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Using the Technology Acceptance Model to explore
community dwelling older adults’ perceptions of a 3D
interior design application to facilitate pre-discharge home
adaptations
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Authors:
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Arthur G. Money1§, Anita Atwal2, Katherine L. Young2, Yasmin Day2, Lesley Wilson2
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Kevin G. Money3
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1Department
of Computer Science, Brunel University, Uxbridge, UB8 3PH, UK
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2Department
of Clinical Sciences, Brunel University, Uxbridge, UB8 3PH, UK
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3Henley
Business School, Greenlands, Henley-on-Thames, RG9 3AU, UK
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§Corresponding
author:
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Email addresses:
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AGM: Arthur.money@brunel.ac.uk
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AA:
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KLY: Katherine.young@brunel.ac.uk
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YD:
Yasmin.day@brunel.ac.uk
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LW:
Lesley.wilson@brunel.ac.uk
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KGM: Kevin.money@henley.ac.uk
Anita.atwal@brunel.ac.uk
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Abstract
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Background: In the UK occupational therapy pre-discharge home visits are routinely
carried out as a means of facilitating safe transfer from the hospital to home. Whilst
they are an integral part of practice, there is little evidence to demonstrate they have
a positive outcome on the discharge process. Current issues for patients are around
the speed of home visits and the lack of shared decision making in the process,
resulting in less than 50% of the specialist equipment installed actually being used
by patients on follow-up. To improve practice there is an urgent need to examine
other ways of conducting home visits to facilitate safe discharge. We believe that
Computerised 3D Interior Design Applications (CIDAs) could be a means to support
more efficient, effective and collaborative practice. A previous study explored
practitioners perceptions of using CIDAs; however it is important to ascertain older
adult’s views about the usability of technology and to compare findings. This study
explores the perceptions of community dwelling older adults with regards to adopting
and using CIDAs as an assistive tool for the home adaptations process.
Methods: Ten community dwelling older adults participated in individual interactive
task-focused usability sessions with a customised CIDA, utilising the think-aloud
protocol and individual semi-structured interviews. Template analysis was used to
carry out both deductive and inductive analysis of the think-aloud and interview data.
Initially, a deductive stance was adopted, using the three pre-determined high-level
themes of the technology acceptance model (TAM): Perceived Usefulness (PU),
Perceived Ease of Use (PEOU), Actual Use (AU). Inductive template analysis was
then carried out on the data within these themes, from which a number of sub-thmes
emerged.
Results: Regarding PU, participants believed CIDAs served as a useful visual tool
and saw clear potential to facilitate shared understanding and partnership in care
delivery. For PEOU, participants were able to create 3D home environments
however a number of usability issues must still be addressed. The AU theme
revealed the most likely usage scenario would be collaborative involving both patient
and practitioner, as many participants did not feel confident or see sufficient value in
using the application autonomously.
Conclusions: This research found that older adults perceived that CIDAs were likely
to serve as a valuable tool which facilitates and enhances levels of
patient/practitioner collaboration and empowerment. Older adults also suggested a
redesign of the interface so that less sophisticated dexterity and motor functions are
required. However, older adults were not confident, or did not see sufficient value in
using the application autonomously. Future research is needed to further customise
the CIDA software, in line with the outcomes of this study, and to explore the
potential of collaborative application patient/practitioner-based deployment.
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Keywords: occupational therapy, pre-discharge home visits, virtual reality, 3D,
collaboration, engagement, empowerment, technology assisted care, patient
perceptions
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Background
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It is becoming increasingly accepted that provision of good quality care is
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synonymous with the notion of providing more person-centred care, and increasing
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the levels of patient involvement in the decisions that are made about their care [1,
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2]. The world population is ageing, one-in-six of the UK’s population is currently aged
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65 and over, which by 2050 will have risen to one-in-four [3]. In addition to the goal
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of providing better quality care, the increased burden that an ageing population puts
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on health care services is driving a search for new technology-enhanced modes of
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care delivery that will be capable of meeting patient needs whilst also adhering to
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anticipated budgetary constraints [4]. The development and use of new software
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applications and information and communication technologies is one of the few
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areas that has the potential to reduce costs whilst improving the quality of care and
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facilitating the provision of patient-centred care [5]. In particular, developing
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information and communication technology applications that enable patients to
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participate alongside practitioners when making care decisions is a key UK
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government strategy which responds to the challenge of catering for the increasing
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health care demands of an ageing population [6].
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The World Health Organisation’s International Classification of Functioning,
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Disability and Health (ICF) framework [7] highlights that loss of independence is not
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only linked to body function but also to environmental factors. Environmental factors
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interact with a health condition to either create a disability or restore functioning,
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depending on whether the environmental factor can be regarded as a barrier or a
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facilitator [8]. The pre-discharge home visit is an integral part of the discharge
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process and involves taking older adults to their home for a short period of time to
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assess their ability to perform some occupations of daily living within their own
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environment [9]. Home modifications and the installation of assistive equipment can
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impact on a client’s life by better supporting safe independent living, but these
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changes are not always viewed in a positive way by patients. By seeking out ways to
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include clients in decision making, Occupational Therapists have the opportunity to
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reinforce their desire to be person-centred. However existing research has found
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dissatisfaction with aspects of the occupational therapy home visit, despite there
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being evidence that there is a consistent positive association between patient
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experience and clinical outcomes [10]. Some older adults found the home visit
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experience demoralising, daunting, and anxiety-provoking because of weak
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communication, poor preparation, and their lack of involvement in decision making
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[11]. As a consequence, less than 50% of assistive equipment installed in homes, as
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a result carrying out pre-discharge home visits, is actually used by patients [12]. This
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low level of engagement may not be surprising, when considering how personalised
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and sensitive the home environment is considered to be by patients.
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Occupational Therapists recognise that the relationship between a client and
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their home can have many layers relating to identity, security, and personal history
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[13]. They also recognise that clients are the best source of information regarding
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how day-to-day occupations are carried out at home. However, there are no existing
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tools or techniques specifically designed to support the collaborative process, which
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should occur between the patient and practitioner, to visualise, negotiate, and make
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decisions about how the home environment may be altered/adapted to best suit and
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facilitate patient needs [14]. There is an urgent need to address the high levels of
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equipment abandonment that occur as a result of the pre-discharge home visit
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process [12]. One approach to addressing this need is to explore how technology,
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particularly 3D interior design software applications, may be used to help patients
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and practitioners collaborate effectively during the process. Moreover, there is a
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need to develop tools which enable patients to communicate the importance of the
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intricacies of their personal home space to practitioners, and for practitioners to
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better visually simulate and communicate the options that are available to patients
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with regards to home adaptations. Likewise there is a need to enable patients to
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communicate how proposed adaptations are perceived to impact upon their personal
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home environment.
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Computerised 3D design applications for home adaptation
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A computerised three-dimensional virtual environment (3DVE) is defined as an
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environment which “capitalizes upon natural aspects of human perception by
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extending visual information in three spatial dimensions” and “enables the user to
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interact with the displayed data” [15]. The areas in which 3DVEs have been applied
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span across a range of domains which include interior design [16], health and
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wellbeing [17], military and defence [18, 19], education [20] and gaming for health
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[21]. Furthermore, mobile 3DVE applications are becoming recognised as valuable
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tools that may be applied to a range of healthcare scenarios [22]. More specifically
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within the domain of home interior design, computerised 3D interior design
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applications (CIDA) are one form of 3DVE which serve as a valuable assistive 3D
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visualisation tool for negotiating adaptations between designers and home owners
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[23]. CIDA supports the process of exploring a variety of potential interior designs
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and home adaptations, and enables users to weigh up the relative benefits and
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challenges which these variations present before committing to having the
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adaptations made in reality. There are a number of potential benefits that CIDA could
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bring to the home adaptation process, such as improving the extent to which the
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practitioner and patient are able to negotiate, collaborate and understand the range
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of adaptation options available. Furthermore, by simulating potential adaptations
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using CIDA, misconceptions and potential misunderstandings of proposed changes
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may be brought to the forefront of a discussion, hence enabling better engagement
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between client and practitioner and facilitating the process of consensus building
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[24]. CIDA, therefore, has the potential to serve as a tool that enables patients and
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practitioners to present simulated representations of the patient’s home and to jointly
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discuss the interior layout of the home and explore the range of adaptations and
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specialist equipment that may potentially be placed within it. This would not only
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provide valuable opportunities to engage in shared decision making, but would also
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opportunity for practitioners to develop a more detailed understanding of their
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patients and for patients to better understand the function, and potential benefits, of
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items of specialist assistive equipment. Effective use of CIDA has the potential of
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empowering patients to participate as more equal partners in decision making, hence
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potentially averting the daunting, demoralising and anxiety provoking experience that
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traditional practitioner-led home-based visits are so often found to be by some
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patients [9].
