“Think of It Like a Game”: Older Adults’ and Health Professionals’ Perspectives on Interactive Exercise Technology Design

Abstract

Purpose: Interactive exercise technology (IET) is an effective and practical way to support physiotherapy for older adults. The purpose of this study was to use design thinking to collect feedback on the first iteration of an IET prototype from older adults and health professionals and to use that feedback to gain an understanding of their needs and values, with the goal of developing recommendations to inform the second iteration of the IET prototype. Method: This study was conducted using three steps of design thinking: (1) test, in which four focus groups were conducted, asking older adults and health professionals about their perspectives on an IET prototype; (2) empathize, in which the focus group discussions were recorded and transcribed and thematic content analysis was conducted; and (3) define, in which the needs and values of the participants were identified. Results: The participants were 19 health professionals and four older adults. Four themes, which represented the values that these groups held regarding IET design, were revealed: instruction, safety, accessibility, and motivation. Conclusions: Older adults and health professionals have specific needs for the design of IET, which should be considered in the development of future IET.

Physical inactivity among older adults is associated with frailty, muscle loss, and poor quality of life.^1,2 Yet only half of older Canadian adults are physically active.³ Older adults do not exercise for many reasons, notably lack of guidance from health care professionals.⁴ They also – especially those who are frail or have multiple comorbidities – often rely on health professionals (e.g., physiotherapists) to provide therapeutic exercise prescriptions aimed at improving their mobility. However, they may not take advantage of these practitioners’ services because of financial and time constraints. After discharge from physiotherapy, older adults are expected to continue exercising with the support of their caregivers (e.g., family members). However, some may stop exercising because they (or their caregivers) do not know how to do the exercises, are not motivated to exercise independently, or do not know how often to exercise to gain the maximum benefit.

Interactive exercise technology (IET) offers individuals a potential modality to help remove barriers to participating in sustainable therapeutic exercise during ongoing physiotherapy treatment and after discharge. It enables a two-way stream of information to flow between a user and a computer, which leads users through exercise sessions and provides a multimedia reaction to their movements.⁵ For example, Wii Fit leads users through fun exercise games while providing an instantaneous digital response to their movements on a television screen.⁶

Growing evidence has indicated that IET could be an effective and practical way to promote exercise and its benefits for older adults. For example, a randomized controlled trial found that older adults who were frail had a reduced incidence and risk of falls after training with IET as opposed to a conventional exercise programme.⁷ Studies have also indicated that IET is both feasible and acceptable for urban-dwelling older adults living with disability.⁸ However, IET, like Wii Fit, is designed by and for a younger population that has different needs than older adults.⁹ To fully optimize both the practicality and the effectiveness of IET, its design must be suitable for and interesting to older adults and the health care professionals who work with them.

Few studies have investigated how IET can be designed to reflect the values of both health care professionals and older adults. When engineers are designing user-centered technology, older adults can offer them valuable feedback to inform their decisions about theme, colour, and sound.¹⁰ Obtaining input from health professionals is also important to ensure that the technology is suitable for their use in practice.¹¹ The few studies that have evaluated health care professionals’ attitudes and opinions about IET suggest that both they and older adults have specific needs (e.g., training to use technology).^12,13 The scant literature considering the design feedback from these two groups limits the potential of IET, which can be optimized only with user-informed design.

Design thinking is a strategy for developing solutions using a human-centered approach. It emphasizes understanding and fulfilling the values of a target population,¹⁴ and it uses an iterative process that is commonly used among engineers and designers and has now entered the health care space. The purpose of this study was to use design thinking to collect feedback from older adults and health professionals on the first iteration of an IET prototype, Arts-Based Exercise Enhancing LongEvity (ABLE). In this study, we aimed to use that feedback to gain an understanding of the needs and values of older adults and health professionals with the goal of developing recommendations to inform the second iteration of the IET prototype.

