A) General attitudes towards using the technology
All participants reported an overall positive attitude towards each discussed technology except the standard camera. All participants showed their interest and believed there would be significant benefits of using technologies to monitor health. Overall, participants were willing to install and test out the technologies in their homes. Table
3 shows a summary of the attitudes.
One participant could see that the technologies could track changes or progress of an individual’s health conditions at home by comparing the data collected by the technologies at different times. She also added,
“it’s usually something else behind it that causes the hip to break it in the first place,” to show that she thought people could use the technologies to understand the underlying causes of some adverse outcomes. The technologies could potentially prevent adverse outcomes such as fractions from happening by detecting early signs. Three other participants believed the data collected and interpreted by the technologies would be useful for both older adults themselves and clinicians to understand their health better and make a more informed decision.
I think if technology like this or you know instruments like this are going to be useful for medical practitioners, then they would be valuable, and I would use it because I think the more information you can give to your doctor, the better off here. She’s going to be when it comes to treating something that you might whether its frailty or whatever and if things like this can help improve the quality of people’s lives as we age, then I think it’s a good thing.
Participants have also seen the technologies overall could benefit the daily living of older adults. One participant thought the technologies could identify and inform potential problems in their daily living and advised them to live healthier lives. Another benefit that the participants have seen was that the more information the technologies could collect and shared with their doctors, the better the doctor could give them advice or diagnosis. Having the technologies at home monitoring their health, participants believed it could promote aging in place with longer independence.
Eight participants across three focus groups indicated that they had experience using a smartwatch, such as a Fitbit. Two participants described the smartwatch as easy to wear and difficult to lose. Similarly, when talking about a smart speaker, two participants indicated that they had spoken with Siri (a virtual assistant by Apple Inc.) on their smart devices, while other participants simply thought they had no problem interacting with a smart speaker.
For the chair and bed sensor mat, motion sensor, and hand dynamometer, participants showed positive attitudes as one participant said, “It (the chair and bed sensor mat) looks like something that I almost forget it was there. It’s not something I need to set up or keep track of or restart or anything like that. It’s very easy, a simple device.” Other comments on these sensors include “it (the chair and bed sensor mat) seems like it would be very simple.”, “I like this (hand dynamometer) actually, it’s very simple.”, and “it’s (the motion sensor) not anything I have to wear or maintain.”
Although participants had no problem installing and trying out the technologies, they questioned the technologies’ usefulness based on their health conditions, needs, and added values. Specifically, participants mentioned that they did not need to use the technology to monitor their health when still healthy and active. Participants indicated that the chair and bed sensor mat would not be useful for them because they were still quite active in their daily life.
After stated “Yeah, I feel comfortable using it.”, the same participant followed by saying, “I don’t think I am at a stage where I need to track this stuff (sedentary behavior). I am fairly active. So practically, you know from a practical point of view, I don't see a use currently."
"I can’t really see at this point and possibly that in the future."
"I mean, It’d be okay to have one (weight scale), I guess. But I don’t see it as being ... unless the person’s got a real problem, you know, with health issues related to obesity."
"I have a scale now and I wouldn’t mind having one like this in the future to detect weight loss, you know, especially with cancer with my parents. That was like a big thing, keeping track of the weight loss. They got more frail."
Limited added value for some technologies was also reported. Some participants gave up using technology such as a smartwatch due to limited perceived contribution to their health. “It didn’t contribute with anything to my wellbeing. I am still active. I basically know how many steps I take and all that.”, said one participant. Another participant felt the technological features and perceived health benefits offered by the smartwatch is merely not appealing by stating, “I first started to investigate this kind of thing earlier, but stopped doing it. Just no attraction to me.” Although participants stated they had no problem wearing a smartwatch, they just could not find a need for it like a participant said, “I wouldn’t have any trouble wearing it, but it’s just em, what it’s telling me I don’t have any use for. I don’t need to know.”
The participants from all three groups voiced several concerns related to the presented technologies. These concerns include:
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Privacy.
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Adherence.
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Appearance.
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Technical concerns.
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Others.
Privacy
The standard camera received the most significant pushback. Fourteen participants reported that they did not feel comfortable having the camera installed in their homes and being monitored 24/7. They felt the use of the camera in their homes was intrusive and violating their privacy. Some of the participants stated, “It doesn’t fit well with me. I like my privacy.”, “I wouldn’t want to feel that somebody was watching my activities.”, “I feel invasive.”, “No, no use for it (standard camera) whatsoever other than security outside, that’d be fine. But inside those there’s no use at all to me.” and “I would not like to use it. I will I would consider it an invasion of privacy.”