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CIDA research relating to home adaptations
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Despite the potential benefits, there are many challenges to realising the utilisation of
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CIDA in practice. Particularly as occupational therapists have been found to be
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reluctant to use information and communication technology in practice [25]. Previous
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occupational therapist focused research related to the current study, exploring the
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concept of utilising CIDA in practice, found that some therapists believed CIDA
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should be treated with caution so as not to be seen as a tool that would replace the
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role of the occupational therapist. However, they also viewed it as a tool that could
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enhance their status within the health care profession and improve communication
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[14]. In a later study, trialling a more developed version of a CIDA software
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application, occupational therapists reported that they were able to use the software.
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However, some ‘fine tuning’ was needed, such as improving the look and feel of the
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application and expanding the library of household items that may be included in
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models of patients’ homes, if the application is to be optimally used in practice [26].
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Whilst the views of therapists are important, patient-focused research has shown
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that they are more likely to adopt technologies if these are viewed as usable and are
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perceived to be compatible with their needs [27]. In particular, it is important to
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ascertain older adults’ views of technology and its potential applicability in practice.
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A systematic review and critical evaluation of smart technologies and their potential
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use in enhancing social connectedness revealed that some technologies augment
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the beneficial effects of traditional older
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another systematic review found that older adults readily accepted smart-home
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technologies, providing they physical activity, function and independence [29]. Other
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studies relating specifically to older adults and technology acceptance have also
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found that perceived usefulness of technology, its ease of use, and effort expectancy
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are key factors that impact on adoption of new technologies [30, 31]. Other older
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adult patient focused studies have found that unhelpful features, inconsistency in
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interface design, and concerns relating to the reliability and stability of the application
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are features which are seen in a particularly negative light by this cohort [32].
adult care practices [28]. Furthermore,
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The application of CIDA must be accepted by patients if it is to serve as a
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feasible tool which may be used by patients within occupational therapy practice
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[33]. If CIDA are not perceived as usable or likable in the eyes of the patient, it is
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unlikely that the technology will remain in use long enough for an evidence-base to
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be explored and established. Although previous studies have explored the use of
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CIDA from the occupational therapists’ perspective [27, 33], no existing research
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explores patient perceptions of utilising CIDA within the pre-discharge home visit
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process. It is therefore crucial that patient perceptions of CIDA technology is
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explored, given the potential impact patient perceptions of such applications could
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have on the potential long term integration of such technology in practice.
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Patient attitudes towards technology
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Involving the patient at every stage of the health care technology design,
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development and deployment process is crucial if new technologies are to be
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optimally used and accepted in practice [34]. Existing research suggests that
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patients are more likely to engage with technologies if they are usable and are
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perceived to be compatible with patient needs [27, 35]. If CIDA is to be adopted in
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practice and serve as a useful tool, it must be perceived as being easy to use, useful
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and patients must see it as having utility in practice [33]. Gaining insights into patient
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acceptance of new technologies has been the subject of much research in recent
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years, in particular, much effort has been invested into understanding users’
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reactions and motivations to using health care technology in practice [36, 37].
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Perhaps the most widely used theory to evaluate user attitudes towards the
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acceptance of technology is the technology acceptance model (TAM) [38]. Although
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it is a relatively straightforward model, the key TAM constructs have been seen to
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typically explain more than forty percent of user related issues around technology
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acceptance [36].
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The model suggests that users’ behavioural intention to use and their Actual Use
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(AU) of technology are mediated by two factors: Perceived Usefulness (PU): ‘the
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extent to which the user perceives that the new technology will aid them in
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performing the task at hand’, and Perceived Ease of Use (PEoU): ‘the extent to
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which the individual believes using the technology would be free of effort’ [39]. TAM
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is now increasingly being applied within the healthcare research domain [40].
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Although, a recent systematic review that examined acceptance of technology for
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aging in place found that post-implementation research on technology acceptance by
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community-dwelling older adults is scarce [41]. Interestingly Or and Karsh [42], in a
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systematic review of acceptance of consumer health information technology, found
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that no studies examined the impact of social and task factors on acceptance and
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few tested the effects of organisational or environmental factors on acceptance. In
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recent years, the TAM factors have been increasingly used as part of more
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qualitative interview studies to structure conversation around the key themes that
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have been found to be key in the user technology acceptance [43].
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This study builds on a previous study, which focused on occupational therapists’
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perceptions of CIDA [26], to gain insights into patient perspectives of using CIDA as
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a tool to aid the pre-discharge home visits process. Therefore, the aim of this study
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is to explore community dwelling older adults’ perceptions of using CIDA in terms of
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its perceived usefulness, ease of use, and actual use and to consider the potential
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barriers and opportunities of using a CIDA application as an assistive tool within the
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pre-discharge home visits process.
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Methods
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This section provides details of the methods used for user trials, data collection and
analysis. Figure 1 provides an overview of the methods used and process followed.
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[Insert Figure 1 about here]
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Participants
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The study sample focused on recruitment of community-dwelling older adults for
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participation within the task-oriented usability sessions. Convenience sampling was
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used for recruitment of participants to this study, for which a total of 10 participants
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were recruited. The inclusion criteria were that participants were aged over 55, had
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basic computer literacy skills, i.e. they were familiar with using desktop computers,
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and considered themselves to be active and healthy. With regards to the computer
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literacy inclusion criterion, this was fulfilled by participants, who all self-reported that
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they were familiar with carrying out everyday computer tasks such as using a
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desktop or laptop computer to check email and browse internet content.
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Consequently, no usability issues were observed during the trials with regards to
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participants manipulating the input/output hardware devices (i.e. the desktop, mouse
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and keyboard setup). The rationale behind recruiting a sample of participants who
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possessed basic computer literacy skills was in part motivated by the aim of this
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study, which was to gain insights into older adults’ perceptions specifically of the
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CIDA software and its functionality. Recruiting participants with basic computer
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literacy skills helped to ensure that the focus remained on the CIDA software and
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was not confounded by usability issues that would arise due to a lack of
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understanding and grasp of the desktop, mouse and keyboard setup and the
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Windows, Icons, Menus and Pointer (WIMP) interaction paradigm. Moreover, the
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profile and technology skillset of older adult users is rapidly changing [44]. It is
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therefore important that present-day studies do not misrepresent the needs of near-
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future older adult populations who will be the users of emerging technologies and
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applications [45]. It has been suggested that carrying out task-focused usability
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sessions with older adults who possess basic computer literacy skills is a useful
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strategy for eliciting insights into the needs of near-future older adult user
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populations, who are more likely to possess basic computer literacy skills as a
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consequence of being more exposed to a range of technologies throughout their life-
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course [44-47]. The number of participants recruited for this study is in excess of the
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recommended threshold of five participants typically considered as a good starting
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point to carry out effective think-aloud interaction and usability testing studies [48,
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49]. Six of the participants were female and five were male. All participants were
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retired with the exception of one who was employed part-time and another who was
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employed full-time. The mean age of participants was 68 years of age with a
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standard deviation of 5.70. Two participants were recruited by word of mouth and
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eight of participants were recruited from the ‘Active 50’s’ exercise group at Brunel
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University Gym. The ‘Active 50’s’ group consists of approximately 120 members,
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who are aged 50 years and over. No financial incentives were offered to take part in
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the study hence participation took place purely on a voluntary basis. Table 1
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provides a summary of participant profiles for this study.