Methods

We used an earlier IET prototype as the basis for this study. We first held four focus groups to obtain feedback on this prototype. We then recorded and transcribed the discussions, analyzed the thematic content, and identified the participants’ needs and values. Finally, we developed recommendations to inform future IET design.

Design thinking process

We designed and iterated ABLE using the design thinking process.¹⁵ This process consists of five steps: empathize, define, ideate, prototype, and test (Figure 1). Before we carried out this study, the first iteration, Steps 1–4 (empathize, define, ideate, and prototype) was completed. The current study focused on Step 5 (test) and the second iteration of Steps 1 and 2. Although some design teams use engineers to execute design thinking, our team intentionally included health science and design experts; we wanted to ensure that we had the skills necessary to ensure that the exercises were taught and executed properly and that the design would be aesthetically pleasing and incorporate the hobbies and interests of older adults, when possible.

Figure 1.

The five steps of design thinking in the context of this study.

Our team also modified the design thinking approach by not only asking for the input of older adults (empathizing) but also doing so in a way that took their communication and individual physical and cognitive needs into account; we wanted to ensure their full participation. To assist them cognitively, as well as to accommodate the need for time-limited research sessions, we brought mocked-up prototypes to the session to motivate them to participate. They were invited to comment on, or even discard, the prototypes and offer new ideas.

Step 4, Iteration 1: prototype

Before we began our study, our interdisciplinary team of health, computer science, engineering, and design researchers at Pulse Lab and the GERAS Centre for Aging Research at McMaster University had developed an IET prototype (ABLE) that would blend artistic components and exercise to encourage older adults to exercise at home (Figure 2).¹⁶

Figure 2.

In our IET design, a user wears sensors and selects an exercise on a mobile app, which is sent to a TV screen and displayed as an image.

IET = interactive exercise technology.

ABLE includes wearable sensors that track users as they exercise. In response to users’ movements, a TV interface produces musical sounds and artistic visuals. The TV display and the sensors are connected through a mobile app.

Step 5, Iteration 1: test

We began this study by testing our prototype to solicit feedback from the target population.¹⁴ We organized four focus groups – two for four older adults and two for the 19 health professionals – in which the participants were asked what they did and did not like about the prototype and why. (The full set of questions is reproduced in the Appendix.) We showed both the older adults and the health professionals the prototype, gave them the opportunity to briefly try it once, and then asked them to discuss the features that they would retain or change. The focus groups were semi-structured and led by the primary investigator (CM). They were audio recorded and transcribed verbatim by AS. We report our findings separately for these two groups.

Step 1, Iteration 2: empathize

In the design thinking approach, to empathize is to gain an understanding of a target population’s values and needs.¹⁴ The transcriptions of the focus groups were coded by AS and JBS using thematic content analysis to establish the overarching themes that reflected the values and needs of the target populations.

Step 2, Iteration 2: define

To define is to use the information gained through empathizing to create problem statements that address the participants’ needs.¹⁴ Using thematic content analysis, we identified problem statement subcategories within each theme that represented the needs and values of the participants that were identified.

Participants

We recruited health professionals from the in-patient and outpatient rehabilitation departments of two hospitals in Hamilton, Ontario. We recruited older adults in the following ways: (1) posters advertising the study were posted in St. Peter’s Hospital and throughout the community; (2) previous study participants were contacted if they had given consent to be contacted for future studies; and (3) activity directors at local retirement homes recruited individuals who were living there.

Health professionals had to meet the following requirements to be eligible for the study: (1) they had to be providing rehabilitation services for older adults, and (2) they had to be able to communicate in English.

Older adults had to meet the following requirements: (1) they had to be aged 65 years or older; (2) those with dementia or cognitive impairment (score <3 on the Mini-Cog test¹⁷) had to be accompanied by a caregiver; and (3) they had to be able to communicate in English. The caregiver’s role was to support the participant throughout the testing and provide any missing pieces of information. Feedback from the caregiver was also transcribed and included in the analysis.

