=Paper=
{{Paper
|id=Vol-3359/paper1
|storemode=property
|title=Older Adults' Perception of Remote Health Management Technology with ADL Recognition
|pdfUrl=https://ceur-ws.org/Vol-3359/paper1.pdf
|volume=Vol-3359
|authors=Josh Cherian,Samantha Ray,Thomas Mernar,Jung In Koh,Paul Taele,Tracy Hammond
|dblpUrl=https://dblp.org/rec/conf/iui/CherianRMKTH23
}}
==Older Adults' Perception of Remote Health Management Technology with ADL Recognition==
https://ceur-ws.org/Vol-3359/paper1.pdf
Older Adults’ Perception of Remote Health Management
Technology with ADL Recognition
Josh Cherian1 , Samantha Ray1 , Thomas Mernar2 , Jung In Koh1 , Paul Taele1 and
Tracy Hammond1
1
Texas A&M University, College Station, Texas USA
2
Gwynedd Mercy University, Gwynedd Valley, Pennsylvania USA
Abstract
Activities of Daily Living (ADL) monitoring systems have the potential to facilitate Aging in Place among older adults and
decrease the burden of care of caregivers. However, limited work has investigated how older adults might perceive the
implementation of such technology. To that end, in this work, we conducted semi-structured interviews with older adults
living in a Continuing Care Retirement Community (CCRC) before and after they participated in a week-long implementation
of a simulated ADL monitoring system. We describe the thematic analysis of these interviews, finding that residents are open
to such a system but have significant concerns over privacy and the specifics of its implementation. Based on this analysis,
we present considerations designers should take into account when developing intelligent user interfaces that leverage ADL
monitoring.
Keywords
aging in place, older adults, semi-structured interviews
1. Introduction hygiene and grooming, bathing/showering, toileting,
dressing, eating & feeding, functional mobility, personal
As of 2022 there were approximately 771 million device care, and sexual activity. Instrumental ADLs,
individuals over the age of 65 globally, a number that characterized by more complex daily interactions, consist
is expected to rise to 994 million by 2030 and 1.6 billion of activities such as health and home management,
by 2050. Their proportion within the global population driving and community mobility, child rearing, meal
is also expected to rise from its current level of 10% to preparation and cleanup, medication management, and
12% in 2030 and 16% in 2050 [1]. This population increase shopping [6]. Generally, if an individual can perform
will likely overwhelm caregivers without improving the all but one or two instrumental ADLs, they can live in
current healthcare paradigm, as nearly 70% of older adults independent living communities. When individuals have
depend on some form of caregiving, and the “caregiver more serious physical or cognitive conditions preventing
support ratio”, or the number of potential caregivers aged them from performing more ADLs, the individual may
45–64 for each person aged 80 or older, is expected to choose to live in assisted living communities or in the most
drop from 7-to-1 in 2010 to 4-to-1 in 2030 and 3-to-1 in serious cases need to reside in skilled nursing facilities.
2050 [2, 3]. These communities provide more regular nursing care to
Often, the level and type of assistance older adults aid with the difficulties in performing ADLs. Continuing
require can be determined by how much assistance they Care Retirement Communities (CCRCs) are a combination
require to perform Activities of Daily Living (ADLs), of all three of these living options, allowing residents to
which are fundamental activities people do on a daily transition between the types as their ability to perform
basis [4, 5]. ADLs can be divided into two categories: ADLs and the corresponding need for assistance changes.
Basic and Instrumental. Basic ADLs, characterized by In addition to being an indicator of the level of
care and movement of the body, consist of personal assistance required, ADL performance is noticeably
affected by the onset of conditions such as lethargy,
Josh Cherian, Samantha Ray, Thomas Mernar, Jung In Koh, Paul Taele, weakness, and decreased appetite, which are clear
Tracy Hammond. 2023. Older Adults’ Perception of Remote Health
Management Technology with ADL Recognition. Joint Proceedings of predictors for the presence of an acute illness [7]. Studies
the ACM IUI Workshops 2023, March 2023, Sydney, Australia have also shown that as individuals begin to require
$ jcherian14@tamu.edu (J. Cherian); sjr45@tamu.edu (S. Ray); higher levels of assistance with an increasing number
mernar.t@gmercyu.edu (T. Mernar); jungin@tamu.edu (J. I. Koh); of ADLs, they have a higher likelihood of not getting
ptaele@tamu.edu (P. Taele); hammond@tamu.edu (T. Hammond) the assistance they need and are at an increased risk of
0000-0002-7749-2109 (J. Cherian); 0000-0003-3189-8899 (S. Ray);
0000-0002-3909-0192 (J. I. Koh); 0000-0001-8950-0914 (P. Taele);
hospitalization, hospital re-admission, and have a higher
0000-0001-7272-0507 (T. Hammond) mortality rate [8].
