Background
It is becoming increasingly accepted that provision of good quality care is synonymous with the notion of providing more person-centred care, and increasing the levels of patient involvement in the decisions that are made about their care [
1,
2]. The world population is ageing, one-in-six of the UK’s population is currently aged 65 and over, which by 2050 will have risen to one-in-four [
3]. In addition to the goal of providing better quality care, the increased burden that an ageing population puts on health care services is driving a search for new technology-enhanced modes of care delivery that will be capable of meeting patient needs whilst also adhering to anticipated budgetary constraints [
4]. The development and use of new software applications and information and communication technologies is one of the few areas that has the potential to reduce costs whilst improving the quality of care and facilitating the provision of patient-centred care [
5]. In particular, developing information and communication technology applications that enable patients to participate alongside practitioners when making care decisions is a key UK government strategy which responds to the challenge of catering for the increasing health care demands of an ageing population [
6].
The World Health Organisation’s International Classification of Functioning, Disability and Health (ICF) framework [
7] highlights that loss of independence is not only linked to body function but also to environmental factors. Environmental factors interact with a health condition to either create a disability or restore functioning, depending on whether the environmental factor can be regarded as a barrier or a facilitator [
8]. The pre-discharge home visit is an integral part of the discharge process and involves taking older adults to their home for a short period of time to assess their ability to perform some occupations of daily living within their own environment [
9]. Home modifications and the installation of assistive equipment can impact on a client’s life by better supporting safe independent living, but these changes are not always viewed in a positive way by patients. By seeking out ways to include clients in decision making, Occupational Therapists have the opportunity to reinforce their desire to be person-centred. However existing research has found dissatisfaction with aspects of the occupational therapy home visit, despite there being evidence that there is a consistent positive association between patient experience and clinical outcomes [
10]. Some older adults found the home visit experience demoralising, daunting, and anxiety-provoking because of weak communication, poor preparation, and their lack of involvement in decision making [
11]. As a consequence, less than 50 % of assistive equipment installed in homes, as a result carrying out pre-discharge home visits, is actually used by patients [
12]. This low level of engagement may not be surprising, when considering how personalised and sensitive the home environment is considered to be by patients.
Occupational Therapists recognise that the relationship between a client and their home can have many layers relating to identity, security, and personal history [
13]. They also recognise that clients are the best source of information regarding how day-to-day occupations are carried out at home. However, there are no existing tools or techniques specifically designed to support the collaborative process, which should occur between the patient and practitioner, to visualise, negotiate, and make decisions about how the home environment may be altered/adapted to best suit and facilitate patient needs [
14]. There is an urgent need to address the high levels of equipment abandonment that occur as a result of the pre-discharge home visit process [
12]. One approach to addressing this need is to explore how technology, particularly 3D interior design software applications, may be used to help patients and practitioners collaborate effectively during the process. Moreover, there is a need to develop tools which enable patients to communicate the importance of the intricacies of their personal home space to practitioners, and for practitioners to better visually simulate and communicate the options that are available to patients with regards to home adaptations. Likewise there is a need to enable patients to communicate how proposed adaptations are perceived to impact upon their personal home environment.