Eligible and interested participants gave written consent to participate in the study and then completed a demographic and health information survey.

Ethics

This project was reviewed and approved by the Hamilton Integrated Research Ethics Board.

Results

Steps 1 and 2, Iteration 2: empathize and define

We recruited 19 health professionals and collected information regarding age, occupation, and work sector (Table 1). We recruited four older adults and collected information regarding their age, sex, and medical history (Table 2).

Table 1.

Demographic Characteristics of Health Professionals (n = 19)

Characteristic	No. (%)*
Age, y, mean (SD)	43(7.7)
Primary profession
Community care	8(42.1)
Occupational therapist	4
Physiotherapist	1
Registered nurse	3
In-patient geriatrics	11(57.9)
Occupational therapist	2
Physiotherapist	4
Kinesiologist	2
Physiotherapist assistant	2
Medical resident	1

^*Unless otherwise indicated.

Table 2.

Demographic Characteristics of Older Adults (n = 4)

Characteristic	No. (%)*
Age, y, mean (SD)	84.3(9.1)
Female	3(75)
Mini-Cog score, mean (SD)	4(3)
Arthritis	3(75)
Heart disease	3(75)
High blood pressure	3(75)
Stroke	1(25)
Diabetes	1(25)

^*Unless otherwise indicated.

The data we collected from the focus groups yielded four major themes: instruction, safety, accessibility, and motivation. Within these themes, nine problem statements were identified; these statements represented the gaps between what the IET prototype provided and what the participants needed (see Table 3).

Table 3.

Themes and Problem Statements from the Focus Groups

		Quotation from
Theme	Problem statement	Health professionals	Older adults
Instruction	Receiving feedback on exercise technique is important.	“Ideally it will tell you what you did wrong”	“The feedback I’m getting on form is vital to doing the exercises.”
	Demonstrations of how exercises should be performed are beneficial.	“It drives me crazy when 1 go to some [exercise] classes and they tell me they want me to do certain things but don’t demonstrate it. If 1 don’t see a person doing what I’m supposed to be doing, 1 don’t know that I’m really confident that I’m doing what I’m supposed to be doing.”	“I would like to know how many people in a retirement home and long-term-care [facility] know what a lunge is.”
Safety	Exercising alone may be risky for some patients.	“As a therapist, 1 wouldn’t want them to do this unless I’ve gone through all the exercises myself. 1 don’t want to rely on feedback a week later from a sensor that says this one was not safe for them … it may be too late.”	“There’s the issue of somebody using it on their own possibly and hurting themselves.”
		“I am very hesitant to prescribe balance exercises to patients to do on their own without somebody there.”
Accessibility	Knowledge of technology is required.	“I’m not that old but I’m getting there, to set something up on my screen at home, like, I don’t know if 1 would know how to do it, it takes some practise.”	“I think that would be great for people like me … that are sort of a little bit computer savvy, but I’m just thinking about the retirement homes.”
	People with cognitive impairment may face unique barriers.	“Having the tutorial first and then going to the screen and then doing the activity … people with memory impairment are going to get to the screen and aren’t going to remember what they are supposed to do.”	-
		“Just complexity, the more complex… the more you’re ruling people out, that’s all.”
	Cost is a barrier.	“Money becomes a big barrier for a lot of [older adults], so if it’s affordable, then people will be willing to do it.”	“Is it [Ontario Health Insurance Plan] covered?”
Motivation	Exercise is fun when it is social.	“That would even be better… like you’re at home, and then your parents are somewhere else, and you could hook up together and race.”	“I’m all for happy stuff… when the 15-year-old grandson texts’Mima, you’re the best.’”
	Working toward goals is motivating.	“You could beat yourself… You’re actually just challenging yourself. If you did 10 seconds on one foot, then next time you have to go further than that, if possible.”	“Yeah that would be great… finding interesting [items in a rainforest while exercising].”
			“If you can get my husband [virtually] fishing or going on World War 1 sites.”
	Blending exercise and artistic expression is enjoyable.	“I like the idea of painting … you have the arms and you could do it easily with the legs and it’s a creative process that they see something that they develop that they can feel like I wanna do that again.”	“That would be fun because that would be like dancing and making your own music.”