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[Insert Table 1 about here]
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CIDA interactive usability sessions
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Task-focused interactive usability sessions lasted for no longer than 90 minutes in
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total for each participant. There were four key stages to each session which were as
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follows:
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1) Issue information sheet, answering of questions, completion of informed
consent form.
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2) Demonstration of software application and question and answer session.
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3) Task-focused design task using the custom CIDA software application.
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4) Interview about perceptions/experience of using the software application.
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On arrival, information sheets were distributed to users prior to participation in
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the session, the content of which was worked through with each participant
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individually. The information sheet provided a brief background and context and
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purpose to the study, and summarised the main activities that would take place
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during the course of the session. Participants were encouraged to ask questions
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throughout the process, and any questions were answered as they arose.
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Participants were then asked to complete a consent form in which their ethical rights
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were explained in terms of informed consent, withdrawal and anonymity.
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Participants were then given a 10 minute demonstration of the SweetHome
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3D application. As part of this presentation, participants were shown how to carry out
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key tasks such as creating a floor plan, walls and inserting items of furniture into the
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3D environment. The CIDA software application used for the purposes of this task
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was a customised version of SweetHome 3D [50]. Figure 2 illustrates the customised
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SweetHome 3D application interface which was presented to the participants and
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which was used to design and develop home interiors by participants in each
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session.
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[Insert Figure 2 about here]
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The application interface for SweetHome 3D consists of four functional quadrants: 1)
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Furniture catalogue; 2) Home plan, 3) Home furniture list, 4) 3D view. The
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application used in this study has been customised to include a library of OT
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specialist assistive equipment necessary for OTs to make typical home adaptation
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recommendations as part of the pre-discharge home visits process. The 3D models
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of the assistive equipment were all custom built for the purposes of this research,
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and were developed using Blender, an open sourced 3D modeling application [51].
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These artefacts were presented within the furniture catalogue quadrant of the
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application within a folder entitled “OT Objects”. Occupational therapy assistive
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devices featured in the library included a bath board, a shower chair, sanitary
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dispenser, portable shower screen, shower commode, bath seat, bath hoist, ramps,
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a range of grab rails, a wheelchair, raised toilet seat and toilet frame. The custom OT
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objects library folder and how this was integrated into the furniture catalogue
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navigation pane and examples of some of these OT objects are also presented in
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Figure 2 (Quadrant 1: Furniture catalogue) as well as how these OT objects may be
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modelled within an example 3D view of a bathroom environment (Quadrant 4: 3D
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view)..
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After the demonstration of the software and a question and answer session,
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participants were provided with basic written instructions, presented in Table 2,
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outlining the key steps necessary to complete the main interactive session task.
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[Insert Table 2 around here]
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For the main task, participants were asked to design a bathroom of their choice. As
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part of the task, they were asked to insert assistive equipment i.e. a bath board, toilet
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frame and shower chair in positions they deemed appropriate. Participants were
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asked to design the bathroom from scratch, whilst adopting a ‘think aloud’ approach,
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which enabled them to verbally share their thoughts whilst interacting with the
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application [52]. The think-aloud technique is a well established technique used for
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eliciting real-time thoughts of users as they interact with software applications. The
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technique is particularly useful as it elicits user preferences but also provides
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valuable insights into the reasoning behind these preferences and thoughts. It has
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been used extensively within the context of usability testing, and with regards to its
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use within occupational therapy, it has been used to explore clinical reasoning [53].
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Users were reminded throughout the task, that there was no urgency in them
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completing the task, and they were encouraged to take as long as they required to
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provide comments and to interact with the application. Standard think-aloud prompts
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such as “what are you thinking?” and “what are you doing now?” were used
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whenever the researcher felt there were extended periods of silence [54]. Written
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notes were taken throughout each session and all sessions were also audio
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recorded. A short interview was carried out with each participant at the end of the
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interactive usability task. Participants were asked to reflect on their experience of
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using the application and discuss the barriers and opportunities of using a CIDA
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application as an assistive tool and any usability issues they experienced during the
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session.
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Data analysis
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Template analysis refers to the process of organising and analysing qualitative data
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[55].
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importance that emerge from the dataset. The analysis approach taken to the
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dataset was both inductive, as some sub-themes were closely linked to the data, and
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deductive as the high-level themes were driven by theory and the researchers’
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analytical interest [56]. The first stage involved creating a template which used the
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pre-defined codes specified by the technology Acceptance Model (TAM). Hence,
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analysis considered the participant perceptions of the CIDA application in the context
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of the three high-level TAM themes relating to the Perceived Usefulness (PU),
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Perceived Ease of Use (PEOU) and Actual Use (AU). Carrying out the analysis in
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this way conforms to what is considered to be a contextual constructivist approach to
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thematic analysis [57]. Initially, all interactive usability sessions and associated
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interview recordings were transcribed verbatim. The entire dataset was then read
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and comments were assigned to the three pre-determined TAM themes and moving
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similar texts into one place and re-reading segments to ensure that connections
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were justified [58]. The dataset was then examined iteratively through several stages
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of splicing, linking, deleting and reassigning sub-themes within each pre-determined
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high-level theme. Sub-themes in the context of individual participants’ accounts were
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considered, as well as examining the data across participants. Sub-themes were
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included because of their relevance to the research question and not necessarily
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because of their prevalence across the data set, as is acceptable in qualitative
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research [56].
This involves developing a template of codes that reflect the themes of
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Ethical considerations
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The study was reviewed and approved by the Brunel University Research Ethics
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Committee prior to any data collection. All participants taking part in the study were
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guaranteed confidentiality and anonymity. Signed consent forms were obtained from
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all participants prior to taking part in the semi-structured interviews. Participants were
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informed of their right to withdraw from the study at any time. This was done both in
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writing and verbally.
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Results
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In this section, the results of the task oriented usability sessions and associated
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interviews are presented. Primarily, results are presented within the three key TAM
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themes used for analysis: Perceived usefulness; Perceived ease of use; Actual use
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of the technology as well as the associated sub-themes that were identified within
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these high-level thematic constructs. Figure 3 presents a summary of the themes
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and sub-themes in the form of a thematic mind-map.
[Insert Figure 3 about here]
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Perceived usefulness
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Collaboration and decision making: Participants felt that the CIDA software provided
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clear and useful 3D visualisations of the home environment. They commented that
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these 3D home representations were understandable and clearly communicated
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their ideas about the home layout. Participants commented that CIDA could serve as
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a valuable tool for joint decision making and collaborating with others in order to
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discuss and explore possible ideas for adaptations to the home environment. They
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also noted that it could enable the patient to have more influence on the decisions
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that are to be made about adaptations to their home environment whilst also
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providing a clear visual representation to the patient of the potential changes that
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may be proposed by the practitioner.
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Participant J: “This works well, you can look at the different options together
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and explain better what you mean, I mean also understand what they mean,
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yes really like the idea of it…”
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Some participants also suggested some useful scenarios in which they felt that the
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software could be a useful tool to help the OT to collaborate with a client and
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illustrate to them the types of changes that could be made to their home. But also
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importantly, a tool which would empower the patient to better voice their preferences
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but also increase their awareness and understanding of the feasibility of a variety of
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options that may be available to them. Furthermore, it was felt that the patient would
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have a more realistic idea of the implications of proposed changes, and how these
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changes could potentially impact upon their day-to-day functioning within an adapted
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environment.
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Participant B: “Yes this is excellent, and of course, you know as a little lady
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you get ‘oh no I don’t want that’, but if you physically see it put in, it’s
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excellent, and I can physically see that that couldn’t fit in there and, or
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because my toilet’s fitted I couldn’t use, you know, this that and the other”
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One of the challenges in the process of making decisions about home adaptations
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arises when the OT is proposing potential adaptations to the patient. Indeed, it was
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envisaged that the CIDA software could actually enable OTs to better communicate
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to patients the feasibility of proposed solutions and enable the patient to perhaps
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better understand and embrace changes that otherwise may have seemed not
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possible or may have been ruled out in the absence of a 3D representation of the
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possible changes.