Computerised 3D design applications for home adaptation
A computerised three-dimensional virtual environment (3DVE) is defined as an environment which “capitalizes upon natural aspects of human perception by extending visual information in three spatial dimensions” and “enables the user to interact with the displayed data” [
15]. The areas in which 3DVEs have been applied span across a range of domains which include interior design [
16], health and wellbeing [
17], military and defence [
18,
19], education [
20] and gaming for health [
21]. Furthermore, mobile 3DVE applications are becoming recognised as valuable tools that may be applied to a range of healthcare scenarios [
22]. More specifically within the domain of home interior design, computerised 3D interior design applications (CIDA) are one form of 3DVE which serve as a valuable assistive 3D visualisation tool for negotiating adaptations between designers and home owners [
23]. CIDA supports the process of exploring a variety of potential interior designs and home adaptations, and enables users to weigh up the relative benefits and challenges which these variations present before committing to having the adaptations made in reality. There are a number of potential benefits that CIDA could bring to the home adaptation process, such as improving the extent to which the practitioner and patient are able to negotiate, collaborate and understand the range of adaptation options available. Furthermore, by simulating potential adaptations using CIDA, misconceptions and potential misunderstandings of proposed changes may be brought to the forefront of a discussion, hence enabling better engagement between client and practitioner and facilitating the process of consensus building [
24]. CIDA, therefore, has the potential to serve as a tool that enables patients and practitioners to present simulated representations of the patient’s home and to jointly discuss the interior layout of the home and explore the range of adaptations and specialist equipment that may potentially be placed within it. This would not only provide valuable opportunities to engage in shared decision making, but would also opportunity for practitioners to develop a more detailed understanding of their patients and for patients to better understand the function, and potential benefits, of items of specialist assistive equipment. Effective use of CIDA has the potential of empowering patients to participate as more equal partners in decision making, hence potentially averting the daunting, demoralising and anxiety provoking experience that traditional practitioner-led home-based visits are so often found to be by some patients [
9].
CIDA research relating to home adaptations
Despite the potential benefits, there are many challenges to realising the utilisation of CIDA in practice. Particularly as occupational therapists have been found to be reluctant to use information and communication technology in practice [
25]. Previous occupational therapist focused research related to the current study, exploring the concept of utilising CIDA in practice, found that some therapists believed CIDA should be treated with caution so as not to be seen as a tool that would replace the role of the occupational therapist. However, they also viewed it as a tool that could enhance their status within the health care profession and improve communication [
14]. In a later study, trialling a more developed version of a CIDA software application, occupational therapists reported that they were able to use the software. However, some ‘fine tuning’ was needed, such as improving the look and feel of the application and expanding the library of household items that may be included in models of patients’ homes, if the application is to be optimally used in practice [
26]. Whilst the views of therapists are important, patient-focused research has shown that they are more likely to adopt technologies if these are viewed as usable and are perceived to be compatible with their needs [
27]. In particular, it is important to ascertain older adults’ views of technology and its potential applicability in practice. A systematic review and critical evaluation of smart technologies and their potential use in enhancing social connectedness revealed that some technologies augment the beneficial effects of traditional older adult care practices [
28]. Furthermore, another systematic review found that older adults readily accepted smart-home technologies, providing they physical activity, function and independence [
29]. Other studies relating specifically to older adults and technology acceptance have also found that perceived usefulness of technology, its ease of use, and effort expectancy are key factors that impact on adoption of new technologies [
30,
31]. Other older adult patient focused studies have found that unhelpful features, inconsistency in interface design, and concerns relating to the reliability and stability of the application are features which are seen in a particularly negative light by this cohort [
32].
The application of CIDA must be accepted by patients if it is to serve as a feasible tool which may be used by patients within occupational therapy practice [
33]. If CIDA are not perceived as usable or likable in the eyes of the patient, it is unlikely that the technology will remain in use long enough for an evidence-base to be explored and established. Although previous studies have explored the use of CIDA from the occupational therapists’ perspective [
27,
33], no existing research explores patient perceptions of utilising CIDA within the pre-discharge home visit process. It is therefore crucial that patient perceptions of CIDA technology is explored, given the potential impact patient perceptions of such applications could have on the potential long term integration of such technology in practice.
Patient attitudes towards technology
Involving the patient at every stage of the health care technology design, development and deployment process is crucial if new technologies are to be optimally used and accepted in practice [
34]. Existing research suggests that patients are more likely to engage with technologies if they are usable and are perceived to be compatible with patient needs [
27,
35]. If CIDA is to be adopted in practice and serve as a useful tool, it must be perceived as being easy to use, useful and patients must see it as having utility in practice [
33]. Gaining insights into patient acceptance of new technologies has been the subject of much research in recent years, in particular, much effort has been invested into understanding users’ reactions and motivations to using health care technology in practice [
36,
37]. Perhaps the most widely used theory to evaluate user attitudes towards the acceptance of technology is the technology acceptance model (TAM) [
38]. Although it is a relatively straightforward model, the key TAM constructs have been seen to typically explain more than forty percent of user related issues around technology acceptance [
36].
