The aim of the present intervention study was to describe and explore the use and experiences of using a passive positioning alarm, over time, in daily life among persons with dementia and their spouses. The main findings revealed changes over time in the participants use and experiences of the PPAP, such that testing and checking the PPAP successively led to trust in the PPAP and in one´ s own ability to use it. Testing and checking seemed to be a prerequisite for the couples to perceive the value of the PPAP in their everyday outdoor life. However, individual variations were observed, within and between couples, based on conditions for learning to use, using and handling the PPAP.
The usability of the PPAP was expressed by the couples in terms of the value of the PPAP. The persons with dementia and their spouses described a feeling of safety and security related to use of the PPAP, that is, they perceived it as valuable in situations that were important to them, e.g., being able to move around freely at the cottage and being located if one was lost. The persons with dementia carried the transmitter when they were alone outdoors and saw the value of it, in terms of their own as well as their spouse´ s feelings of safety and security. Safety and security aspects described by both persons with dementia and relatives have also been found in earlier studies on the use of tracking technologies in the care of persons with dementia [2, 19, 23, 40]. The present study also identified the need for support and repeated practice using and handling the PPAP to promote a feeling of trust in the PPAP and in one´ s own ability to use it. The participants talked about the importance of the PPAP being easy to use, and this was expressed by the couples and observed in statements about the physical and functional design of the PPAP and about the abilities, knowledge and skills needed to be able to use the device (cf. ). The present results also revealed that, mostly for the spouses, trust in one´ s own abilities to use and handle the ICT and trust in the ICT itself were important for actually using the device. Although some persons with dementia felt no current need for the PPAP, describing themselves as ”too healthy”, all reported wanting the PPAP in the future. However, at the outset of the study, all couples described occasions when the person with dementia had gotten lost while he/she was alone outdoors. In view of this, it appears important that persons with dementia and their spouses receive adequate information and be given the opportunity to discuss different types of ICT with healthcare personnel. Such discussions with the couple, relatively early in the disease process, could facilitate joint decision-making regarding both current and future use of ICT in daily life (cf. ). In additional it is important that the technology being developed based on the needs and experiences of the person with dementia and their relatives and that such need-based development should go hand in hand with collaboration between the research community and private enterprise.
The present study showed that the couples´ perceptions of the PPAP increasing their safety overshadowed any risk of violating personal integrity. None of the couples in the present study spontaneously raised the ethical issue of whether use of the PPAP was intrusive, and the implementation of a hidden zone was not a desired feature. On the contrary, not being seen was considered a source of insecurity. These findings are in contrast to the ethical debate concerning tracking technology, which has focused on the risk of offending and violating the integrity of persons with dementia [24, 30–32]. One explanation for this discrepancy may be that the PPAP used in the present study allowed only the spouses to monitor the persons with dementia on their outdoor walks. Several studies have reported that implementation of ICT in the care of persons with dementia needs to be preceded by extensive ethical discussions [11, 32, 42]. Welsh and colleagues  reported that some ICT (e.g., tracking technology) devices used in dementia care were perceived by healthcare staff as violating human dignity and freedom, given the use of similar technology in criminal surveillance. While this stance is understandable considering that all such devices are based on GPS, it could also be argued that it is unethical to deny persons with dementia and their relatives the opportunity to use a service, such as the PPAP, that could give them independence and security in daily life. It is also important that the tracking technology be adapted to the individual and used as an aid to living a daily life that is as fulfilling and active as possible despite the presence of a dementia disease. Finally, gender differences in testing and checking one’s own abilities as well as the PPAP were described and revealed in the present study. Further studies are needed to investigate these differences.
The main strength of the present study was the use of repeated participant observations and informal conversations, an approach that allowed us to follow the couples and the development of their use of the PPAP over time  and can thereby be seen as appropriate. A further strength was that the observations and conversations were performed in the couples´ own homes and that the persons with dementia participated actively as informants. Despite the emotional upheaval of describing and reflecting on their situation, all of the participants (both persons with dementia and their spouses) appreciated being given an opportunity to speak with someone who showed an interest in hearing their stories. The observers´ knowledge and experience of caring for persons with dementia and their relatives were considered a prerequisite for admission to the home, for creating a trusting environment in which to carry out the observations and conversations, and for being given the opportunity and permission to return (on the next occasion) (cf. ).
Credibility [37, 43] was achieved by the first and last authors discussing the steps used in the process of analyzing the observation and conversation occasions. All authors were engaged in a critical discussion of the analysis at all levels, from code to category. To further strengthen the credibility, excerpts from the interviews were included in the results. To increase the dependability of the study, the data collection and analysis process were continually discussed in the research team. The findings may be transferable to groups of people with other cognitive disabilities, although decisions about transferability must be made by the readers [34, 37, 43]. A limitation that should be taken into account is that data collection was carried out during a time of year when outdoor activity is limited, due to snow and low temperatures. This might have influenced the frequency of the couples´ use of the PPAP. Moreover, future research is needed to explore the experiences of persons with dementia in later stages of the disease. Persons with severe dementia may experience deterioration of their verbal communication skills, which is why a longitudinal observation study should be considered.