442
Participant B “ … if you were physically drawing it [using the SweetHome 3D,
443
you can say, ‘oh get rid of that bath love’ and put a shower in and you’ll have
444
so much more space, and they can physically see that that would be really
445
good … because a lot of old people say no that’s impossible, move on.
446
Whereas if you physically drag, got rid of the bath and put a shower unit there,
447
they say, ‘oh there’s space around the toilet now, yes that looks alright’”
448
Interestingly, some participants reported being already familiar with the use of CIDA
449
software, and have found it very useful when used it in collaboration with interior
450
designers to negotiate home improvements with high-street vendors. The CIDA
451
software was reported to typically being used as a collaborative tool, as opposed to a
452
tool which the participant would use on their own. Typically, an expert user would
453
draw up plans of a proposed interior design, which then would be used as a mock-up
454
around which a discussion could be had. The prior experience of using such
455
software, however, was seen as positive and served as a useful tool which facilitated
456
enhanced shared understanding and improved joint decision making.
457
Participant F: “It’s hard sometimes to know what’s meant when someone
458
says, move this here, take this out and put a sink in there. At least with this, I
459
can actually understand what they mean and see if it’s something I want… I
460
had exactly this conversation with the man from [a high-street DIY store] when
461
we had our new kitchen designed and fitted”
- 14 -
462
Educational value: Perhaps unsurprisingly, the majority of participants were
463
unfamiliar with the occupational therapy objects that were included in the customised
464
furniture library of this application. The participants were asked to incorporate a
465
minimum of three specialist ‘OT objects’ into their plan, including a bath board, a
466
shower stool and a toilet frame. Out of the ten participants, two were familiar with the
467
equipment, one a retired physiotherapist and the other, her partner.
468
Participant E: “What’s a Mowbray Toilet Frame, sorry I don’t know these
469
terms”
470
A lack of knowledge of the OT specialist objects impacted upon the perceived
471
usefulness of the application. It was difficult for participants to know whether they
472
were actually proposing solutions which were of any real value to them in reality and
473
meant that participants were unclear of the function of the specialist objects and how
474
the equipment should be fitted. They were unclear how the person, environment and
475
equipment interacted within a real life setting, something that an occupational
476
therapist may take for granted. As a result they did not always make safe
477
suggestions for placing the equipment in the room.
478
Participant C: “So this presumably is either something that you’d sit on and it
479
would go down into the water or it’s […] to step on” Participant C
480
Facilitator: “A bath board is something that sits across the top of the bath”
481
It was clear that the intended function of specialist OT objects was not intuitively
482
understood by the lay user, despite being presented with its name and 3D visual
483
representation of the object. Only those participants with prior knowledge of such
484
items were able to independently make decisions about placement of these objects
485
within their home environment. However, as a result of discussing the function of OT
486
objects with the facilitator, participants quickly developed their understanding of the
487
intended function of specialist equipment.
488
Participant A: “Right, I don’t know what the framework is for, that goes round
489
it”
490
Facilitator: “... It’s a piece of OT equipment, the toilet frame ... helps you lever
491
yourself on and off.”
- 15 -
492
At the end of the interactive sessions participants successfully proposed the use of
493
specialist OT objects within their home environment by the end of each session. The
494
interactions between the facilitator and the participants, therefore, did highlight the
495
educational value that could be realised as a result of having a conversation around
496
the function of the OT objects whilst using the CIDA application to model these
497
objects within the 3D home environment.
498
Perceived ease of use
499
There were a number of issues identified, in terms of the usability of the software, by
500
this sample cohort. Bringing to light that in its current form, it is unlikely that CIDA
501
application could be used independently by patients within the home setting in order
502
to propose adaptations to practitioners.
503
Interface design considerations: Participants found it challenging to interact with
504
numerous aspects of the CIDA user interface. For example, establishing the function
505
of various buttons in the menu bar at the top of the quadrant view was a theme
506
which reoccurred with a number of participants. Participant B noted that the small
507
icons meant the software was not “user friendly”. In particular, this was considered to
508
be as a result of the application not being designed specifically for use by older
509
adults and consequently, and the size of visual icons representing the function of
510
each button being too small.
511
Participant A: “these icons are quite small … if it was bigger you might have a
512
better chance of seeing [them]”.
513
514
In order to manipulate the size and position of furniture objects which had been
515
placed into the ‘Home plan’ and ‘3D view’ quadrants, participants were expected to
516
hover the mouse pointer over respective furniture objects before selecting them.
517
Participants reported that they struggled to click on or hover over objects of furniture
518
largely due to their size.
519
Participant C: “I think it’s so intricate to actually get that really right change in
520
the size of an object I would have a lot of trouble”
521
- 16 -
522
Visual sign-posting and textual descriptors of the function of the buttons on the menu
523
bar was also suggested as a requirement if the interface was to be more usable for
524
participants. The visual representations used to communicate the function of each
525
respective button was not considered to be sufficient for the needs of the user group.
526
Participant G: “It’s knowing what the controls actually mean […] I mean there
527
are no signposts to tell you”[…] it would just be useful to know that on the
528
controls, on the corner, on the object itself, this corner means this, that corner
529
means that”.
530
531
Difficulties were also noted in terms of finding appropriate objects of furniture and
532
specialist OT equipment within the furniture library. Identifying appropriate objects
533
and placing these into the Home plan was a core aspect of the task, however, one
534
which also caused difficulties. All of the items were located in folders, according to
535
the room they would most often be found in, on the left hand side of the screen.
536
However, there was a separate folder for customised ‘OT objects’. It was suggested
537
that perhaps the OT objects should be placed within the respective room folders as
538
opposed to being placed in a separate folder. This would help users know which
539
room the OT objects could be used in. One participant noted that it was time
540
consuming to find the objects she wished to place in her plan.
541
Participant C: “It was quite complicated … and I would say I’m reasonably
542
computer literate, but there was a lot involved, up and down to find the bits I
543
need ... if I’m totally honest I would have given up [on my own] … I’m not an
544
occupational therapist, but you’ve got 8 gadgets used in the bathroom …
545
instead of this whole list is to have physical pictures of those 8 items and slot
546
them in [to the bathroom folder]. ….
547
548
Size and scale: The notion that developing home interior representations tended to
549
be time consuming was compounded by the fact that many participants felt it was
550
important to have accurate measurements of furniture objects and floor plans of the
551
rooms being modelled. This outcome was unexpected, particularly when considering
552
that participants were given clear instructions that dimensions and location of items
553
within the VR models were to be decided upon at the discretion of the participant.
- 17 -
554
Nevertheless, participants spent a considerable amount of time exploring whether
555
the scale of the floor plan looked realistic and indeed whether the size of the furniture
556
items seemed reasonable in the context of the floor plan they had created. This
557
seemed important to participants who believed that in the absence of correct scale
558
and size, the exercise would have little value to either party.
Participant I: “On scale, the room has to be set out … all the measurements of
the bathroom need to be to scale.”
559
560
561
562
Some participants felt that it would be useful to be provided with the floor plan of the
563
house/flat prior to starting the task of populating it with furniture and customising it to
564
represent their own personal space. It appeared to be difficulty for participants to
565
propose approximate measurements of floor plans and represent these within the
566
application without any guidance on this matter.
567
Participant C: “You’d need to have the proportions of actually what you are
568
going to, what size the flat is actually going to be. This is the size the
569
bathrooms going to be and then you can say right, if that’s the size it’s going
570
to be this is the best place to put the different things…”
571
572
Dexterity and motor skills: The skills required by the individual to use the software
573
were highlighted throughout the sessions, both by the participants themselves and
574
through an observation of their actions. Good eyesight was noted to be essential to
575
see the items on the screen, particularly due to their size.
576
Participant H: “You’ve got to be quite dexterous especially when you’ve got a
577
small object”.
578
It was also noted that dexterity and fine motor skills were required to use the
579
software successfully. Participants noted the size of the objects required her to be
580
quite skilful to position them on the plan
581
Participant H: “Because if you’ve got the bath close to the wall and you’ve got
582
to turn it … You actually end up moving the wall, which you don’t want to do,
583
by moving the object or the bath. The bath board. It’s quite delicate.”
