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a Department of Geriatrics, Geneva University Hospitals, Switzerland
b Rehabilitation Research and Development Center, Atlanta VA Medical Center, Decatur, GA
Correspondence: Katharina V. Echt, PhD, Atlanta VA Rehabilitation Research and Development Center, Mail Code 151/R, 1670 Clairmont Rd., Decatur, GA 30033. E-mail: kecht{at}emory.edu.
Decision Editor: Eleanor S. McConnell, RN, PhD
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Abstract |
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Key Words: Aging • Elderly • Computer technology • Usability • Expert system • Exercise counseling
New approaches to health promotion for the growing geriatric population are needed (Smith 1988
). The potential of interactive technology in health promotion has been convincingly demonstrated in younger individuals (Ben-Said, Consoli, and Jean 1994; Street, Voigt, Geyer, Manning, and Swanson 1995). Little is known about the use of computer technology in health promotion with older adults. A plethora of computer products for patient education and health promotion is emerging (Kieschnick 1996). These software packages are intended to facilitate the prevention efforts of health providers; however, a number of issues remain unresolved. Are older adults, who often have considerably less computer experience than younger individuals, able and willing to use health promotion software programs? Are they accepting of computer-generated recommendations to improve their health behavior? No, or little, information is available to inform caregivers regarding the usability and acceptability of such products among older adults.
There are a number of reasons to expect that using interactive technology for health promotion with older adults will be feasible and advantageous. First, data suggest that increasing numbers of older individuals are enthusiastic users of computers and the World Wide Web in particular for self-initiated access to health information (Marwick 1999; Morrell, Mayhorn, and Bennett 2000). Secondly, by analyzing a wealth of personal, behavioral, and environmental factors for each individual, computer-based health education software can tailor health promotion interactions to an extent that is impossible with another medium (Kieschnick 1996). Highly personalized health recommendations are most likely to impact a change of health behavior (Bandura 1986). Finally, the use of interactive technology might motivate more health providers to engage in health promotion practice with their older clients by addressing some of the most cited barriers to doing so: time constraints, absence of insurance reimbursement, and general lack of experience (Young, Gray, and Ennis 1983).
The purpose of this study was to examine if older adults are capable and willing to complete a computerized questionnaire and to what extent they accept computer-generated exercise recommendations. We chose, therefore, an exercise expert system (Boyette, Boyette, Lloyd, Manuel, and Echt 2001) as an exemplar of interactive technology developed for health promotion. We then evaluated older adults' (a) time and assistance requirements while completing a computerized questionnaire on this system to generate an exercise prescription, (b) ability to interface successfully with the software using a mouse, and (c) subjective ease of use and prescription acceptability ratings.
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Methods |
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Materials and Measures
Exercise Expert System
Developed by Boyette and colleagues 2001, this software generates individualized exercise prescriptions for older healthy individuals based on responses given by clients and their practitioners to three different questionnaires. These computerized questionnaires pertain to medical history, mood, functional status, mental status, and specific preferences, or determinants, which are known to influence initiation of exercise behavior and maximize subsequent adherence. These factors are taken into account by the software in generating the resulting exercise prescription.
Computer and Exercise Expert System Training Manual
We developed an illustrated training manual similar to that used by Echt, Morrell, and Park 1998 to provide older adults, regardless of computer skill level, with elementary mouse training and general instructions for interaction with the Exercise Expert System. This manual provided step-by-step illustrated instructions for the procedures required to use the mouse and to complete the computerized questions. Briefly, participants were seated in front of the computer and left alone with the illustrated manual until they were ready to start the computerized questionnaire. We measured the time needed to review the training manual and encouraged the participant to ask questions once their review of the manual was completed.
Practicality
We measured system practicality by having participants independently complete the 81-item computerized questionnaire and obtaining objective and subjective measures. We measured performance using time and requests for assistance. We chose these measures because in practice the time required by the patient and the time expended by staff providing assistance are a critical aspect to determining if health promotion software such as this system is practical. We classified requests for assistance as either mouse related or non-mouse related. The Ease-of-Use Questionnaire was a subjective measure of practicality and consisted of five dichotomous items (Yes/No) concerned with different aspects of the participants' impressions of the usability of the system. We implemented this measure because subjective impressions of older patients are equally critical for evaluating the practicality of implementing a system like the Exercise Expert System in practice. In this manner, we were able to determine (a) whether the older adults tested could use the software, and (b) whether they thought the software was easy to use or not.
Acceptability
We measured prescription acceptability using a six-item Likert-type questionnaire (1 = not at all satisfied to 4 = very satisfied). Items were concerned with the overall degree of satisfaction with the customized exercise prescription form and the specific prescriptions for aerobic, resistance, and flexibility exercise.
Equipment
We administered the computerized questionnaire in a typical office setting using a Dell PC with 17-inch monitor. The software recorded responses to the computerized items and subsequently generated each prescription for review with the participant.
Procedure
Following the completion of the screening, we gave each participant as much time as needed to read the Exercise Expert System Training Manual and, when ready, to respond as independently as possible to the computerized questionnaire. We recorded time and requests for assistance and completed the ease-of-use evaluation. We then printed the exercise prescription and explained it using a standardized exercise counseling protocol. Lastly, we completed the prescription acceptability questionnaire.
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Results |
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Computer and Exercise Expert System Training
The average time needed to review the illustrated training manual was 3.76 min (ranging from 1 to 7 min, Median = 3.00, SD = 1.5). The participants asked no questions after review of the manual, and we noted no difficulties during the training session.