On the contrary, all participants were more positive towards a depth camera, which would not reveal a person’s clear image but only its silhouette. Participants felt more appropriate and more acceptable to this approach. Participants stated, “I think it (depth camera) is an improvement over a previous technology (standard camera) regarding privacy.”, “I would be much more comfortable with this (depth camera), and I wouldn’t mind, I don’t think if it was in the bedroom. You can’t see what I’m wearing, and you can’t see my face; you don’t’ know anything about my body other than the outline. Yeah. I wouldn’t have an issue.”, “It (depth camera) allows for privacy. Yah, on the other hand, the camera (depth camera) provides information in addition to the individual. It may record the person is not dressing properly, and it could be a further clue of deterioration for the clinician. So, I find a balance between privacy and clinicians to assessing deeply than with a regular camera.” and “My face is not seen. So, what’s my problem? I don’t have any problem.”
Adherence
The second most mentioned concern is the adherence to technology, especially for body-worn technologies like the smartwatch. Participants noted that people could find it hard always to remember to wear the smartwatch or forget to wear it in urgent situations. One participant stated as a general comment for all technologies, “So everything that’s automated I would prefer over something that I have to interact.”
Skepticism about technologies could be another reason for poor adherence, particularly for body-worn technologies. Like one participant said, “I would like to try, but it’ll probably go the way (giving up) of all the other things that I’ve tried.” This participant did not think the technologies would work, so he gave up using them. Three more participants also shared that they had stopped using a smartwatch that they used to use because they did not think it would work or be attractive. “It didn’t contribute to anything.”, said one participant. “I first started to investigate this kind of thing earlier, but stopped doing it. Just no attraction to me.”, said another participant.
Appearance
Participants would be more likely to use technology if the technology is aesthetically pleasing. Two participants stated, “I think that something like that (chair and bed sensor mat) is probably very practical for a senior, especially if they could put a pillow over top of it to make it a little bit less, more cosmetic and less obtrusive.” and “But, aesthetically, I think this is I can’t see it (chair and bed sensor mat) getting used in a practical point of view until somebody became so old that they really didn’t care what, like this, to have this sitting in the middle of their living room or something. I think, you know, uh, I don’t see this is something that somebody will use in the long term.”
Technical concerns
The concerns around the technical aspects of the technologies include the data accuracy, operating interface, interaction with the technologies, and power supply. Participants across all three focus groups questioned whether a motion or fridge door sensor could differentiate people living in the same house as people may live with their spouses, children, or roommates. Three participants stated:
"My grandson comes over, and the door (fridge door) is open every minute. They’re in and out all the time."
"I rent a room from a friend of mine who has a Filipino girlfriend and three little Filipino girls. And the fridge is open five hundred times a day. I might open the fridge three times a day. They open it five hundred times a day. So, for me too, it’s not going to detect anything from for me."
"It (motion sensor) cannot differentiate. So, if you live with somebody else or have guests over, it would pick up their activity too, so that’s kind of not beneficial."
The locations for food storage could also affect data accuracy. Participants expressed their concerns as follows:
"There’s very little stuff in my fridge other than water and ginger ale,” “that’s not the only place you get food is out of the fridge."
"That wouldn’t work for nutrition, like if I open the door to get a bottle of water, that’s not nutrition."
"You can prepare meals from your fridge. But you could also make a sandwich and a soup and heat it up. You’re still eating, but you are not using your fridge."
The concern over the operating interface of the technologies was focused on the camera. One participant said she would find it helpful if the technology could visually present her what data would be shared with her clinician.
"It would really help me a lot if, as part of this presentation, you had a second photo that says this is what the clinician or the person on the end of the viewing can actually see."
Technologies such as motion sensors, door sensors, or cameras do not require its user to operate; therefore, there were no concerns about the interaction with the technologies. However, participants were concerned about interaction with the smart speaker, which required its user to answer questions verbally and periodically. One participant asked, “What if I missed it (a smart speaker asking questions).”
The last concern was about the power supply of the chair and bed sensor. Two participants expressed opposite concerns, with one preferring battery power and another preferring plug-in power supply.
Others
Other concerns include feeling guilty (“I don’t know if I’d use that, that would make me feel guilty if I use something like that because then I would know how sedentary I am.”), cost (“All of this technology I have an issue with a lot of seniors I know are living on very low incomes and they have like no extra money to spend on even a Fitbit”).
B) Conditions for accepting certain technologies
Participants’ positive attitudes were built on certain conditions for some of the technologies. In other words, participants would become more acceptable to certain technologies if certain conditions were met. These conditions were summarized in Table
4.