584
- 18 -
585
Participant B: “I think somebody, not necessarily with worse eyesight than me
586
but that might have problems with their fingers ... [it] might be a problem”.
587
Actual use
588
Assisted use: Perhaps as a consequence of the significant challenges that
589
participants faced when utilising the CIDA software, in general participants did not
590
believe that patients could use this application on their own, in its current form. When
591
discussing the potential actual use of this application in practice, participants
592
generally believed that users would need to be supported by an expert user, perhaps
593
an occupational therapist, which could explain the function of specialist OT
594
equipment and also assist in using the application. Typically, participants believed
595
that considered the level of support people would require if the software were used in
596
reality, between an occupational therapist and a client.
597
Participant B: “Personally I don’t think the little old lady would want to do the
598
actual putting in […] I think she’d probably want to tell you […] the baths here,
599
that’s here, that’s there”.
600
Participant A: “I think you’re going to rely on an awful lot of knowledge ... and
601
you know, I think they’re going to need someone like you [Occupational
602
Therapist] sitting with them…but that’s not unreasonable”.
603
604
Participants were however positive about the prospect of actually being involved in
605
the use of this software alongside practitioners. It seemed that the potential for
606
becoming a participant in the decision making process and working alongside
607
practitioners as joint experts is something that some participants believed would be a
608
valuable opportunity which they looked forward to being part of.
609
Participant F: “... it’s a case of, here use this, or take this medicine without
610
explaining why. Using this [software application] with someone like a therapist
611
would be much better, I’d love to do that, yes, I think everyone would like to
612
do it ...”
613
In terms of the scenarios in which this software was perceived to be useful, however,
614
some participants felt that it may only be useful for major adaptations to patient’s
615
homes or indeed planning new-builds for particular patient groups as opposed to
- 19 -
616
being used for minor adaptations. This was the case, particularly in light of the
617
considerable overhead that participants saw in using the application to develop an
618
initial floor plan to scale and then populate it with basic items of furniture.
619
Participant J: “I wouldn’t want to have to draw up a whole plan of my
620
bathroom and then end up only putting in one toilet frame afterwards....”
621
Participant H: “I think it would be very useful for actually, if you are going to be
622
designing disabled flats for disabled people”.
623
Existing applications: An interesting finding was that a number of participants already
624
had prior knowledge of CIDA software and discussed examples of where they had
625
personally had some knowledge/experience of its use in practice. This appeared to
626
impact positively on their views of the potential feasibility of using such software
627
applications within an OT context. In general, participants were positive about it’s
628
potential utility in practice and used case examples to substantiate their view of it
629
being of potential value within the OT context.
630
Participant G: “... it is excellent, because a lot of people can’t visualise things,
631
so, even if you go to Wickes for a kitchen or something, they will do this and it
632
is very, very useful”
633
634
Participant C: “Oh it’s very clever and I find this interesting because I know
635
estate agents use it”.
636
637
Interestingly, when discussing the actual contexts in which CIDA could be deployed,
638
one participant reported having used similar home design software in the past when
639
designing their own rooms at home.
640
Participant D: “I did mine when we had our extension, I designed the kitchen
641
for the extension we had, I worked everything, where I wanted it to go, how
642
big a window I wanted”.
643
Discussion
644
With the increased need to deliver person-centred care, coupled with the recognised
645
growing potential use of technology within the healthcare, there is a need to identify
- 20 -
646
new and innovative uses of technology which respond to these needs and exploit the
647
functionality of emerging technological innovations within the healthcare context.
648
This study considered community dwelling older adults’ perceptions of using a
649
customised virtual reality interior design application as a tool to assist and engage
650
patients in the pre-discharge home visits process. A total of ten participants used a
651
CIDA as part of a home interior design task which incorporated the use of specialist
652
occupational therapy assistive equipment. A think aloud perceptions and semi-
653
structured interviews were carried out with participants during and after the
654
interactive design task. Analysis of think aloud and interview data aimed to gain
655
detailed insights into the key technology acceptance model (TAM) factors: perceived
656
usefulness (PU); perceived ease of use (PEOU); and actual use (AU) of CIDAs as
657
part of the pre-discharge home visits process. The results revealed a number of sub-
658
themes that related to the TAM factors. Table 3 provides a summary of the themes,
659
sub-themes and the associated study outcomes.
660
661
[Insert Table 3 about here]
662
663
Based on the findings of this study, in terms of PU, patients see the use of
664
CIDA as a promising solution which they believed generated intuitive and
665
understandable representations of the home environment. Importantly, participants
666
expressed the view that CIDAs would serve as a valuable tool to facilitate
667
patient/practitioner collaboration. Furthermore, CIDAs were seen as being a
668
potentially important and useful visual aid which would facilitate shared
669
understanding of the purpose and function of the proposed home adaptations. This
670
is particularly valuable given that, to date, insufficient explanation and notification
671
of home adaptations during home visits has resulted in some users feeling
672
dissatisfied with their experience resulting in equipment abandonment levels in
673
excess of 50% [12]. Enabling people to stay at home and maintain independence at
674
home can add to an increased sense of control and improved quality of life [59-61].
675
Interestingly evidence from a study involving older adults from eleven European
676
countries found that older adults wanted to have a trusting relationship with the
677
practitioners, to be respected about their preferences, and to receive clear health
678
information from the healthcare providers [62]. CIDAs were seen as having potential
679
to help facilitate the delivery of healthcare according to all of these factors and to
- 21 -
680
improve patient/practitioner communication and collaboration within the pre-
681
discharge home visits process.
682
It was also noted that the use of CIDAs would help to enable patients to be
683
more involved in decisions made about their care, hence improving the potential for
684
shared decision making about home adaptations, reducing anxiety, and empowering
685
patients to become more equal partners within the pre-discharge home visits
686
process. A key enabling factor for patients to be empowered is the promotion of
687
health literacy. Health literacy is defined as the ability to ‘access, understand,
688
evaluate, and communicate information as a way to promote, maintain, and improve
689
health in various settings over the life-course.’ [63]. Traditionally health literacy tools
690
have typically taken the form text-based information leaflets [64]. However, a strong
691
relationship exists between poor literacy skills and poor health outcomes [65].
692
Therefore, the use of more visually focused health communication tools such as
693
CIDAs, are likely to provide the opportunity to overcome some of the communication
694
imbalances that exist in current practice given the current reliance on health leaflets
695
which are not effective for patients with poor literacy. A recent study exploring the
696
use of a virtual reality application to assess whether it could be used for persons with
697
intellectual disabilities to achieve improved levels of health literacy has achieved very
698
promising results [66].
699
In terms of PEOU, despite all participants self- reporting to be computer
700
literate, the current application interface requires further development if it is to be
701
considered usable by community dwelling older adult patients. There were a number
702
of usability issues suggesting that the size of the icons were too small, that textual
703
descriptors describing the function of buttons and icons were missing and the folder
704
locations of furniture within the application were not intuitive. Furthermore, the
705
current design of the user interface appears to be overly demanding in terms of the
706
motor skills and level of dexterity required from the user which seems to impact upon
707
the extent to which participants believed they would be able to use the application
708
independently. Indeed existing research relating to interface design for older adult
709
users suggests that many of these usability issues may be overcome if design
710
considerations specific to this user group are adhered to when designing and
711
developing the user interface and system functionality [61, 67].
712
There was also a tendency for older adults to expend significant effort to
713
ensure that the measurements in terms of size and scale accurately represented the
- 22 -
714
real-life equivalent of the home environment being modelled, despite being advised
715
that this was not necessary for the purposes of the set task. The personal home
716
reflects notions of identity, expression of self, and a sense of control [68]. Indeed
717
older adults have reported appreciating the independence of living at home and the
718
autonomy that living in their own home affords them [69]. Evidence suggests that
719
older adults have an increased reluctance to leave home, and a deeper emotional
720
attachment to their home than their younger counterparts (Saunders 1989) even to
721
the extent that they would stay in their home when, as a physical home, it may be
722
less suitable [70]. This is a potentially time consuming overhead which could present
723
a challenge if the CIDA was used independently by patients.
