearly argumented. I especially liked the theoretical background starting from the idea of responsibilisation and then proceeding to present co-creation and co-management of technology enabled care as an alternative. The results section presenting four ways of responding to 'health technology responsibilisation' is consistent and discusses nicely with the chosen theories. 

However, I had difficulties to follow the reasoning of the research methods section. The data were collected in two waves. The first wave contained interviews, but how many and with whom (the number of interviews of the second wave are presented in the end of the section)? I also would like to read more about it, what happened between the first and second interviews/waves. Did the project research team do in collaboration with the staff members some kind of action research trying to 'persuade (or responsibilise) the residents to increase their self-governed use of health technologies? And did this happen in all four research sites? Furthermore, I would like to read more about the thematic analysis from the point of view how the residents' and staff members' interviews were emphasised in relation to each other: whose voice matter?  So, it seems to me that the research methods section needs to be improved before the paper is ready to be published.

Author Response

Thank you for taking the time to review our article. Please find our letter outline how we have addressed your feedback. 

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

I like this version better. Although, I am still unsure of what is the take home message of the article.

The findings of the empirical investigation are not surprising - older people have varying attitudes towards using technology and, providing support when introducing technological devices improves the persons’ ability to take them into use.

The “packaging” of these findings are considerations regarding the responsibility of social housing sector, arguments regarding retrenchment and responsibilisation, and a framework regarding agency.

To me it is still unclear why the housing sector is important. I understand that services and housing are parts of a package. Everybody has to live somewhere. However, it is the provision of services that is the main focus of the article. Likewise, health issues are mentioned several places. From the empirical findings, I read that social interaction, hobbies and banking are the most important issues. Important for wellbeing, but not so health related. I understand that fall censors and similar items were also introduced. I do not find empirical examples of the effect of such instruments.

As retrenchment and responsibilisation are policies implemented at the macro level, it applies to all of your subjects. Is your notion that retrenchment and responsibilisation necessitates the introduction of tech devices? I would rather understand the introduction as elements of empowerment and enabling self-sufficiency. I am not convinced that responsibilisation is an adapt framework, I therefor suggest alternatives. Sorry… :)

 

Agency is an individual trait and can be defined as the ability to take action or to choose what action to take. I therefor understand why you conclude that co-management is important. Unfortunately, the empirical section does not provide good examples of how co-management plays a role in inducing tech devices, nor in broadening the perceived agency of some of your subjects. I would assume several would not start using a smart phone unless they knew they had someone to ask. Furthermore, you do not explore whether persons in the resistant user category end up more deprived than users in the first categories. Retrenchment and responsibilisation policies would suggest that to be the case as the services they resist to obtain for themselves would not be provided by service providers. I also ask why most of your quotes in the resistant user category are subjects using other persons as examples, and subjects who have computers and phones, but choose to not use them much.

I would challenge you to present your study in a model. You write that the aim of the article is to examine the role that technology plays in promoting ‘responsibilisation’ in contemporary housing provision and the consequences for older individuals.  The research questions are 1. How can assistive technology support agency and independence of older residents? 2. What role does agency play in accepting and using assistive technology and how is this facilitated through social support networks? 3. How effective is responsibilisation in improving wellbeing and independence amongst older residents?  I think you need to distinguish between the macro and micro levels and the direction of impact. Does tech promote responsibilisation, or is the intro of tech caused by responsibilisation policies? Does tech support agency or does agency influence the willingness to use tech devices? Where and how do the social support networks come into play? Does responsibilisation improve wellbeing or does wellbeing obtained by tech devices improve despite responsibilisation policies? These questions need clearification.

Author Response

Please see attached the response to reviewer 1 (round 2). 

Author Response File: Author Response.docx