The model suggests that users’ behavioural intention to use and their Actual Use (AU) of technology are mediated by two factors: Perceived Usefulness (PU): ‘the extent to which the user perceives that the new technology will aid them in performing the task at hand’, and Perceived Ease of Use (PEoU): ‘the extent to which the individual believes using the technology would be free of effort’ [
39]. TAM is now increasingly being applied within the healthcare research domain [
40]. Although, a recent systematic review that examined acceptance of technology for aging in place found that post-implementation research on technology acceptance by community-dwelling older adults is scarce [
41]. Interestingly Or and Karsh [
42], in a systematic review of acceptance of consumer health information technology, found that no studies examined the impact of social and task factors on acceptance and few tested the effects of organisational or environmental factors on acceptance. In recent years, the TAM factors have been increasingly used as part of more qualitative interview studies to structure conversation around the key themes that have been found to be key in the user technology acceptance [
43].
This study builds on a previous study, which focused on occupational therapists’ perceptions of CIDA [
26], to gain insights into patient perspectives of using CIDA as a tool to aid the pre-discharge home visits process. Therefore, the aim of this study is to explore community dwelling older adults’ perceptions of using CIDA in terms of its perceived usefulness, ease of use, and actual use and to consider the potential barriers and opportunities of using a CIDA application as an assistive tool within the pre-discharge home visits process.
Discussion
With the increased need to deliver person-centred care, coupled with the recognised growing potential use of technology within the healthcare, there is a need to identify new and innovative uses of technology which respond to these needs and exploit the functionality of emerging technological innovations within the healthcare context. This study considered community dwelling older adults’ perceptions of using a customised virtual reality interior design application as a tool to assist and engage patients in the pre-discharge home visits process. A total of ten participants used a CIDA as part of a home interior design task which incorporated the use of specialist occupational therapy assistive equipment. A think aloud perceptions and semi-structured interviews were carried out with participants during and after the interactive design task. Analysis of think aloud and interview data aimed to gain detailed insights into the key technology acceptance model (TAM) factors: perceived usefulness (PU); perceived ease of use (PEOU); and actual use (AU) of CIDAs as part of the pre-discharge home visits process. The results revealed a number of sub-themes that related to the TAM factors. Table
3 provides a summary of the themes, sub-themes and the associated study outcomes.
PU | Collaboration & decision making | • Clear and understandable 3D home representations |
• Valuable tool for joint decision making and collaboration |
• Empower patients to have influence on decisions |
• Increase awareness and understanding of the design options |
Educational value | • Function of specialist OT equipment not intuitive |
• Potential of learning equipment function from using CIDA |
PEOU | Interface considerations | • Increase size of icons |
• Provide textual descriptors |
• Revise folder structure/location of OT equipment |
Size & scale | • Accuracy of measurements |
Dexterity & motor skills | • Redesign interface/functions to require less dexterity/motor skills |
AU | Assisted use | • More suitable to be used alongside an expert user/practitioner |
Existing applications | • Confidence in value and applicability |
• Familiarity with CIDA in existing real-world contexts |
Based on the findings of this study, in terms of
PU, patients see the use of CIDA as a promising solution which they believed generated intuitive and understandable representations of the home environment. Importantly, participants expressed the view that CIDAs would serve as a valuable tool to facilitate patient/practitioner collaboration. Furthermore, CIDAs were seen as being a potentially important and useful visual aid which would facilitate shared understanding of the purpose and function of the proposed home adaptations. This is particularly valuable given that, to date, insufficient explanation and notification of home adaptations during home visits has resulted in some users feeling dissatisfied with their experience resulting in equipment abandonment levels in excess of 50 % [
12]. Enabling people to stay at home and maintain independence at home can add to an increased sense of control and improved quality of life [
59‐
61]. Interestingly evidence from a study involving older adults from eleven European countries found that older adults wanted to have a trusting relationship with the practitioners, to be respected about their preferences, and to receive clear health information from the healthcare providers [
62]. CIDAs were seen as having potential to help facilitate the delivery of healthcare according to all of these factors and to improve patient/practitioner communication and collaboration within the pre-discharge home visits process.