Notes: Dash indicates that a quotation was unavailable.

Instruction (feedback and demonstrations)

It was important to both the health care professionals and the older adults that exercise instruction be personalized and easy to follow. The participants explained that personalized feedback was essential to ensuring that users were doing the exercises properly. They also suggested that users of IET may not know how to do the exercises without seeing a demonstration. For instance, an older adult participant stated, “I would like to know how many people in a retirement home and long-term-care [facility] know what a lunge is.”

Safety (risk mitigation)

The participants thought that safety was another important consideration when developing IET. The older adults shared their worries about users injuring themselves while attempting to use IET independently, and the health professionals echoed these concerns. They specifically expressed worry about the balance exercises, suggesting that a physiotherapist should first ensure that all the exercises were safe for a user to perform before having them attempt them independently.

Accessibility (knowledge, cognitive ability, cost)

The participants agreed that it was important that IET was inclusive and accommodated diverse populations. They considered knowledge, cost, and cognitive ability to be barriers to IET.

The health professionals were concerned that older adults might not know how to use or navigate the technological requirements of IET, and the older adults were worried that some users might not be computer savvy enough to use it independently. The older adults also expressed interest in the cost by asking whether insurance or therapy providers paid for the IET and whether any additional purchases (e.g., a tablet) were required. This implied that cost might be a barrier for these individuals. The health professionals agreed with this; one commented, “Money becomes a big barrier for a lot of [older adults].”

Finally, the health professionals were concerned that older adults with cognitive impairment might be excluded from IET. They thought that it was necessary to have more supportive instruction available for this population (e.g., repetitive instructions or reminders).

Motivation (socialization, goals, art)

The participants believed that it was important that IET motivate users to exercise through a particular social aspect, goal, or artistic component. The older adults described their values as revolving around family and socialization. Similarly, the health professionals suggested that older adults could be more motivated to use IET if it provided the opportunity to socialize, particularly with family members such as grandchildren. They suggested that IET should allow family members to exercise together online.

The older adults also expressed interest in IET that was goal oriented, and they suggested goals that were exploratory and non-competitive in nature. For instance, as users were exercising, they could search for items in a virtual rainforest. For their part, the health professionals suggested goals that were more targeted to improving physical abilities (e.g., users could strive to beat their personal record for length of time standing on one foot). They also agreed that measurable goals and rewards could be included in IET to make it more motivating. Finally, both the older adults and the health professionals suggested incorporating artistic components into IET, such as dancing and music, because it would make the exercise more fun.

Discussion

Our study explored how IET could be designed to reflect the needs of older adults and health professionals, and it identified four important themes: instruction, safety, accessibility, and motivation. These themes represented key insights provided by the health professionals and older adults, which are crucial to, but often left out of, research and design in this area. Our results can be used to ensure that the design of future IET considers the views of older adults and health professionals, thereby improving its usability and applicability.

Step 3, Iteration 2: ideate

Ideating involves generating ideas to improve an existing prototype.¹⁴ On the basis of our results and the supporting literature, we developed recommendations that can be used to inform future IET design. We have provided specific recommendations for future IET design (Box 1), based on our findings and other existing literature. Future studies should be conducted to investigate the value of these recommendations in practice.

Box 1. Recommendations for Future Interactive Exercise Technology Design.

Instruction

• Provide demonstrations of exercises to ensure that users know what to do.

• Give personalized feedback on form and quality of movements.

Safety

• Follow exercise plans prescribed by health professionals.

Accessibility

• Provide a technology support center.

• Provide detailed instructions on how to set up technology.

• Provide continuous instructions for those with memory impairment.

• Make it compatible with existing technology to maintain low cost.