Time and Requests for Assistance
It took the participants an average of 33 min (ranging from 12 to 79 min, Median = 28, SD = 15.57) to answer the computer questions. On average, three requests for assistance were made (ranging from 0 to 9, Median = 2, SD = 2.5); 5 participants completed the questions without any assistance. The majority (78%) of these requests were because of non-mouse-related difficulties and included difficulties with question presentation (i.e., Can I mark more than one response? How do I continue?), wording, or content (i.e., My answer to the question is not one of the options listed). Mouse-related difficulties (how to click, how to point, or coordination) only accounted for 22% of the total requests for assistance (see Table 1 ).
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Correlational Analyses
Age was directly related to the number of requests for assistance made (r = .53, p < .01) and in particular to non-mouse-related requests for assistance (r = .49, p < .01). There was no significant relationship between age and the time required answering the items. Thus, although the older participants, on average, made more requests for assistance, they did not take longer to answer the questions overall. Computer experience, not education level or OMCT score, was significantly related to shorter response time and fewer requests for assistance (r = - .46, p < .01; see Table 2 ). Ease-of-use ratings were negatively correlated to response time and requests for assistance. Participants who took longer and required more assistance, especially for non-mouse related difficulties, rated the system less easy to use than those with shorter questionnaire times and less assistance. No association was found for prescription acceptability ratings, time, and requests for assistance. Regardless of time and assistance needs, the exercise prescription was highly accepted (see Table 3 ).
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Discussion |
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). It is commonly assumed that older people do not like computers, but there is growing evidence that they are readily able and even eager to acquire and retain computer skills (Lawhorn, Ennis, and Lawhorn 1996), particularly for acquiring health information (Morrell et al. 2000). This study demonstrates that (a) a highly-educated, healthy, volunteer sample of older adults was able to complete the questionnaire on the computer within a reasonable amount of time and with minimal assistance to get an individualized exercise prescription, (b) the computer mouse did not hinder the participants, and (c) the subjective ratings of the system and exercise prescriptions were high.
The finding that virtually all of these healthy older adults were able to interact successfully with the computerized questionnaire interface supports the idea that computerized health promotion systems have much potential in daily practice with older individuals. Clearly, compared to younger individuals, older adults take longer and make more errors when performing computer tasks (Echt et al. 1998). Thus, time issues might play a greater role in the applicability of interactive technology with older adults because older adults tire more easily. However, half an hour seems to be a reasonable time amount for the healthy, well-educated, older individuals to interact with a computerized questionnaire in a practice setting. The tested sample of older volunteers needed minimal assistance to complete the computer session; however, higher age and little computer experience were significantly related to higher assistance need. Minimal or no staff assistance should be required to preserve the health provider's resources and time. The use of elder-friendly interfaces and designs (Echt 2002; Holt and Morrell 2002) may help to reduce time and assistance constraints of emerging health promotion technologies.
Coordination of a computer mouse has been described as a potential source of difficulty for older individuals and, therefore, a concern to those hoping to implement technology in daily practice (e.g., Hutchinson, Eastman, and Tirrito 1997). The results of this study replicate those of Echt and colleagues 1998, who suggest that older adults are able, without too much difficulty, to acquire the skills necessary to use a computer mouse. Newer technologies, such as touch screen, are promising (Buxton, White, and Osoba 1998), but not as readily available.
Older adults' acceptability of computer-generated health recommendations are at least as important for a successful implementation of interactive health promotion technology as the older adults' ability to interface with a computer system. The finding that the study participants, regardless of time need or requests of assistance, found the health recommendation highly acceptable supports previous reports about older adults' positive attitude toward computer technology (Lawhorn et al. 1996). The overall high mean values of the ease-of-use ratings stress further the elders' positive attitudes toward computer technology. However, participants who took longer and needed more assistance to complete the computer session rated the questionnaire's ease of use substantially lower.
The question of how computers should be applied in medicine has been raised (Winker and Silberg 1998). The results of this study indicate that interactive computer technology may be a practical tool for promoting healthier exercise behaviors in older individuals. More research is needed to examine the extent to which such technology is able to promote the initiation of and adherence to healthier behaviors in older adults. This is the case particularly for older individuals who experience a variety of barriers to health promotion program access. In terms of the Exercise Expert System evaluated here, studies are currently underway to evaluate the system's effect on older adults' exercise behavior compared to more traditional exercise promotion methods.
The small sample size, the overall high education level, and the generally higher motivation of study volunteers (Halbert, Silagy, Finucane, Withers, and Hamdorf 1999) make these data exploratory and not necessarily representative of older adults in general. Clearly, the high education level and the volunteer nature of this sample threatens the generalizability of the findings reported here to other older adults who may participate in and benefit from health promotion programs such as this one. Nevertheless, the results of this study provide some first insights into the potential of interactive technologies as tools for health promotion in the growing geriatric population. Studies with larger and more diverse samples are needed to explore the impact of this technology on the health behavior and well being of older people.
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Acknowledgments |
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Received for publication October 18, 2000. Accepted for publication October 17, 2001.
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  M. A. Sweeney and D. A. Chiriboga Evaluating the Effectiveness of a Multimedia Program on Home Safety Gerontologist, June 1, 2003; 43(3): 325 - 334. [Abstract] [Full Text] [PDF]
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