Designing an E-coaching System for Older People to Increase

Adherence to Exergame-based Physical Activity

Despoina Petsani, Evdokimos I. Kostantinidis and Panagiotis D. Bamidis

Lab of Medical Physics, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece

Keywords: E-coaching, Physical Activity, Exergames, Elderly.

Abstract: E-coaching technologies constitute an emerging trend because they differ from the ordinary methods that tend

to patronize user’s behavior. E-coaching focuses on co-organization and personalisation of the intervention

by the user and the system. The current work describes some important features that must be studied in the

design process of an e-coaching system that promotes the adherence of physical activity in older adults. The

proposed system will be based upon already existing exergame platform for elderly, the webFitForAll. Firstly,

the significance of physical activity in elder’s everyday life and how the physical activity guidelines are

implemented in webFitForAll are discussed. Furthermore, the behavior change techniques, that are an

important part of e-coaching systems, are presented as well as the design plans for the e-coaching

environment.

1 INTRODUCTION

For the last few years it has become notable a constant

shift from instructing and patronizing a person during

her daily exercise to coaching and helping towards

making own choices. It is now well known that it is

crucial to encourage patient involvement, motivation,

and empowerment in adapting to lifelong changes.

The key term of co-design with seniors their everyday

exercise plan has been dropped in the scene. To this

extent, coaching has been defined as an ongoing

process of self-enhancement and effective goal

striving with the observation, aid and collaborative

conversation with an expert, referred as coach(Ives,

2008).

Another emerging necessity both in industry and

academia is the digitalization of various functions in

a wide variety of domains, including coaching

practices. An automatic, digital coaching system

could be ubiquitous, individualized, constantly

adapting and gathering information while providing

the necessary feedback. Human-to-human interaction

is irreplaceable but the financial cost and the human

resources needed may be dissuasive. The rapid

advances in technology along with its broader

penetration in our everyday life may increase the

acceptance and necessity of non-human coaches that

may also cover the inclusion of human coaches.

At this point, it needs to be highlighted that most

articles use the term e-coaching for systems that are

used to enable communication with human coaches

(Boratto et al., 2017)(Allen et al., 2008). However,

the terms should not refer to systems that facilitate or

conceptualize the coaching but to systems that do the

coaching (nonhuman coaches).

It is also important to accept an explicit definition

of what an e-coaching system is and what are the key-

points that must include, in order to effectively

develop the e-coaching environment. As B. A.

Kamphorst (Kamphorst, 2017) states, the e-coaching

system must have a sufficient level of sophistication

and independence and he defines it as “a set of

computerized components that constitutes an

artificial entity that can observe, reason about, learn

from and predict a user’s behaviours, in context and

over time […]” (Kamphorst, 2017, p. 5). This

definition underlines some key-points in e-coaching

systems:

 must be context-aware (Ives, 2008)(Pecora et

al., 2012)

 must be personalized

 must collect information from the user (direct

or other measurements)

 needs to have the ability to forecast and plan

future steps

This paper presents a proposed e-coaching system for

promoting physical activity for elderly population,

258

Petsani, D., Kostantinidis, E. and Bamidis, P.

Designing an E-coaching System for Older People to Increase Adherence to Exergame-based Physical Activity.

DOI: 10.5220/0006821502580263

In Proceedings of the 4th International Conference on Information and Communication Technologies for Ageing Well and e-Health (ICT4AWE 2018), pages 258-263

ISBN: 978-989-758-299-8

expanding an already existing exergaming platform.

Three major points are covered, including the

importance of physical activity for older people, what

are the behavior change techniques (BCTs) that have

been developed for physical activity enhancement

and the designing goals for the proposed system.

2 PHYSICAL ACTIVITY IN

ELDERLY POPULATION

As the aging population is rapidly increasing in size

and is estimated to keep increasing, the concept of

active and healthy aging has become a significant

socioeconomic phenomenon. According to the World

Health Organization (WHO) physical activity plays a

decisive role in maintaining or achieving a good

quality of life (QoL) (World Health Organization,

2010). Regular physical activity has been associated

with reduced risks of developing Alzheimer disease

(Laurin et al., 2001), osteoporosis (Nguyen, Center

and Eisman, 2000) and cardiovascular disease

(Geffken et al., 2001). Furthermore, a great cohort of

studies has exhibited the positive impact physical

exercise has on psychology, functional capacity,

autonomy and general QoL(Taguchi et al.,

2010)(Vagetti et al., 2014)(Konstantinidis et al.,

2016)(Chodzko-Zajko et al., 2009).

Although the positive effects of physical activity

in health are well established, activity levels are

decreasing with age. Elderly face cessation of

physical activity as an inevitable consequence of

aging. They believe exercise to be a time consuming

task that often perceived as having negative effects on

their body (sweating, muscle soreness, etc.)(Schutzer

and Graves, 2004) while 50%

of exercise

intervention participants tend to drop out before

realizing any health benefits (Bennett and Winters-

Stone, 2011). Another deterrent factor is the abstract

guidelines given by the healthcare specialists. All the

above indicate the need for an e-coaching system.

Furthermore, environmental factors may restrain

elderly’s devotion to physical activity more than

younger people. For example, most elderly will avoid

walking outside when it is raining or snowing. Social

or economic barriers are also reported (Brawley,

Rejeski and King, 2003). Apparently, e-coaching

system could and should facilitate the personalization

and adaptability on each individual’s needs.