Motivation

• Incorporate social online gaming aspect so that users can remotely exercise with their family and friends.

• Use game-like component with goals:

  • Exploring historical sites
  • Finding items in a forest
• Incorporate artistic components:

  • Dancing
  • Music
  • Painting

Instruction

Instruction is an important component of formal exercise. This study indicates that instruction for IET should include demonstrations and personalized feedback. Other research has shown that participants are more motivated to exercise and more confident in their performance when they are shown a video demonstration rather than a static image of an exercise.¹⁸ Demonstrations could also promote safety and efficacy by ensuring that participants are doing each exercise properly. One study showed that IET users appreciated feedback that encouraged or helped them to properly perform the exercises.¹⁹ Another study found that when participants were given real-time feedback on the quality of their movements, their exercise performance using IET was closer in quality to their performance when working with a therapist.²⁰

Feedback could also validate effort and promote goal setting because it would allow users to strive for positive feedback. Incorporating feedback into IET would necessitate incorporating machine learning so that the sensors could determine what the correct repetition of each exercise looked like; this highlights the importance of using inter-professional teams to develop IET. On the basis of our results and the supporting literature, we recommend that future IET include visual demonstrations of exercises and personalized feedback on movement quality.

Safety

Safety is an important consideration when developing exercise activities for older adults. Other research has found that one of the main reasons for inactivity in this population is fear of falling or overexertion.^21,22 The participants in our study, both the older adults and the health professionals, were particularly concerned about the safety of the IET balance activities, especially if they were to be done without supervision. Other literature has indicated that because of these safety concerns, health professionals preferred to prescribe low-intensity exercises for participants to perform at home.²³

On the basis of our results and the existing literature, IET activities should follow exercise plans prescribed to users by their physiotherapist. This will ensure that they are safe for the user and also provide sufficient challenge to achieve improvements in the desired outcomes (e.g., physical function, decreased falls, improved strength and mobility).

Accessibility

Lack of accessibility can prevent older adults from exercising. Our study indicated three barriers to accessing IET for older adults: lack of knowledge, cognitive impairment, and cost. We found that to use IET independently, a user must have some knowledge of technology. Other research involving focus groups with older adults has found that one of the greatest barriers to using technology is lack of knowledge and instruction in how to use it.²⁴ An IET user’s physiotherapist may need to take on the responsibility of helping the user learn how to use the IET. We suggest that future IET include detailed instructions on how to effectively use it. A technology support center may also be helpful. Future studies should seek feedback from older adults on these specific recommendations.

As with other forms of physical activity, IET poses unique challenges for older adults with cognitive impairment. Research has shown that these individuals face barriers to exercise such as remembering the exercises and following a complex activity.²⁵ IET should incorporate a thoughtful design so as to accommodate as great a diversity of user abilities as possible. The participants in our study suggested that having constant reminders of instruction might be a way to eliminate this barrier (e.g., having a continuous demonstration of an exercise).

Cost is another barrier that older adults may face in accessing exercise activities, including IET. One study identified it as an important barrier to physical activity for older adults, such that they would not participate in an exercise activity that was not free or covered by their health care plan, even if they wanted to.²⁶ Another study found that participants were worried that IET would be too costly for many individuals and, as a result, might contribute to inequalities in rehabilitative care.²⁷ Given these findings, we suggest that IET be low cost and compatible with technology that older adults may already have, so that they do not have to make unnecessary purchases. For instance, it could be in the form of a free app that could be downloaded to a smartphone or smart television.