724
From the perspective of AU, participants expressed a preference for using the
725
application in an assisted context, i.e. alongside a practitioner, as opposed to
726
independently. This preference may in part be as a result of the interface design
727
considerations which were noted as a function of PEOU and hence potential users
728
may feel more confident to use the application independently if the application is
729
developed further to overcome some of the usability issues noted. Nevertheless, the
730
community dwelling older adult participants also suggested that the use of CIDAs
731
offered the valuable potential of discussing ‘different options together’ which,
732
regardless of the usability of the application, would deliver a valuable opportunity for
733
patient/practitioner interaction and shared decision making which currently is lacking
734
in the pre-discharge home visits process [9, 12, 71]. The potential applicability of the
735
CIDA within real-world settings, had clear potential according to participants, some of
736
whom reported to have had personal experience of using similar software
737
applications in more commercial contexts, for example when redesigning their home
738
kitchen. This is a promising finding which is likely to support the potential actual use
739
and adoption of CIDAs as a useful assistive tool within the occupational therapy
740
setting and the pre-discharge home visits process.
741
When comparing the findings of this study with those of the study exploring the
742
use of CIDA with occupational therapists [26], It is clear that there are some
743
similarities and differences. Both older adults and occupational therapists perceived
744
the use of CIDA as a promising solution which they believed generated intuitive and
745
understandable representations of the home environment. Importantly, participant
746
groups in both studies expressed the view that CIDAs would serve as a valuable tool
747
to facilitate patient/practitioner collaboration, communication and empower older
- 23 -
748
adults to be more involved in decisions about their care. This could be a positive
749
feature of CIDA, compared with other communication tools/devices used in this
750
space, such as information leaflets. Effective information exchange between older
751
adults and health care professionals is essential to ensure active participation in
752
decision making and maintain older adults sense of self-worth and dignity [72]. This
753
is a particularly important factor when considering that home visits can have a
754
negative impact upon care if decisions are not made collaboratively and if older
755
adults and therapists have different perceptions [9]. In addition older adults who are
756
involved in a meaningful way in decisions surrounding devices are likely to be more
757
satisfied and less likely to abandon using specialist devices and installed items of
758
equipment [73]. Communication is critical for providing efficient and effective care to
759
patients. However, there were noticeable differences between the two groups with
760
regards to how they believed the CIDA could actually be used in practice to improve
761
communication between patients and practitioners. Whilst both occupational
762
therapists and most older adults were able to create 3D representations of their
763
homes, service users expressed a preference for using the application in an assisted
764
context, i.e. alongside a practitioner, as opposed to independently. This suggests
765
that older adults may value the expertise and knowledge of health care professionals
766
and value their input within the communication process as suggested, existing
767
research support this finding [71]. In addition, working together in a more
768
collaborative way could help to promote more positive practitioner attitudes towards
769
older adults, and enhance trust between practitioners and older adults. Research
770
has found that family members may find communicating with professionals and
771
contributing to care decisions as challenging [74]. The use of CIDA in an assited
772
context, as suggested by community-dwelling older adults in this study, may provide
773
valuable opportunities to begin to overcome some of the challenges that patients and
774
family members experience when contributing to care decisions.
775
776
Study limitations
777
The participants who took part in this study all self-reported to be healthy, active and
778
familiar with the use of desktop computers. It is therefore important to note that this
779
sample may not be representative of the typical groups of older adults that OTs
780
frequently engage with, and should be taken into consideration when interpreting the
- 24 -
781
results. Indeed, it is likely that OTs and other health professionals frequently deliver
782
care to older adults who have, for example, serious co-morbidities, difficulties with
783
vision and memory, and some level of cognitive impairment and dementia. With
784
regards to the typical level of ICT experience possessed, however, the typical older
785
adult patient profile is changing, as younger and more technologically aware
786
generations make the transition into the older adult category, so the typical level
787
familiarity with ICT of this cohort will increase [44]. Therefore, although the sample in
788
this study is biased, such participants were recruited with the motivation of gaining
789
insights from a sample, that may to some extent, better represent the more
790
technologically aware older adult user group of the future. The number of
791
participants that took part in this study may be considered to be too small to make
792
generalisations about older adult perceptions of the use of CIDAs in the pre-
793
discharge home visits process more generally. Furthermore, a limitation of the
794
qualitative data collected for this study meant that quantifiable outcomes in terms of
795
the effect of CIDA as an intervention before and after hospital discharge, and its
796
comparison against a control group, was not explored. This direction of enquiry
797
would have provided further tangible insight into the clinical effectiveness of using
798
CIDA within the pre-discharge home adaptations process and should be considered
799
in future, once the software application has been further developed to incorporate
800
the end-user needs revealed in this study. With regards to sample size, however, the
801
number of participants that took part in this study exceeds the minimum starting point
802
of five participants that are necessary to provide useful and effective feedback when
803
using the think-aloud protocol for research with interactive software applications [48].
804
The deductive approach adopted in the initial phase of analysis, via the use of the
805
three high-level TAM themes, may also be considered to be a limitation of this study.
806
In particular, this approach may have reduced the breadth of themes that may have
807
emerged from the data if a purely inductive approach was adopted. However,
808
adopting a deductive approach also afforded the analysis to focus in more detail on
809
factors that related specifically to technology acceptance, which was the aim of this
810
study.
811
Conclusions
812
In summary, we have investigated from a TAM perspective, community dwelling
813
older adults’ perceptions of using a customised CIDA as an assistive tool in the pre-
- 25 -
814
discharge home visits process. As a result of completing a home interior design task
815
using the tool, valuable insights were gained into the potential value and utility of
816
using a CIDA within the occupational therapy setting and more specifically within the
817
pre-discharge home visits process. Notably, participants found the 3D interior
818
models of the home clear and understandable, they saw clear potential for using the
819
tool to facilitate joint decision making about home adaptations and to improve their
820
understanding of the potential value and function of proposed adaptations.
821
Community dwelling older adults suggested the usage scenario which would most
822
likely be of value, would involve both the patient and the practitioner using the
823
customised CIDA application collaboratively in a face-to-face setting. Further
824
research is needed to explore patient and practitioner perceptions of using CIDAs
825
collaboratively as part of the pre-discharge home visits process. Additional
826
development work is also needed to incorporate the requirements suggested by
827
participants as a result of this study and to identify practitioner specific requirements
828
which will ensure that both patients and practitioners are able to optimally benefit
829
from using this application in practice.
830
List of abbreviations
831
3DVE: Three-Dimensional Virtual Environment
832
AU: Actual Use
833
CIDA: Computerised 3D Interior Design Applications
834
OT: Occupational Therapist
835
PEOU: Perceived Ease of Use
836
PU: Perceived Usefulness
837
TAM: Technology Acceptance Model
838
839
Competing interests
840
The authors declare that they have no competing interests.
- 26 -
841
Authors’ contributions
842
AGM, AA, KLY, YD and LW contributed to the conceptual design of this study. AGM
843
and KLY carried out primary data collection and analysis. AGM, AA and KLY drafted
844
the manuscript. KGM made significant contributions to the theoretical underpinnings,
845
rationale and interpretations of outcomes of the study.
846
Acknowledgements
847
The authors would like to thank all of the participants that took part in this study and
848
Brunel University for providing the facilities and materials necessary to carry out the
849
interactive sessions with participants. The authors would also like to thank Julian
850
Hamm for providing technical support during sessions.
- 27 -
851
References
852
853
854
855
856
857
858
859
860
861
862
863
864
865
866
867
868
869
870
871
872
873
874
875
876
877
878
879
880
881
882
883
884
885
886
887
888
889
890
891
892
893
894
895
896
897
898
899
900
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Bodenheimer T, Lorig K, Holman H, Grumbach K: Patient selfmanagement of chronic
disease in primary care. The Journal of the American Medical Association 2002, 288:24692475.
DoH: Health and Social Care (Independent Living) Bill. London, UK: The Stationery Office;
2011.
The ageing population [http://www.parliament.uk/business/publications/research/keyissues-for-the-new-parliament/value-for-money-in-public-services/the-ageing-population/]
Federici S, Scherer MJ, Borsci S: An ideal model of an assistive technology assessment and
delivery process. Technology and disability 2014, 26:27-38.