An interesting finding is that non-wrist-worn wearable sensors such as a necklace sensor or ankle sensor might be more appropriate for a particular older population to accommodate their special conditions such as dermatitis. One participant who has been a Fitbit user indicated that she had dermatitis and did not like to wear things on her wrist. Instead of wearing a Fitbit watch on her wrist, she uses a Fitbit clip clipped to her clothes to monitor her health. Another participant stated, “…also something that you could attach to your ankle or something.” The third participant liked the sensor to be worn as a necklace by saying, “something like a necklace…you know like wearing a necklace that would detect some frailty things and make it attractive enough that you can just like wear it as a necklace or something like that.”
Participants believed that people with specific health issues could become more inclined to use technologies to monitor their health. The reason is when the benefits of technology would outweigh the negative aspects (e.g., invasiveness) in the case of severe health risks or medical conditions. People with a high risk of falls, who are currently in rehabilitation, or currently living alone, could be keener and more acceptable to use technologies. They may even consider using invasive devices, such as a standard camera if their health conditions changed.
One participant commented on her opinion about the standard camera as “It’s probably good for somebody that’s in recovery and being in their bedroom in recovery. And then you know, their physiotherapist comes in, and their occupational therapist comes in, and so you have to stand up five times today. You gotta roll over, sit up, stand up.” Two participants who indicated that the standard camera was invasive also expressed that this could change with the decline in their health by saying, “This may change if my situation, my healthy situation, my problem changed dramatically. In that case, the boundary will be moved a little bit.” and “Perhaps if I was in a different place in terms of my frailty, I might be more open to it.”
For the chair and bed sensor mat, one participant suggested that the sensor mat could be useful for people with lower back issues as the mat could remind people to change their postures if they stayed in a sedentary position for too long.
“I think it’s good, you know, having that kind of reminder for some people with probably some lower back issues because it’s you know I was that long lying down, right? You know, they will think, all well that’s I got to change that but if they have if their beds telling the truth or their chair is telling the truth back. They can’t argue.” Another participant indicated that the mat could be useful for caregivers caring for someone who could not leave the bed.
"If someone is declining so much that they can’t get out of bed or they have to, then this might be useful for a caregiver to record how many hours somebody is lying in one position and they need to be turned, so they don’t develop bedsores. It could be useful to a caregiver for somebody who’s really declined a lot. So I do see some additional plus possible pluses for this."
Participants also believed a more appropriate installation location and monitoring time for certain technologies could make a difference in accepting the technologies. Four participants expressed a similar idea that they would become more open to use a standard camera if the camera was only installed at a specific location or a public space in their homes, such as a living room or a dining room. “I feel invasive unless it (the camera) was only kept to say one certain room. But I wouldn’t feel good about it being in a bedroom or washroom,” said one participant. Participants were not convinced that the door sensor installed only on the fridge was useful for measuring food intake. However, by adding the door sensors on kitchen cabinet doors where food is stored, participants thought the device could become more practical.
For monitoring time, participants would not object to a standard camera if the camera was turned on only during a specific period of just for frailty assessment at a doctor’s request and switched off outside the requested monitoring period. For example, one participant stated, “I’m gonna enable this for you between 10 in the morning and 11 o’clock tomorrow so you can watch how I walk. That would make sense. But 24 hours a day constantly. No, I’m not comfortable with it.”
Lastly, technology with assistive functions could promote its acceptance rate. For example, besides the original function of asking questions for self-report exhaustion and food intake, participants found it would be more favorable if a smart speaker can also remind a person to take medication, go out for a walk or measure the grip strength. Like one participant stated,
“I think there is good use of additional, you know, not only ask somebody eat, but also remind somebody to take their medication.” Three more participants suggested adding a built-in reminder function such as a timer and an alarm to the chair sensor mat and the hand dynamometer.
"if you’re in a sedentary job, it’s good to get reminded to get up and go for a walk."
"I think you’d have to get in your day timer something to remind you to do it (grip strength test using hand dynamometer)."
"To have a built-in alarm of any type to alert a senior that, let’s say 30 minutes or an hour had passed. They should make an effort to stand up…The problem is that people can get too sedentary that can be alarming sometimes to realize how long you’ve been sitting in one spot, you know, without moving, and I’m finding as I get older than I’m more and more getting...You could be watching television for all night."
Table 4
Conditions for accepting certain technologies
Smartwatch | • Wearing locations other than on the wrist |
Chair and Bed Sensor | • Aesthetic appearance • Has heating function • Has vibration function |
Motion Sensor | |
Standard Camera | • Only turned on during a limited period at clinician’s request • Only installed at specific areas in a home |
C) Existing living habits or patterns related to the use of the technologies
Participants also shared their living habits or patterns that could influence the use of the technologies. These habits or patterns were centered around three areas: (1) food intake, (2) physical activities, and (3) weight. We found a diverse pattern ranging from food intake habits that had not changed too much for decades to experiencing a gradual change of eating habits, to a significant change in eating habits. Additionally, some participants reported they could not cook anymore and rely on the microwave oven to heat food only, while others mentioned they have a healthy and balanced food intake. Regarding the physical activities, several participants reported that they
“never sit, never had a sitting job” or walk a lot because of the nature of their jobs (e.g., a chef, or most clients are downtown where walking might be better than driving). In contrast, other participants reported having more sedentary behavior than they used to have.
