Technology based Interventions to Promote Healthy and Active Aging

The Role of Positive Emotions and Physical Activity

Miriam Cabrita

1,2

, Monique Tabak

1,2

and Miriam Vollenbroek-Hutten

1,2

Telemedicine Group, Roessingh Research and Development, Enschede, The Netherlands

Telemedicine Group, Faculty of Electrical Engineering, Mathematics and Computer Science, University of Twente,

Enschede, The Netherlands

1 RESEARCH PROBLEM

The proportion of the global population aged above

60 years old is growing more rapidly than any other

age group (World Health Organization (WHO), 2002,

p. 6) creating several socio-economic challenges.

Supporting independent living is a priority to enhance

quality-of-life of the older population for as long as

possible. Part of this support comes from the

community and public health policies. However, a big

part of the responsibility is for older citizens

themselves to assume an active role in prevention and

management of their health. Physical activity is very

important to improve and maintain physical

functioning in daily life. By physical activity, we

mean not only exercising, but every type of

movement during daily behaviour.

An active lifestyle is not limited to a high level of

physical activity. The WHO defines Active Ageing as

“the process of optimizing opportunities for health,

participation and security in order to enhance quality

of life as people age” (World Health Organization

2002). As such, older adults should maintain an active

lifestyle, not only by means of physical activity, but

also by being engaged in their social environments.

This is achieved by engaging in leisure activities,

contributing to the overall quality-of-life of the older

adults. Although some individuals can achieve an

active lifestyle by themselves, others seem to be in

need of an external drive. One way to provide this

external drive is through community-based

interventions, such as buddy-based programs to walk

in park, yoga lessons in the community centres or a

daily TV show dedicated particularly to exercises for

older adults. However, usually these community-

based interventions fail to target individual needs that

could better be matched in tailored interventions. The

technological developments of the last years have

given place to a new sort of interventions that,

through the use of unobtrusive and ubiquitous

technology, provide real-time recommendations

tailored to the current status of each individual. A

mobile phone application that sends motivational

messages based on current location or mood? A piece

of art on the wall that changes colours when the

physical activity is too low? A large screen that shows

a funny companion that substitutes the conventional

training coaches? The imagination is the limit. The

current research intends to bring these technology-

based interventions beyond the current state of the art

by designing strategies to motivate people to be

physically active through engagement in pleasant

activities. Before developing technology, we need to

understand the factors that influence a pleasant life

and how they relate to physical activity in the daily

lives of the older adults. That is the main focus of the

presented PhD trajectory.

2 OUTLINE OF OBJECTIVES

The ultimate goal of this PhD trajectory is to provide

recommendations to design technology-based

interventions to promote healthy and active ageing,

thereby helping older adults to live independently for

as long as possible. Our approach aims at designing

tailored interventions to be carried out in the daily

lives, by helping older adults in being physically

active and actively engaged in their social

environments. To do so, we look at how physical

activity relates to experience of positive emotions in

the daily lives of older adults. This has three main

reasons. First, the ‘upward spiral of lifestyle changes’

theory from Fredrickson defends that positive

emotions act as openers for acceptance and adoption

of new behaviours (Fredrickson 2013). Second, due

to the fact that experience of positive emotions is

inversely related to depression and anxiety (for a

review see (Santos et al. 2013)), two major mental

conditions among older adults. Last but not least,

there is growing evidence supporting the link between

positive emotions and overall health (e.g. (Pressman

Cabrita, M., Tabak, M. and Vollenbroek-Hutten, M.

Technology based Interventions to Promote Healthy and Active Aging - The Role of Positive Emotions and Physical Activity.

In Doctoral Consortium (DCICT4AWE 2016), pages 3-9

& Cohen 2005; Chida & Steptoe 2008; Lamers et al.

2012)).

Based on this, we define the primary goal of this

work by the following two objectives:

 Objective 1: Increase understanding on the

relationship between positive emotions and

physical health in daily lives of older adults

living independently;

 Objective 2: Investigate how technology can

support in monitoring and coaching towards

active ageing in daily life.

3 STATE OF THE ART

The last decades have experienced the emergence of

Positive Psychology, with attention being given to the

promotion of positive emotions as a way to reach a

pleasant life (Seligman et al. 2006). Several

technology-based interventions have promoted

positive emotions, for example, as a treatment or

prevention of depression (e.g. (Proyer et al. 2014; Sin

& Lyubomirsky 2009). However, to the best of our

knowledge, the study of the link between physical

activity and positive emotions is fairly new,

especially in what concerns the older population.

Participation in leisure activities increases overall

levels of positive emotions (Onishi et al. 2006) and

delays functional decline (Simone & Haas 2013),

contributing to the support of independent living.