Newman J, Kuhlmann E: Evidence-informed patient choice: Practical issues of involving
patients in decisions about health care technologies. Journal of European Social Policy
2007, 17(2):99-111.
DoH: Equity and Excellence: Liberating the NHS (White Paper). London, UK: The Stationery
Office; 2010.
International Classification of Function [http://www.who.int/classifications/icf/en/]
Mirza M, Gossett AZ, Borsci S, Federici S, Scherer MJ: The assessment of the environments
of use: accessibility, sustainability, and universal design. In: Assistive Technology
Assessment Handbook. Edited by Federici S, Scherer MJ. Boca Raton, Florida, USA: CRC
Press; 2012: 67-81.
Atwal A, McIntyre A, Craik C, Hunt J: Older adults and carers' perceptions of pre-discharge
occupational therapy home visits in acute care. Age and Ageing 2008, 37(1):72-76.
Doyle C, Lennox L, Bell D: A systematic review of evidence on the links between patient
experience and clinical safety and effectiveness. BMJ Open 2013, 3(3):1.
Atwal A, Spiliotopoulou G, Plastow N, McIntyre A, McKay E: Older adults' experiences of
occupational therapy pre-discharge home visits: A systematic thematic synthesis of
qualitative research. British Journal of Occupational Therapy 2012, 75(3):118-127.
Nygard N, Grahn U, Rudenhammer A: Reflecting on practice: are home visits prior to
discharge worthwhile? Scandinavian Journal of Caring Science 2000, 18:183-203.
Crabtree A, Hemmings, T., Rodden, T., Chevherst, K., Clarke, K., Dewsbury, G., Hughes, J. and
Rouncefield, M.: Designing with care: adapting cultural probes to inform design in sensitive
settings. In: OzCHI. Brisbane, Australia: UQ Print; 2003: 4-13.
Atwal A, Money AG, Spiliotopoulou G, McIntyre A: Occupational therapists’ perceptions
about the clinical utility of the 3D interior design software. Disability and Rehabilitation:
Assistive Technology 2012:In Press.
Wann J, Mon-Williams M: What does virtual reality NEED? Human factors issues in the
design of three-dimensional computer environments. International Journal of HumanComputer Studies 1996, 44(6):829-847.
Merrell P, Schkufza E, Li Z, Agrawala M, Koltun V: Interactive furniture layout using interior
design guidelines. ACM Transactions on Graphics (TOG) 2011, 30(4).
Depledge MH, Stone RJ, Bird WJ: Can Natural and Virtual Environments Be Used To
Promote Improved Human Health and Wellbeing? Environmental Science and Technology
2011, 45(11):4660-4665.
Qiu H, Chen L: Real-Time Virtual Military Simulation System In: International Conference on
Information Science and Engineering: 26-28 December 2009; Nanjing, China: IEEE; 2009:
1391-1394.
Fong G: Adapting COTS games for military experimentation. Simulation & Gaming 2006,
37(4):452-465.
Petersson H, Sinkvist D, Wang C, Smedby R: Web-Based Interactive 3D Visualization as a
Tool for Improved Anatomy Learning. Anatomical Sciences Education 2009, 2(61-68).
- 28 -
901
902
903
904
905
906
907
908
909
910
911
912
913
914
915
916
917
918
919
920
921
922
923
924
925
926
927
928
929
930
931
932
933
934
935
936
937
938
939
940
941
942
943
944
945
946
947
948
949
950
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
Blakely G, Skirton H, Cooper S, Allum P, Nelmes P: Educational gaming in the health
sciences: systematic review. Journal of Advanced Nursing 2008, 65(2):259-269.
Chang Liua, Qing Zhua, , , Kenneth A. Holroydb, Sengb EK: Status and trends of mobilehealth applications for iOS devices: A developer's perspective. Journal of Systems and
Software 2011, 84(11):2022-2033.
Chong A, Lee J, Park J: A Web-Based 3D System for Home Design. In: Universal Access in
Human-Computer Interaction. Edited by Stephanidis C, vol. 5615. Berlin, Germany: SpringerVerlag; 2009: 29-38.
Yoon S, Oh H, Cho J: Understanding Furniture Design Choices Using a 3D Virtual Showroom.
Journal of Interior Design 2010, 35(3):33-50.
Schaper LK, Pervan GP: ICT and OTs: A model of information and communication
technology acceptance and utilisation by occupational therapists. International journal of
medical informatics 2007, 76(1):212-221.
Atwal A, Money AG, Harvey M: Occupational Therapists’ Views on Using a Virtual Reality
Interior Design Application Within the Pre-Discharge Home Visit Process. Jourmal of
Medical Internet Research 2014, 16(12):e283.
Calvin KL, Ben-Tzion K: A Systematic Review of Patient Acceptance of Consumer Health
Information Technology. Journal of the American Medical Informatics Society 2009,
16(4):550-560.
Morris ME, Adair B, Ozanne E, Kurowski W, Miller KJ, Pearce AJ, Santamaria N, Long M,
Ventura C, Said CM: Smart technologies to enhance social connectedness in older people
who live at home. Australasiona Journal of Ageing 2013, 33(3):142-152.
Morris ME, Adair B, Miller K, Ozanne E, Hansen R, Pearce AJ, Santamaria N, Viegas L: SmartHome Technologies to Assist Older People to Live Well at Home. Journal of Ageing Science
2013, 1(101):1-9.
Barnarda Y, Bradleyb M, Hodgsona F, Lloydc AD: Learning to use new technologies by older
adults: Perceived difficulties, experimentation behaviour and usability. Computers in
Human Behavior 2013, 29(4):1715-1724.
Gell NM, Rosenberg DE, Demiris G, LaCroix AZ, Patel KV: Patterns of Technology Use Among
Older Adults With and Without Disabilities. The Gerontologist 2013, 55(3):412-421.
Mitzner TL, Boron JB, Fausset CB, Adams AE, Charness N, Czaja SJ, Dijkstra K, Fisk AD, Rogers
WA, Sharit J: Older adults talk technology: Technology usage and attitudes. Computers in
Human Behavior 2010, 26:1710-1721.
Schaper LK, Pervan GP: ICT and OTs: A model of information and communication
technology acceptance and utilisation by occupational therapists. International journal of
medical informatics 2007, 70(1):S212-S221.
Money AG, Barnett J, Kuljis J, Craven MP, Martin JL, Young T: The Role of the User within
the Medical Device Design and Development Process: Medical Device Manufacturers’
Perspectives. BMC Medical Informatics and Decision Making 2011, 11(15).
Borsci S, Kurosu M, Federici S, Mele ML: Computer Systems Experiences of Users with and
Without Disabilities: An Evaluation Guide for Professionals. Boca Raton, Florida, USA: CRC
Press; 2013.
Lee Y, Kozar KA, Larsen KRT: The technology acceptance model: Past, present, and future.
Communications of the Association for Information Systems 2003, 12:752-780.
Holden RJ, Karsh B: The technology acceptance model: its past and its future in health care
Journal of Biomedical Informatics 2009, 43(1):159-172.
Bagozzi RP: The legacy of the technology acceptance model and a proposal for a paradigm
shift. Journal of the Association of Information Systems 2007, 8:244-254.
Davis FD: Perceived usefulness, perceived ease of use, and user acceptance of information
technology. MIS Quarterly 1989, 13(3):319-340.
- 29 -
951
952
953
954
955
956
957
958
959
960
961
962
963
964
965
966
967
968
969
970
971
972
973
974
975
976
977
978
979
980
981
982
983
984
985
986
987
988
989
990
991
992
993
994
995
996
997
998
999
1000
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
Yarborough AK, Smith TB: Technology acceptance amongst physicians. Medical Care
Research and Review 2007, 64:650-672.
Peek ST, Wouters E.J., van Hoof J, Luijkx KG, Boeije HR, Vrijhoef HJ: Factors influencing
acceptance of technology for aging in place: a systematic review. Int J Med Inform 2014,
83(4):235-248.
Or CK, Karsh BT: A systematic review of patient acceptance of consumer health
information technology. J Am Med Inform Assoc 2009, 16(4):550-560.