It was also noted that the use of CIDAs would help to enable patients to be more involved in decisions made about their care, hence improving the potential for shared decision making about home adaptations, reducing anxiety, and empowering patients to become more equal partners within the pre-discharge home visits process. A key enabling factor for patients to be empowered is the promotion of health literacy. Health literacy is defined as the ability to ‘access, understand, evaluate, and communicate information as a way to promote, maintain, and improve health in various settings over the life-course.’ [
63]. Traditionally health literacy tools have typically taken the form text-based information leaflets [
64]. However, a strong relationship exists between poor literacy skills and poor health outcomes [
65]. Therefore, the use of more visually focused health communication tools such as CIDAs, are likely to provide the opportunity to overcome some of the communication imbalances that exist in current practice given the current reliance on health leaflets which are not effective for patients with poor literacy. A recent study exploring the use of a virtual reality application to assess whether it could be used for persons with intellectual disabilities to achieve improved levels of health literacy has achieved very promising results [
66].
In terms of
PEOU, despite all participants self- reporting to be computer literate, the current application interface requires further development if it is to be considered usable by community dwelling older adult patients. There were a number of usability issues suggesting that the size of the icons were too small, that textual descriptors describing the function of buttons and icons were missing and the folder locations of furniture within the application were not intuitive. Furthermore, the current design of the user interface appears to be overly demanding in terms of the motor skills and level of dexterity required from the user which seems to impact upon the extent to which participants believed they would be able to use the application independently. Indeed existing research relating to interface design for older adult users suggests that many of these usability issues may be overcome if design considerations specific to this user group are adhered to when designing and developing the user interface and system functionality [
61,
67].
There was also a tendency for older adults to expend significant effort to ensure that the measurements in terms of size and scale accurately represented the real-life equivalent of the home environment being modelled, despite being advised that this was not necessary for the purposes of the set task. The personal home reflects notions of identity, expression of self, and a sense of control [
68]. Indeed older adults have reported appreciating the independence of living at home and the autonomy that living in their own home affords them [
69]. Evidence suggests that older adults have an increased reluctance to leave home, and a deeper emotional attachment to their home than their younger counterparts (Saunders 1989) even to the extent that they would stay in their home when, as a physical home, it may be less suitable [
70]. This is a potentially time consuming overhead which could present a challenge if the CIDA was used independently by patients.
From the perspective of
AU, participants expressed a preference for using the application in an assisted context, i.e., alongside a practitioner, as opposed to independently. This preference may in part be as a result of the interface design considerations which were noted as a function of PEOU and hence potential users may feel more confident to use the application independently if the application is developed further to overcome some of the usability issues noted. Nevertheless, the community dwelling older adult participants also suggested that the use of CIDAs offered the valuable potential of discussing ‘different options together’ which, regardless of the usability of the application, would deliver a valuable opportunity for patient/practitioner interaction and shared decision making which currently is lacking in the pre-discharge home visits process [
9,
12,
71]. The potential applicability of the CIDA within real-world settings, had clear potential according to participants, some of whom reported to have had personal experience of using similar software applications in more commercial contexts, for example when redesigning their home kitchen. This is a promising finding which is likely to support the potential actual use and adoption of CIDAs as a useful assistive tool within the occupational therapy setting and the pre-discharge home visits process.