Positive emotions are often forgotten when

promoting physical activity among the older

population (Phoenix & Orr 2014). Physical activities

in daily living seem to enhance affective states also in

the older population (Kanning et al. 2015). However,

Kanning et al. did not look at the influence of daily

environments on this relation. Do all activities

contribute in the same way? What is the influence of

the environment? Also, what is the effect of inactivity

/ sedentary behaviour in positive emotions? The

answers to these questions will help us meeting

Objective 1.

Technology plays a key role in supporting

independent living and enhancing quality of life

through monitoring, diagnosis/screening and

treatment (Schulz et al. 2015). There is strong

evidence for the effectiveness of technology-based

interventions for promotion of physical activity

(Fanning et al. 2012). Monitoring of physical activity

is fairly easy due to the development of smaller and

less obtrusive sensors that can be comfortably used in

daily life. However, monitoring of positive emotions

using technology is still in its infancy. Currently,

most studies make use of experience sampling

techniques (Csikszentmihalyi & Larson 1987) to

assess emotions in daily life.

Pleasure and enjoyment are mentioned by the

older adults as one of the motivators to perform

physical activity (Baert et al. 2011). However, to the

best of our knowledge, enhancement of pleasure has

not been explored in technology-based interventions

to promote exercise or daily physical activity (i.e.

physical activity obtained while performing daily

activities). As physical activity contributes to an

increase in the experience of positive emotions

(Hogan et al. 2014; Kanning & Schlicht 2010;

Bossmann et al. 2013), one can say that promotion of

physical activity entails promotion of positive

emotions. However, that is different than promoting

physical activity based on what is pleasurable for

each individual and, therefore, likely increasing

adherence and motivation. This is the second gap that

we aim to fill in by bringing technology to promote

active ageing in daily life beyond its current state of

the art (Objective 2).

4 METHODOLOGY

This PhD trajectory comprises a combination of

theoretical, observational and modelling studies to

achieve the goals abovementioned. In the following

sections we provide a description of each step of the

research.

4.1 Literature Study: Positive

Emotions to Support Independent

Living

With a systematic literature review, we evaluate

whether, based on previous empirical studies,

positive emotions are related to functional status of

older adults, and consequently are relevant to the

support of independent living. Particularly, we are

interested in investigating how the ability to perform

activities of daily living (ADL) independently relates

to the experience of positive emotions on a daily

basis. Eligibility criteria concern the study population

(older adults living independently), the nature of

intervention (observational, peer-reviewed papers

investigating the relation between positive emotions

and functional status) and outcome variables (studies

that assessed ability to perform ADL – basic or

instrumental, and exclusive measures of positive

emotions – such as happiness, calmness and

pleasure). Studies which consider a broader range of

emotions (e.g. satisfaction with life) are excluded.

DCICT4AWE 2016 - Doctoral Consortium on Information and Communication Technologies for Ageing Well and e-Health

The study selection follows the PRISMA guidelines

(Moher et al. 2014) and each step is taken under

agreement among two or three researchers.

This theoretical study provides insights in (1) the

relation between positive emotions and physical

health of older adults (Objective 1), as well as in (2)

the way in which technology can support bringing

this understanding forward and support tailored

interventions for promotion of Active Ageing

(Objective 2).

4.2 Observational Studies: Positive

Emotions and Physical Activity in

Daily Life

During the presented PhD trajectory two longitudinal

studies take place to investigate the relation between

positive emotions and physical activity in the daily

lives of older adults. We are interested to know what

are the factors that contribute to a pleasant life and

how we can make physical activity more pleasurable.

Clearly, we are not able to change the social

environments of the individuals (e.g. where a person

lives or his or her marital status) but we can, instead,

help individuals in finding what makes their life

pleasurable in daily living and to promote specifically

those activities. We hypothesize that what brings

pleasure in daily life is highly personal. Therefore, the

analysis of our studies will focus on a deep

understanding in an individual level. In order to

achieve this, our studies aim to gather a large amount

of information for each individual subject. The

participants in the study are in general active and

engaged in the society. Our objective is to look at role

models, what is called as positive deviance, look at

when it works well to see how to motivate others to

do the same.

In the first study we look exclusively at the

relationship between positive emotions and physical

activity in daily life (solid arrow in Figure 1). In the

second study, we investigate how daily activities

influence positive emotions, physical activity and the

relation between positive emotions and physical

activity (dashed arrows in Figure 1). In both studies

data is gathered using self-assessment questionnaires,

wearable technology and experience sampling on a

smartphone.

Figure 1: Relations investigated in the first (solid arrow)

and second (dashed arrows) observational studies.