© 2023 Copyright for this paper by its authors. Use permitted under Creative Commons License
Attribution 4.0 International (CC BY 4.0).
Currently, the performance of ADLs is predominantly
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tracked manually and directly [9]. Caregivers, family has looked at PERS, with little work investigating the
members, or individuals themselves need to explicitly viability of monitoring and Check in Systems [27, 28, 29].
notice a difference in the person’s physical or cognitive Studies have found that while there are notable
abilities for a realization to be reached that the type benefits to tools to support health management,
or level of care required needs to change. Thus if significant barriers remain that prevent their widespread
the performance of ADLs could be monitored, it could adoption. Benefits include increasing safety, increasing
alleviate this caregiving bottleneck, facilitating aging in confidence, providing a support network, increasing
place for older adults: both alleviating the burden of social interaction, and providing enjoyment and leisure.
care on caregivers and enabling them to provide more Barriers on the other hand include concerns over
person-centered care, and reducing the overall cost of usability, cost, the need for specialized training,
healthcare [10, 11, 12, 13, 14, 15, 16, 17, 18]. security risks, potential for over-reliance, and privacy
In recent years, researchers have explored the use of concerns [30, 27, 31, 32, 33, 34, 35, 28, 29, 36, 37]. In
human activity recognition as a means of automatically addition, studies have found that people prefer traditional
recognizing ADL performance. While much of the healthcare caregivers [38] and, in a similar vein, found
literature in this space has focused on recognizing the that people had concerns over the lack of human contact
ADL performance of the working-age population, several such devices might engender [31, 33, 39].
studies have looked at recognizing the activities of older In this work, we explore the viability of an ADL
adults [19, 20, 21, 22]. A few studies have taken this a monitoring system that leverages smartwatches as the
step further and tested these systems in long-term care sensing medium. We focus on older adults living in
facilities, e.g., the Center to Stream HealthCare In Place at personal care, a population that is understudied when it
the University of Missouri has done a significant amount comes to understanding the views of assistive technology
of work in this space [23, 24, 25]. among older adults. Furthermore, smartwatches are
If actualized, human activity recognition could serve an attractive medium for providing assistance, as
as the foundation of intelligent user interfaces that allow general-purpose systems are generally better accepted
older adults to age more independently, safely, and than devices dedicated for specific aging assistance
comfortably and reduce the burden of care on caregivers. purposes [26].
However, for these systems to see widespread adoption,
it is crucial to properly understand the perspective
and opinions of the older adults who would use this 3. Methodology
technology. To that end, we conducted a user study with
We conducted a study with five residents living in
residents at a CCRC involving interviews before and after
personal care within a CCRC in the Northeastern USA.
a week-long simulation of participating in a remote ADL
These resident’s demographics can be seen in Table 1.
monitoring system. In this work-in-progress, we share
The study consisted of a pre-interview, a week-long
the results of thematic analysis from these interviews
period during which residents wore smartwatches on
to understand how such technology might be received
both wrists and logged their activities in a written log,
and what design considerations are necessary to improve
and a post-interview. Both pre- and post-interviews were
chances of successful adoption.
semi-structured and were recorded and subsequently
transcribed for analysis.
2. Related Work For this study, we used two Polar M600 smartwatches,
one worn on each wrist. We collected accelerometer and
Designing and developing technology to support older gyroscope data from these watches; however, analysis
adults has long been an area of interest for researchers. In of the data collected from these sensors are not reported
many cases, the goal of these technologies is to support in this work. Participants did not have to directly
“Aging in Place”, which entails older adults retaining interact with the smartwatches with the exception of
as much of their independence as possible as they putting them on in the morning and taking them off at
age. These tools can be broadly classified into Personal night; i.e., the data collection happened passively without
Emergency Response Systems (PERS), Monitoring, and participant interaction. A researcher visited participants
Check in Systems [26]. Of these groups, PERS are the every night of the study to ensure that the watches were
most commonly used by older adults, generally taking charged overnight.
the form of a device that can be worn that has a button
users can press in the case of emergencies (e.g., falls). 3.1. Pre-Interviews
Despite their prevalence, these systems are not popular
with older adults. Consequentially, much of the research The goals of the pre-interviews were to understand
that has looked at older adults’ opinions on technology participants’ current experience using technology and
Table 1
Demographics of Nurses and Nursing Assistants Interviewed
Participant Age Gender Years in Assisted Living
P1 91 M 22
P2 88 F 0.5
P3 92 M 5
P4 91 F 10
P5 66 F 1.16
to gauge their potential acceptance of a technology read the news, shop online, and assist in maintaining
designed to monitor their ADL performance. To that an exercise routine. Participants did not use technology
end, we begun the interview by asking participants what to track their own health, with the exception of P3 who
types of technology they used, what they liked and tracked a number of health metrics using a combination
disliked about technology, how their use of technology of their iPhone and Apple Watch. P3 was by far the most
has changed after moving into personal care, if and comfortable with technology, actively seeking out and
how they use technology to manage their health, and learning new technologies to use in their personal life.
