Cultural Determinants of Assistive Health Technology Acceptance in Asian Older Adults in Low- and Middle-Income Countries: A Mixed-Methods Systematic Review

The global population aged 60 years and over is projected to double from 1.06 billion in 2020 to 2.13 billion by 2050, with the most rapid demographic transitions occurring in Asia's low- and middle-income countries (LMICs). In Southeast Asia alone, the number of older adults is expected to rise from 77.4 million in 2020 to 173.3 million by 2050, while the total elderly population across Asia is projected to exceed 937 million by mid-century. This unprecedented demographic shift is generating urgent demand for assistive health technologies (AHTs) — including wearable health monitors, telehealth platforms, mobile health applications, smart home monitoring systems, and assistive robotic devices — to support functional independence, chronic disease management, and healthy aging among older populations. Despite the growing availability and demonstrated benefits of AHTs, access and adoption remain critically low in LMICs. According to the World Health Organization, as few as 3% of people in some low-income countries have access to the assistive products they need, compared to 90% in some high-income countries. In LMICs broadly, only 5–15% of those who require assistive technology have access to them. A 2025 global market report further reveals that unmet need in LMICs is estimated to be 10 times larger than the current demand being served, representing a significant market failure with direct implications for population health and equity. This access gap is compounded among older adults, who remain among the most resistant groups to adopting digital health technologies due to factors including limited digital literacy, usability concerns, lower self-efficacy, privacy fears, and a strong preference for in-person healthcare interactions. Critically, the dominant theoretical frameworks used to study technology acceptance — the Technology Acceptance Model (TAM) and the Unified Theory of Acceptance and Use of Technology (UTAUT) — were developed primarily within Western, industrialized contexts. A recent meta-analysis examining health care technology acceptance in older adults based on TAM and UTAUT found considerable heterogeneity across studies, making it difficult to determine consistent predictors of acceptance behavior. Existing reviews have identified that cultural factors influencing technology adoption are more frequently reported in literature about Asian countries — including filial expectations in South Korea, collectivist decision-making dynamics, stigma regarding aging and dependency, and hierarchical social structures — yet these cultural dimensions remain insufficiently integrated into mainstream acceptance frameworks. Research has demonstrated that cultural values such as nationalism, collectivism-individualism, and egalitarianism-hierarchism significantly influence public attitudes toward health interventions, often outweighing the effects of scientific literacy and rational risk perception. Nevertheless, no systematic review has comprehensively synthesized the evidence on how culture-specific determinants in Asian LMICs shape older adults' acceptance of AHTs. This mixed-methods systematic review aims to address this critical gap by (1) identifying and synthesizing the cultural determinants that influence acceptance of assistive health technologies among older adults (aged 60 years and above) in Asian LMICs, and (2) examining how these cultural factors interact with individual, technological, and contextual variables to shape acceptance or rejection behaviors. The review employs a convergent integrated mixed-methods design following the Joanna Briggs Institute (JBI) methodology for mixed-methods systematic reviews, with reporting guided by the PRISMA 2020 statement and the ENTREQ framework for qualitative synthesis transparency. Quantitative findings (effect sizes, statistical associations) and qualitative findings (themes, lived experiences, cultural narratives) will be integrated through thematic synthesis to produce a holistic understanding of the phenomenon. Systematic searches will be conducted across four electronic databases — PubMed, Scopus, IEEE Xplore, and Web of Science — supplemented by grey literature searches in Google Scholar, ProQuest Dissertations, and the WHO Global Index Medicus. Studies will be included if they investigate acceptance, acceptability, adoption, intention to use, or actual use of AHTs among older adults in Asian LMICs with at least one cultural factor examined as a determinant, barrier, or facilitator. Both quantitative (cross-sectional, cohort, experimental), qualitative (interviews, focus groups, ethnography), and mixed-methods study designs published in English from January 2014 onward will be eligible. Two independent reviewers will conduct screening at the title/abstract and full-text stages, with inter-rater reliability assessed using Cohen's Kappa (target ≥0.80). Methodological quality will be appraised using JBI critical appraisal tools for quantitative and qualitative designs, and the Mixed Methods Appraisal Tool (MMAT) version 2018 for mixed-methods studies. Confidence in qualitative review findings will be assessed using the GRADE-CERQual approach. Expected outcomes of this review include: (a) a comprehensive taxonomy of cultural determinants of AHT acceptance among older adults in Asian LMICs, organized by type (values, beliefs, norms, practices), level of influence (individual, family, community, societal), and direction of effect (facilitator versus barrier); (b) identification of subregional variations across South Asia, Southeast Asia, and East Asia; (c) a critical appraisal of how existing theoretical frameworks (TAM, UTAUT, and variants) accommodate or fail to accommodate cultural dimensions; and (d) evidence-based recommendations for culturally sensitive design, implementation, and policy strategies to enhance AHT adoption in aging Asian LMIC populations. This review is expected to contribute to the fields of gerontology, health informatics, and global health by providing the first mixed-methods synthesis specifically focused on cultural determinants of assistive health technology acceptance in this population and context. Findings are intended for publication in a peer-reviewed journal and will inform both technology developers seeking to design culturally appropriate AHTs and policymakers developing age-friendly digital health strategies in LMICs.