4.2.1 Investigating the Relation between

Physical Activity and Positive

Emotions

The main question we want to answer with this

observational study is which operationalization of

daily physical activity relates the most to the

experience of positive emotions in daily life: number

of sedentary minutes, number of very active minutes

or total number of steps in a day? Additionally, we

investigate whether the experience of positive

emotions during a day relates stronger to physical

activity on that day or on the following day. To

answer these questions, we perform between- and

within-individual analysis.

In this first study, participants (n = 30) wear a step

counter during 4 weeks and every day, report on to

which extend they experienced 6 positive emotions

throughout the day. The emotions chosen were based

on the modified Differential Emotions Scale (mDES,

(Fredrickson et al. 2003)) to cover low- and high

arousal emotions, such as relaxed and excited,

respectively. The data analysis considers the overall

experience of positive emotions and also the values

of each discrete emotion.

4.2.2 Investigating the Influence of Daily

Activities on Physical Activity, Positive

Emotions and Relation between

Physical Activity and Positive

Emotions

With this second observational study we aim to

answer the following questions:

a. How do daily activities influence physical

activity?

b. How do daily activities influence the experience

of pleasure?

c. How do daily activities influence the relation

between physical activity and pleasure?

Technology based Interventions to Promote Healthy and Active Aging - The Role of Positive Emotions and Physical Activity

During approximately thirty days, participants (n

= 10) are asked to answer questions approximately

every hour – from 08h00 to 20h00 – on a smartphone

reporting their current activity (‘what are you

doing?’), location (‘where?’), social companion

(‘with whom?’), and the pleasure experienced while

performing that activity (rated in a visual analogue

scale and translated to a continuum from 0 to 10).

Additionally, participants carry a hip worn

accelerometer during the time of the experiment.

To answer question a), we categorize the physical

activity level of each day as ‘Inactive’, ‘Moderately

Active’ and ‘Highly Active’ using the K-means

clustering algorithm. The clustering analysis is

performed within-individual in contrast to using pre-

defined cut-off points. Next, we categorized the

answers of ES-events in four properties, each one

with several values as follows: ‘location’ (values:

outdoors or indoors), ‘social companion’ (values:

alone, with partner, with family, with friends or

colleagues and unknown), ‘type of activity’ (values:

go out or relaxation, commuting, eat or care,

association, household and work or study) and ‘time’

(values: each one of the weekdays). Finally, we

investigate the relation between the daily physical

activity level and the relative frequency of ES-events

with each value registered per day.

Questions b) and c) are answered through multi-

level models with ES-events nested within subjects.

4.3 Modelling: Simulation Study

Combining Information Acquired

The last step is to propose a model to support the

technical implementation of tailored technology-

based interventions for promotion of healthy and

active ageing. The parameters and relations to be

included in the model depend on the results of the

theoretical and observational studies. The intention is

to provide (real-time) motivational messages that will

help older adults reaching an active lifestyle.

Therefore we build upon current models of tailoring

motivational messages for promotion of physical

activity (op den Akker et al. 2015). We also look at

the state of the art of ontologies for identification of

human behaviour and for support of behaviour

change. Furthermore, this model should be able to

continuously adapt to the user in order to follow

possible functional decline or changes based on life

events.

This technical study intends to answer two

research questions:

a. What is the minimum time interval that we should

monitor an individual to be able to have a reliable

model on the relation between physical activity

and positive emotions in daily life using the setup

from the previous experiments?

b. What are the parameters and relations of a model

to provide motivational messages based on the

information gathered in the previous studies?

5 EXPECTED OUTCOME

5.1 Literature Study: Positive

Emotions to Support Independent

Living

The systematic review was conducted up to May

2015 using the PsycINFO, Scopus and PubMed

electronic databases. From the 963 unique results

retrieved, 10 papers met the inclusion criteria and

were therefore selected for further analysis. Relevant

data was summarized in standardized tables

previously agreed on by two authors. Both cross-

sectional (n=5) and longitudinal papers provided

evidence for a relation between positive emotions and

functional status. The longitudinal studies suggest a

bi-directional relation with lower experience of

positive emotions predicting functional decline, but

also, with higher functioning predicting higher

experience of positive emotions at follow-up.

Differences were found based on age, culture and

gender. Our findings support the potential value of a

holistic approach promoting physical activity and

positive emotions for supporting independent living.

This work was submitted and is currently under

revision.

5.2 Observational Studies: Positive

Emotions and Physical Activity in

Daily Life

5.2.1 Investigating Relation between

Physical Activity and Positive

Emotions

This study is planned to start in February 2016. We

expect to find individual differences on the relation

between physical activity and positive emotions in

daily life. While for some people bouts of vigorous

activity might provide an increased experience of

positive emotions during the day (operationalization:

number of very active minutes), others might benefit

from a more cumulative and balanced activity

throughout the day (operationalization: total number

of steps). Based on our previous experience, we

DCICT4AWE 2016 - Doctoral Consortium on Information and Communication Technologies for Ageing Well and e-Health

hypothesize that, in general, an increase in daily

physical activity is related to higher positive

emotions. In our analysis, we will look at a global

score of positive emotions but also at discrete

emotions related to both low- and high arousal, such

as calmness and excitement, respectively.