how they think technology could possibly support them By contrast, one participant, P1, had no ability to use
through the aging process. In the last portion of the technology at all. When asked about his technology use
interview we asked them to imagine that a system was he explained:
put in place within their facility that recognized their
ADL performance and allowed caregivers to monitor that “I try to limit it [my use of technology]
performance. Then we asked them how they would feel because my ability is not very good for
about the use of such a system and how it could both technicalities and stuff like that. They’re
benefit and disadvantage both residents and caregivers. not in my heart and mind. [...] Anything
that’s really new, I don’t even attempt to
do. I stay away from it.”
3.2. Post-Interviews
The goal of the post-interviews was to understand In general, participants had no desire to learn or use
how participants felt about the experience of wearing unfamiliar technologies, regardless of their reported
smartwatches over the course of one week and what comfort level with using technology. Participants either
impact it had, if any, on their opinions of using felt that they were too old to learn how to use new devices
technology for health management. To that end we asked or expressed that they were content with their daily life
residents what they liked and disliked about wearing and saw no need for new technology. For instance, P2
the smartwatches on a daily basis, if their opinion on noted that a close relative bought her an expensive laptop
technology use to monitor ADLs has changed, and what but that she could not get used to it. When asked why
they think older adults in general might think about such she explained:
a system.
“If I had gotten to it maybe two years ago I
probably would have been fine. But I just
4. Results did not want to bother with; I was at a loss
[as] to how things worked. Now maybe if I
We analyzed the interview data using thematic analysis. was more interested in technology, I would
Three computer science researchers independently coded have spent the time to do it. It’s too late
the interviews, discussed the extracted codes, and settled for me because I’ve come to technology so
on final themes. These themes can be found in Table 2. late.”
Participants currently use some assistive technology
5. Pre-Interview Themes within the facility, most notably an emergency pendant
that is worn around the neck. None of the participants
Through our interviews, we found that most participants
liked wearing the pendant, considering it ugly and noting
used some level of technology on a daily basis, typically
that it has a very limited range. P4 attributed her
in the form of specific apps and functionality on
unwillingness to wear the pendants to personal dislike
smartphones and/or tablets. Participants used technology
of the process:
to communicate with their friends and family members,
Table 2
Themes from Resident Thematic Analysis
Pre Post
Selective technology competencies No issues wearing smartwatches
Strong opinions regarding technology No change in opinion regarding technology
Criticisms of existing technology Desire to remain independent
Conscious of health management Acknowledged utility of remote health tracking
“I don’t, no. That’s just stubbornness. I have they were excellent really. Yep, I had no
it and they keep checking it [...] I believe at problem with it.”
least every two months or something they
make sure everything works. I don’t wanna However, participants did bring up minor issues they
hang it around.” had, noting they would like different options for watches
as they were a little too big for their wrists, an ugly color,
On the subject of health management, participants or difficult to put on given their poor eyesight.
were generally aware that they were being monitored When asked if their opinions regarding the imple-
by caregivers. The most noticeable form of monitoring mentation of an ADL-monitoring system had changed,
to them was location during meal times, as caregivers participants largely echoed their initial viewpoints, albeit
are required to ensure that residents are present in the with the added emphasis of wanting to maintain their
cafeteria during meals. Other participants noted that independence. Both participants who had felt that the
caregivers would come around and check vital signs system was a step too far noted that they were okay with
regularly, ensure that residents took medications at using such a system but still had reservations about the
appropriate times, and would have a staff meeting in specific implementation and the privacy implications. P4
the mornings presumably to discuss residents’ statuses. was perhaps the most apprehensive about the widespread
Participants had mixed feelings about the potential implementation of the idea, noting:
implementation of an ADL-monitoring system. On the “I know at our eating table, there are four of
one hand, P1 noted that if it was done, he was confident us, and we change often with other people,
that it would be done for a good reason: but I know one in particular. I think she
was asked but she didn’t want any parts of
“If it’s important to have it done, then I
it because it’s, she feels technology knows
have it done. [...] Whenever they ask for
enough about her. So, I think that’s a big
something this, that, and the other thing,
hurdle for tech people.”
it’s important.”