Wu PF: Opening the black boxes of TAM: towards a mixed methods approach. In:
Thirteenth International Conference on Information Systems: 2009; Phoenix, Arizona, USA:
Association of Information Systems; 2009: 1-10.
Peine A, Rollwagen I, Neven L: The rise of the “innosumer”—rethinking older technology
users. Technological Forecasting and Social Change 2014, 82:199-214.
Cagnin C, Havas A, Saritas O: Future-oriented technology analysis: its potential to address
disruptive transformations Technological Forecasting and Social Change 2013, 80(3):379385.
Neven L: 'But obviously not for me': Robots, laboratories and the defiant identity of elder
test users. Sociology of health and illness 2010, 32(2):335-347.
Ostlund B: Silver age innovators: a new approach to old users. In: The Silver Market
Phenomenon: Marketing and Innovation in the Ageing Society. Edited by Kohlbacher F,
Herstatt C. Berlin: Springer; 2011: 15-26.
Borsci S, Macredie RD, Barnett J, Martin J, Kuljis J, Young T: Reviewing and Extending the
Five-User Assumption: A Grounded Procedure for Interaction Evaluation. ACM
Transactions on Computer-Human Interaction (TOCHI) 2013, 20(5):e29.
Nielsen J, Landauer TK: A mathematical model of the finding of usability problems. In:
INTERACT’93 and CHI’93 Conference on Human Factors in Computing Systems. New York,
USA: ACM Press; 1993: 206-213.
Barlow J, Wright C, Sheasby J, Turner A, Hainsworth J: Self-management approaches for
people with chronic conditions: a review. Patient Education and Counselling 2002,
48(2):177-187.
[Blender, Cited on 10 October 2014 at: http://www.blender.org/]
Hanington B, Martin H: Universal Methods of Design. Beverley, MA, USA: Rockport; 2012.
Unsworth CA: Using a head-mounted video camera to study clinical reasoning. The
American Journal of Occupational Therapy : Official Publication of the American
Occupational Therapy Association 2001, 55(5):582-588.
Cooke L: Assessing concurrent think-aloud protocol as a usability test method: A technical
communication approach. Professional Communication 2010, 53(3):202-215.
King N: Using templates in the thematic analysis of text. In: Essential Guide to Qualitative
Methods in Organizational Research. Edited by Cassell C, Symon G. London, UK: Sage; 2004.
Braun V, Clarke V: Using thematic analysis in psychology. Qualitative Research in Psychology
2006, 3(2):77-101.
Madill A, Jordan A, Shirley C: Objectivity and reliability in qualitative analysis: Realist,
contextualist and radical constructionist epistemologies. British Journal of Psychology 2000,
91:1-20.
Crabtree BF, Miller WL: Doing Qualitative Research. Thousand Oaks, California, USA: Sage
Publications; 1999.
Iwarsson S, Wahl HW, Nygren C, Oswald F, Sixsmith A, Sixsmith J, Széman Z, Tomsone S:
Importance of the home environment for healthy aging: conceptual and methodological
background of the European ENABLE-AGE Project. The Gerontologist 2007, 47(1):78-84.
Money AG, Fernando S, Lines L, Elliman AD: Developing and evaluating web-based assistive
technologies for older adults. Gerontechnology 2009, 8(3):165-177.
- 30 -
1001
1002
1003
1004
1005
1006
1007
1008
1009
1010
1011
1012
1013
1014
1015
1016
1017
1018
1019
1020
1021
1022
1023
1024
1025
1026
1027
1028
1029
1030
1031
1032
1033
1034
1035
1036
1037
61.
1038
Figure 1: Overview of trials methods and process
1039
Figure 2: The SweetHome 3D application interface
1040
Figure 3: Thematic mind map of themes and sub-themes
62.
63.
64.
65.
66.
67.
68.
69.
70.
71.
72.
73.
74.
Money AG, Lines L, Fernando S, Elliman AD: e-Government Online-Forms: Design Guidelines
for Older Adults in Europe. Universal Access in the Information Society 2011, 10(1):1-16.
Bastiaens H, Van Royen P, Pavlic DR, Raposo V, Baker R: Older people's preferences for
involvement in their own care: a qualitative study in primary health care in 11 European
countries. Patient education and counselling 2007, 68(1):33-42.
Levasseur M, Carrier A: Integrating health literacy into occupational therapy: findings from
a scoping review. Scandinavan Journal of Occupational Therapy 2012, 19(4):305-314.
Johnson A, Sandford J, Tyndall J: Written and verbal information versus verbal information
only for patients being discharged from acute hospital settings to home. Cochrane
Database 4 2008, CD003716.
Bostock SaS, A.: Association between low functional health literacy and mortality in older
adults: longitudinal cohort study. British Medical Journal 2012, 1602:1-10.
Hall V, Conboy-Hill S, Taylor D: Using virtual reality to provide health care information to
people with intellectual disabilities: acceptability, usability, and potential utility. Journal of
Medical Internet Research 2011, 13(4):e91.
Money AG, Lines L, Fernando S, Elliman AD: Older adults' experiences of interacting with
online forms. In: 2008 Workshop on HCI and the Older population at the 22nd BCS HCI Group
Annual Conference: 2008; 2008.
Sixsmith J: The meaning of home: An exploratory study of environmental experience.
Journal of Environmental Psychology 1986, 6(4):281-296.
Haak M, Fänge A, Iwarsson S, Ivanoff SD: Home as a signification of independence and
autonomy: experiences among very old Swedish people. Scandinavian Journal of
Occupational Therapy 2006, 14(1):16-24.
Blunt A, Dowling R: Home. Abingdon, Oxfordshire, UK: Routledge; 2006.
Atwal A, McIntyre A, Craik C, Hunt J: Occupational Therapists’ Perceptions of Predischarge
Home Assessments with Older Adults in Acute Care. British Journal of Occupational Therapy
2008, 71(2):52-58.
Woolhead G, Calnan M, Dieppe P, Tadd W: Dignity in older age: what do older people in the
United Kingdom think ? Age and Ageing 2004, 33(2):165-170.
Martin JK, Martin LG, Stumbo NJ, MOrrill JH: The impact of consumer involvement on
satisfaction with and use of assistive technology. Disability and Rehabilitation: Assistive
Technologies 2011, 6(3):225-242.
Digby R, Bloomer MJ: Families and caregivers of older people: expectations,
communication and care decisions. Collegian 2014, 21(4):345-251.
Figure legends
1041
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1042
Table 1: Summary of community dwelling older adult profiles
Participant Gender
Age
Occupation
A
Male
66-70
Software developer
B
Female
56-60
Teacher
C
Female
66-70
Personal assistant
D
Male
76-80
Engineer
E
Male
66-70
Market researcher
F
Male
71-75
Administrator
G
Male
61-65
Financial adviser
H
Female
66-70
NHS Manager
I
Female
66-70
Teacher
J
Female
66-70
Analyst
1043
1044
Table 2: Written instructions for interaction task with SweetHome 3D.
Participant Instruction Sheet
1. Create a room with four walls, one door and one window and a floor.
2. Add a bathtub, followed by a bath board to the room (the bath board is to sit across the bath
width ways).
3. Add a toilet, followed by a toilet frame to the room (the toilet frame is to sit around the toilet).
4. Finally, add a shower, followed by a shower chair to the room (the shower chair is to sit inside
the shower tray).
*Dimensions and location of items within the room are entirely your choice*
1045
1046
Table 3: Study outcomes
Theme
PU
Sub-theme
Collaboration
&
decision making
Educational value
PEOU
AU
Interface
considerations
Size & scale
Dexterity & motor
skills
Assisted use
Existing
applications
Study outcomes
 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
 Function of specialist OT equipment not intuitive
 Potential of learning equipment function from using CIDA
 Increase size of icons
 Provide textual descriptors
 Revise folder structure/location of OT equipment
 Accuracy of measurements
 Redesign interface/functions to require less dexterity/motor skills
 More suitable to be used alongside an expert user/practitioner
 Confidence in value and applicability
 Familiarity with CIDA in existing real-world contexts
1047
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