Motivation

Motivation is critical in promoting sustained exercise. Older adults who are more motivated have higher levels of physical activity,²⁸ and IET that is highly motivating has greater potential to help older adults increase their activity level. As have previous studies, our results indicate three ways in which IET can motivate older adults: socialization, goals, and an artistic component. Other studies have also shown that social contact and a sense of belonging motivate older adults to commit to an exercise activity,²⁹ and older adults who have exercise goals are also more active than those who do not.³⁰

Finally, IET that incorporates an artistic component can motivate older adults to exercise by making physical activity more fun. A recent study found that older adults in an exercise programme with an artistic component had higher attendance and retention than those in a traditional exercise programme.³¹ Another study reported that participants were more focused and engaged with their movements when interacting with an IET that provided real-time artistic feedback.³² Artistic expression has also been found to contribute to older adults’ overall well-being; they rated their perceived overall health higher after completing an arts programme that involved activities such as quilting.³³

Our findings and the existing literature indicate that future IET should be designed to incorporate these motivating factors. For instance, IET could include a social gaming aspect with music and graphics, and users could play with family members or friends online. Users could also collaborate to achieve a goal – for example, contributing to a painting together.

Our study had several strengths. First, we sought the perspectives of both older adults and their health professionals. Second, and more important, we allowed older adults and health professionals to try the IET prototype for themselves before attending the focus group rather than simply explaining it to them; this ensured that the participants had a comprehensive understanding of the technology before discussing it. Finally, we ensured that participation in our study was accessible to older adults with varying cognitive abilities. We did this by allowing caregivers to accompany and support participants throughout their involvement in the study.

Our study also had a few limitations. The first was the small sample size of older adults (n = 4); however, we included a range of ages and a variety of cognitive function. The participants interacted only briefly with the prototype, and only once; future work will allow older adults to use an IET prototype continuously for a longer time before giving us feedback. Finally, we did not consider the differences in perspective of the various health professionals; instead, we grouped all the professions together. Further studies could compare and contrast the perspectives of different types of health professional.

Conclusion

Instruction, safety, accessibility, and motivation are four important values for older adults and health professionals, and they need to be incorporated into the design of IET. The target users of IET should be consulted in the design process to ensure that their values and needs are met and that the technology will be useful and effective for them.

Key messages

What is already known on this topic

Interactive exercise technology (IET) is effective in promoting physical activity and its benefits for older adults. Older adults and the health professionals who provide their care have specific values regarding technological design that often differ from the values of those who develop such technology. To ensure that IET is well suited to older adults, design thinking can be used to incorporate their perspectives and those of health professionals into the design process.

What this study adds

Our study is one of only a few that have investigated how IET can be designed to reflect the values of both health care professionals and older adults. Our study used design thinking to collect feedback from older adults and health professionals that would inform the design of a new IET.

Appendix: Focus Group Guide

Now that you have had a chance to try out ABLE for yourself, we want to ask you some questions about your experience. We will be audio recording the conversation. If you have something to say that you do not want audio-recorded you can tell the facilitator and we will turn off the audio recorder. You can also speak to the facilitator after the group discussion. Your responses will be kept confidential, and you will not be identified in any presentations or publications of the results.

1. What did you like about ABLE?

Follow-up/probing questions:

• a)Why did you like it?
• b)What did you like about the physical features (visuals, sounds)?
• c)What did you like about the setting (group vs. individual participation)?
• d)What did you like about the different programmes (paint, music, game)?
• e)What was your favourite programme, and why?
• f)Did you prefer to use ABLE alone or with another person, and why?

2. What would you change about ABLE?

Follow-up/probing questions:

• a)Why would you change it?
• b)How would you change it?

3. How could you see yourself using ABLE?

Follow-up/probing questions:

• a)Would you use it on your own (older adults) or prescribe it to be used alone (service providers) or with (your) family? Why?
• b)Which programmes (music, paint, game) would you use (older adults) or prescribe (service providers)? Why?

4. What would make it difficult to use ABLE?

Follow-up/probing questions:

• a)What would stop you from using (older adults) or prescribing (service providers) ABLE? Why?
• b)How could we make it easier to use (older adults) or prescribe (service providers) ABLE?

5. What would make it easier to use ABLE?

Follow-up/probing questions:

• a)What would help you to use (older adults) or prescribe (service providers) ABLE? Why?