"Yeah, I sit a lot more than I used to."
Moreover,
an apartment’s small size limits participants’ moving around at home and thus fewer physical activities.
“I don’t move around too much, haha I just live in an apartment.”, said one participant.
For weight, participants reported diverse weight loss. Some reported unintentional weight loss, whereas others reported constant weight or even weight gain.
Table 5
Existing living habits or patterns as related to frailty criteria and the technologies for assessing frailty
Smartwatch | Physical Activity, Immobilization | • Regular indoor bike riding • Much outdoor walking for work |
Chair and Bed Sensor | Physical Activity, Immobilization | • Few to no sitting due to work |
Motion Sensor | Physical Activity, Immobilization | • Has roommates • Small apartment |
Standard Camera | Physical Activity, Immobilization | • Wear shorts at home |
Depth Camera | Physical Activity, Immobilization | None |
Door Sensor | Life Space | • Open and close door without going out |
Hand Dynamometer | Muscle Strength | None |
Fridge Door Sensor | Food Intake | • Has roommates |
Smart Speaker | Food Intake, Exhaustion | • Never eat too much • Significantly change in eating habits • A gradual change in eating habits • Eat the same always • Eat healthily • Cannot cook • Microwave cooking only |
Bathroom Scale | Weight | • Constant weight for years • Unintentional weight loss in the past nine years • Weight gain |
D) Constructive suggestions related to the technologies
Participants have given constructive suggestions on the use of the technologies. Some of these suggestions were about other potential uses of the discussed technologies, although some of these suggestions were not directly related to frailty assessment. Participants suggested that there could be more ways to use a smart speaker in addition to assessing self-report exhaustion. For example, older adults could communicate with the smart speaker to mitigate social isolation. Moreover, the smart speaker used to ask exhaustion-related questions could gain more interest from users if it offers added features such as playing music, notifying lab results remotely, and other helpful features. Participants stated that besides collecting food intake information from the smart speaker, it could also suggest to users what to eat based on the food intake information collected from the user. Furthermore, participants thought the smart speaker could ask questions about users’ movements and physical activity.
Technologies would become more acceptable if they could provide more functionalities while performing the core functions for frailty assessment. Just like what a participant said, “Like if it (bed and chair sensor mat) gets warm and vibrates, I’d love one.” Another participant also said, “If it (door sensor) had an alarm on it like a beeping sound if you were concerned about somebody that’s going out on their own. You know, like your spouse, they’d be getting some cognitive disorientation. Or they’re taking medications, and it’s making them a little wonky, you know, sort of like if they go and they are just going to the store to get milk, and you hear the door open if this is going to have like a buzzer on it and close, so you have: ah they’re going, and you’re like ‘’ you’re on the clock’’ because you know how long it’s gonna take for them to go to the store and get back.”
The groups frequently mentioned the safety of people with cognitive decline or dementia. Participants could see extra benefits of technologies if technology could provide reminders to individuals with cognitive decline when users forget to turn off a stove, feed themselves, close a door, or leave home for a long time.
Once powered on, the environment embedded technologies such as camera, motion, door, and pressure sensors are designed to operate automatically and continuously at home without much manual operation needed from the users, such as turning on and off every day. The continuous operating technologies at home raised concerns from participants; however, most of the concerns came from the camera mentioned in the previous section. In turn, the participants made suggestions about if the technology can be switched from continuous monitoring to be turned on and off only at the doctor’s request.
Table 6
Constructive suggestions related to the technologies for assessing frailty
Smartwatch | • Reminder for completing a certain amount of daily activity |
Chair and Bed Sensor | • More functions including getting warm and vibration |
Motion Sensor | • Safety reminder for people with cognitive decline or dementia |
Standard Camera | • Use in certain rooms • Can be turned on and off by doctors • Use outside of the home • Use for individuals in recovery and monitor compliance to doctor’s plan |
Depth Camera | None |
Door Sensor | • Safety reminder for people with cognitive decline or dementia |
Hand Dynamometer | • Reminder for use • Strength test for other parts of the body • Bone density test |
Fridge Door Sensor | • Reminder for food intake for people with cognitive decline or dementia |
Smart Speaker | • Reminder for taking medication • Can be used to mitigate social isolation • Engage older adults and avoid resistance to technology by building in more functions such as playing music |
Bathroom Scale | None |