When comparing the findings of this study with those of the study exploring the use of CIDA with occupational therapists [
26], It is clear that there are some similarities and differences. Both older adults and occupational therapists perceived the use of CIDA as a promising solution which they believed generated intuitive and understandable representations of the home environment. Importantly, participant groups in both studies expressed the view that CIDAs would serve as a valuable tool to facilitate patient/practitioner collaboration, communication and empower older adults to be more involved in decisions about their care. This could be a positive feature of CIDA, compared with other communication tools/devices used in this space, such as information leaflets. Effective information exchange between older adults and health care professionals is essential to ensure active participation in decision making and maintain older adults sense of self-worth and dignity [
72]. This is a particularly important factor when considering that home visits can have a negative impact upon care if decisions are not made collaboratively and if older adults and therapists have different perceptions [
9]. In addition older adults who are involved in a meaningful way in decisions surrounding devices are likely to be more satisfied and less likely to abandon using specialist devices and installed items of equipment [
73]. Communication is critical for providing efficient and effective care to patients. However, there were noticeable differences between the two groups with regards to how they believed the CIDA could actually be used in practice to improve communication between patients and practitioners. Whilst both occupational therapists and most older adults were able to create 3D representations of their homes, service users expressed a preference for using the application in an assisted context, i.e., alongside a practitioner, as opposed to independently. This suggests that older adults may value the expertise and knowledge of health care professionals and value their input within the communication process as suggested, existing research support this finding [
71]. In addition, working together in a more collaborative way could help to promote more positive practitioner attitudes towards older adults, and enhance trust between practitioners and older adults. Research has found that family members may find communicating with professionals and contributing to care decisions as challenging [
74]. The use of CIDA in an assited context, as suggested by community-dwelling older adults in this study, may provide valuable opportunities to begin to overcome some of the challenges that patients and family members experience when contributing to care decisions.
Study limitations
The participants who took part in this study all self-reported to be healthy, active and familiar with the use of desktop computers. It is therefore important to note that this sample may not be representative of the typical groups of older adults that OTs frequently engage with, and should be taken into consideration when interpreting the results. Indeed, it is likely that OTs and other health professionals frequently deliver care to older adults who have, for example, serious co-morbidities, difficulties with vision and memory, and some level of cognitive impairment and dementia. With regards to the typical level of ICT experience possessed, however, the typical older adult patient profile is changing, as younger and more technologically aware generations make the transition into the older adult category, so the typical level familiarity with ICT of this cohort will increase [
44]. Therefore, although the sample in this study is biased, such participants were recruited with the motivation of gaining insights from a sample, that may to some extent, better represent the more technologically aware older adult user group of the future. The number of participants that took part in this study may be considered to be too small to make generalisations about older adult perceptions of the use of CIDAs in the pre-discharge home visits process more generally. Furthermore, a limitation of the qualitative data collected for this study meant that quantifiable outcomes in terms of the effect of CIDA as an intervention before and after hospital discharge, and its comparison against a control group, was not explored. This direction of enquiry would have provided further tangible insight into the clinical effectiveness of using CIDA within the pre-discharge home adaptations process and should be considered in future, once the software application has been further developed to incorporate the end-user needs revealed in this study. With regards to sample size, however, the number of participants that took part in this study exceeds the minimum starting point of five participants that are necessary to provide useful and effective feedback when using the think-aloud protocol for research with interactive software applications [
48]. The deductive approach adopted in the initial phase of analysis, via the use of the three high-level TAM themes, may also be considered to be a limitation of this study. In particular, this approach may have reduced the breadth of themes that may have emerged from the data if a purely inductive approach was adopted. However, adopting a deductive approach also afforded the analysis to focus in more detail on factors that related specifically to technology acceptance, which was the aim of this study.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
AGM, AA, KLY, YD and LW contributed to the conceptual design of this study. AGM and KLY carried out primary data collection and analysis. AGM, AA and KLY drafted the manuscript. KGM made significant contributions to the theoretical underpinnings, rationale and interpretations of outcomes of the study. All authors read and approved the final manuscript.