While P3, who already wears a smartwatch daily,
P5 echoed this idea: although initially comparing such expressed that he would be amenable to having his
a system to Big Brother, she followed up by noting that activities tracked and was unsure of how others might
it could be beneficial for many of the older adults living react. However, he did offer a potential way of
within the facility as well as their caregivers. On the implementing such a system:
other hand, a couple of the participants were against
the idea, feeling as if it was too much of an invasion of “Well, I think people would raise the issue
privacy. of privacy. I don’t know, I just really don’t
know how other people would feel about
that. They may feel that the nurses are
6. Post-Interview Themes acquiring too much information. But they
can also be motivated to keep up somewhat
Despite asking residents to wear smartwatches on of a daily routine. You know, if you know
both wrists, participants had no major complaints with you’re being watched you might be more
wearing the watches on a daily basis. P1 went as far as motivated to perform. [...] It might be
to note: what difference does it make how much
activity I [do]? It’s not the nurse’s business.
“I didn’t have any feeling one way or the So I think they have to be oriented to
other, they became a part of me. [...] Well the fact that what you eat, what you do,
the first day I had this difficulty in [using and activities [you do are] the institution’s
them], but after that it was very easy, then business. That’s why you’re here.”
Despite these opinions, participants acknowledged smartwatch OSs such as Apple’s watchOS or Android’s
that such a system would be useful for caregivers. P5 Wear OS would allow older adults to choose from
provided the following example use case: a number of different watches with a variety of
customization options. This design choice creates
“So, let’s say somebody was getting weaker opportunities for ecosystem synergy with other devices
and [...] all of a sudden, you’re not seeing the older adults may own and for selecting a more
them going around and doing their laps. comfortable watch band. To generalize, providing
That I could see, it would help because freedom of choice enables the older adults to pick
they’re getting older every—and they’re a watch that matches their personal aesthetics and
sitting more during the day. And these preferences, providing implicit incentive to wear the
people aren’t necessarily talking with their watch. Additionally, using commercially available
friends on the phone or on the iPad.” products allows the possibility of loved ones giving the
device itself or accessories as a gift, creating an emotional
attachment.
7. Discussion
Intelligent user interfaces that leverage human activity 7.3. Participation in ADL monitoring
recognition algorithms could be a powerful means of both should be voluntary
facilitating aging in place and reducing the burden of care;
however, this work shows that older adults will not be Given the mixed feelings residents had towards the
convinced to utilize these systems without thoughtful use of ADL monitoring, usage of such systems should
design. In this section, we discuss how these findings can be voluntary. This takeaway was even suggested
help inform the design of ADL monitoring technologies. verbatim by one of the participants. As supported
by the literature and the analysis from this work,
older adults strongly value their own independence
7.1. General-purpose systems are more and autonomy. While participating in these systems is
likely to be accepted beneficial to practicing proactive health management,
Going into the study, we expected participants to making these systems mandatory will likely lead to
dislike wearing smartwatches on both hands every resistance and noncompliance. A standout example is the
day, especially considering that the Polar M600 is current paradigm of wearing fall alert pendants: several
bulky compared to most watches in general. However, participants flatly refuse to wear them due to negative
residents’ responses were uniformly non-negative or perception of what they can imply about their current
directly positive, with several even noting that they didn’t health status. However, this distaste can be mitigated by
normally wear watches but found themselves using the making the device appealing to use, as discussed, and
smartwatch just as a watch at times during the study. involving the older adults in the design of the overall
This attitude represented as a contrast to perception of system so that they feel actively involved in their own
the fall pendants, which were a source of complaints health management. To give specific examples, older
from all participants. This outcome confirms findings by adults and/or their family members should be informed
Caldeira et al., where older adults mentioned they would what data is being collected, who would have access to
prefer smartwatches to PERS [26]. Smartwatches also that data, and how that data would be utilized. Thus,
represent a passive monitoring system, as they require no older adults could decide whether or not they are willing
technical interaction to function; this design allows older to allow caregivers to have the additional knowledge of
adults with limited to no technical literacy to successfully their daily activity. As such, the older adults can endorse
use these devices. In summary, it is recommended that wearing the device instead of being explicitly required
the device have utility outside of its health management to wear it.
purpose in order to make the device appealing even to
someone who uses little technology in their daily life. 8. Limitations and Future Work
7.2. Allow older adults to customize their This work represents an initial exploration on this topic
due to a small sample size. To strengthen the contribution
personal system
of these findings, this experiment will need to be repeated
Although participants were broadly positive about at other facilities with more participants.
wearing the watches, they did have minor issues
that could be rectified by offering more options for
personalization. An application designed for popular
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dakowski, R. G. Martsolf, A. E. James III, Adverse
While ADL monitoring system offer a powerful means consequences of unmet needs for care in high-
of ensuring that older adults are able to age comfortably, need/high-cost older adults, The Journals of
independently, safely, work still needs to be done to Gerontology: Series B 75 (2020) 459–470.
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