5.2.2 Investigating Influence of Daily

Activities on Physical Activity, Positive

Emotions and Relation between

This study took place between November 2014 and

December 2015 with ten older adults (aged 65 to 83)

during approximately 33 days (range 24 – 38). A total

of 3735 experience sampling (ES) events were

collected. The data analysis is ongoing as follows.

a. How do daily activities influence physical

activity?

The data of the first 5 participants in the study was

used to answer this question, providing a total of 146

days and 1534 ES-events. Our results suggest that

location, social companion, type of activity and day

of the week do significantly influence the daily

activity level of the participants. For example, being

more outside the home (‘outdoors’) increases the

likelihood of having a highly active day comparing to

an inactive day. Also, being with friends or

colleagues seems to increase the likelihood of having

a moderately active day when compared to inactive

day. The results of this work can be found at (Cabrita

et al. 2015). The same data analysis will be performed

with the data from all participants but no significant

differences are to be expected.

b. How do daily activities influence experience of

pleasure?

c. How do daily activities influence the relation

between physical activity and pleasure?

The data of ten participants is currently being

analysed with multi-level modelling to answer

question b) and c). We expect that generally,

activities performed outside the house and with other

people will be the most pleasurable. However, we

expect differences between individuals.

5.3 Modelling: Simulation Study

Combining Information Acquired

This part of the work will start in March 2016 and it

is currently in the ideation phase. The outcome of this

study is strongly dependent on the results of the

literature and observational studies, as they serve as

input to decide on the parameters and relations to be

included in the model. The model should be

implemented in the new version of the Activity

Coach, a mobile system developed at Roessingh

Research and Development to motivate people to

become more active (Op den Akker et al. 2012).

6 STAGE OF THE RESEARCH

At the current moment (February 2016) the literature

study is finished and submitted. The data acquisition

of one of the observational studies is completed, and

its data is being analysed. The lessons learnt so far on

each one of the objectives can be summarized as

follows in the rest of this section.

 Objective 1: Increase understanding on the

relation between positive emotions and

physical health in daily lives of older adults

living independently;

The results of the literature review suggest that,

independently of the cause-effect direction, positive

emotions and functional status do relate in daily life.

This means that, by promoting positive emotions in

daily life, we are contributing for the general health

and supporting independent living of older adults.

Furthermore, in this theoretical study we see that the

strength of the relation between positive emotions and

functional status highly relates to demographic

aspects as gender, age and culture. Also, preliminary

analysis of one observational study suggest that the

influence of daily environments on the experience of

positive emotions and physical activity is highly

personal.

 Objective 2: Investigate how technology can

support in monitoring and coaching active

ageing in daily life.

The findings in objective 1 reinforce the need for

tailored interventions. For example, based on the

results of the second observational study, when

classifying the level of activity of a certain day, it

does not seem appropriate to select a predefined cut-

off for the older population. Instead, one should look

at within individual data. This is important for

example when setting goals as, according to the Goal-

Setting Theory, when thriving for best results one

should set challenging but achievable goals ((Locke

& Latham 2002)). Also, the same study suggests that,

instead of motivating people to get physically active,

a coaching strategy could thus be to motivate people

to engage in outdoor- or social activities, increasing

physical activity indirectly. This motivation by proxy

could add to the diversity of coaching of such systems

and potentially increase adherence and pleasure in

using the system. This information will be combined

with the results of the other two points of this study

Technology based Interventions to Promote Healthy and Active Aging - The Role of Positive Emotions and Physical Activity

in order to provide recommendation for pleasurable

activities that increase the physical activity level.

Our results also provide information on how

technology can be used in research to improve the

knowledge on the field. The results of the literature

study suggest that there is a need of incorporating

more objective measures of functioning in research.

All the studies included in the literature review used

paper based questionnaires, vulnerable to the

subjectivity (and sometimes, optimism) of the

participants. The use of GPS or wearable technology

in this type of research might provide different

results. Furthermore, there is a clear need for

longitudinal research and with more continuous data

collection. This can be achieved with home

monitoring or experience sampling. Only in this way

we will be able to follow the functional decline when

it occurs. One single assessment is not able to

evaluate how physical and mental health relate over

time.

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Technology based Interventions to Promote Healthy and Active Aging - The Role of Positive Emotions and Physical Activity