2.1 Physical Activity Guidelines

In accordance with the key-points mentioned above

for e-coaching systems, the context and the target

group have to be carefully studied in order to

elucidate specific needs and barriers. For this reason,

we present the recommended levels of physical

activity for elderly as reported by the academic

community. The Center for Disease Control and

Prevention (CDC) propose that every adult should be

as active as their abilities allow, avoiding inactivity

(CDC, 2015). The minimum suggested activity by

CDC for achieving health benefits is 150 minutes of

moderate-intensity aerobic activity or 75 minutes of

vigorous-intensity aerobic activity and muscle

strengthening activities for all muscle groups on at

least two days of the week. The American College of

Sports Medicine (ACSM) also suggests at least two

days per week strength exercises to improve

flexibility and balance(Chodzko-Zajko et al., 2009).

Aerobic activities may include bicycle, dancing,

walking or jogging, swimming, tennis etc. (U.S.

Department of Health and Human Services, 2008).

Muscle strengthening activities are carrying

groceries, pilates, washing windows or the floor,

some activities of gardening, etc.

2.2 The webFitForAll Exergaming

Platform

There are also exergame platforms that encapsulate

the necessary amount of exercise in an attractive way

for the elderly (Konstantinidis et al., 2016)(Brox and

Hernandez, 2011). Since the physical activity

solutions for an older adult are of great amount, the

need and potentiality of developing a personalized

plan is even greater.

In our approach the basic exercise plan will be

based on the webFitForAll (wFFA) game platform

(Konstantinidis, Bamparopoulos and Bamidis, 2017).

The wFFA is a web based serious game platform

specially designed for elderly. It consists of physical

exercises and games that promote physical activity

and contribute in advance and maintenance of

wellbeing and QoL. A wFFA session constitutes of

aerobic, strength, balance and flexibility exercises

designed in a playful, simple and understandable way,

lasting for 60 minutes. A participant can complete the

proposed physical activity per week if engaged for a

minimum of 3 times per week with wFFA.

Its predecessor, FitForAll (FFA) has been widely

tested and exhibited significant results in

improvement of QoL and physical

condition(Konstantinidis et al., 2016). The wFFA has

shown high acceptability rates between elderly and

increased the ease of use of FFA (Konstantinidis,

Bamparopoulos and Bamidis, 2017) while as well

Designing an E-coaching System for Older People to Increase Adherence to Exergame-based Physical Activity

259

displayed effective differences in participants’ fitness

(Zilidou et al., 2016).



Figure 1 Example of two wFFA games. In the hiking game

(above), the user walks in a Google Street View

environment according to his/her body posture and steps. In

the golf game the user moves a ball according to his/her

body movement, trying to put it in the hole.

3 BEHAVIOR CHANGE

TECHNIQUES

IMPLEMENTATION IN THE

E-COACHING SYSTEM

As mentioned above, e-coaching systems support an

ongoing process and effort to achieve a goal, improve

or change a situation. Consequently, it is critical for

the design of these systems to focus on the inclusion

of BCTs that can be associated with effectiveness.

The use of persuasive strategies have demonstrate

positive influence on the outcome of the interventions

in physical activity.(Orji and Moffatt, 2016)

Although the importance of inclusion of BCTs is

undeniable, the majority of e-coaching systems lack

examination and adjustment of that techniques (Orji

and Moffatt, 2016)(Mollee et al., 2017).

3.1 Proposed Taxonomy of Behavior

Change Techniques

Michie et al. have defined a taxonomy including 40

BCTs that should be implemented when developing

an intervention for physical activity behaviors, the

CALO-RE (Michie et al., 2011). However, it should

be carefully considered how these BCTs are altered

in accordance with the corresponding target group.

Elderly are more susceptible in quitting and it is often

more complex for them to make long-lasting changes

in their lifestyle and behavior.

The BCTs of the proposed e-coaching system will

be designed in 3 phases: the starting, the design and

adaptation and the intervention phase. The design

and intervention phases are not strictly segregated as

the design phase could re-implemented through the

intervention.

In the starting phase, the readiness for change and

motivation should be assessed and enhanced. Firstly,

it is critical to recognize which adults are at risk of

developing adherence issues by determining the

willingness to change and improve self-regulatory

skills (Culos-Reed et al., 2000). The main challenge

is to adequately answer the question “Why changing

my physical activity routine if I currently function

satisfactorily?”. For this reason, the system has to

provide information about the consequences that the

upcoming intervention will have in the individual and

in general, based on existing studies. Information

about the general approval of the system, the

behaviour of other groups and the reliability must also

be reported.

Consequently, the behavior goal and overall

outcome goal would be clarified in the design phase.

In this section the main effort should be to personalize

the intervention. The system and the participant must

co-organize the actions that have to be taken. Asking

the right questions to the elderly is crucial in order to

engage him in the process. The general plan is

constructed, giving special attention to the

environmental, socioeconomic and individual

barriers each participant may face. These information

is stored for possible readjustment of the behavior

plan. The participant is encouraged to participate

actively in the problem solving procedure. Depending

on these information, the tasks must be realistic and

avoid overestimating each person’s abilities. The

coachee, in our case the elderly, will make a

behavioral “contract” that they accept the designed

plan and will commit to it. This may be in form of

formal consent with the system or a selected familiar

person (Michie et al., 2009).

The most significant phase is the intervention

phase, when the behavior change happens. It consists

of the tasks that were agreed in the previous phase. To

retain adherence, the system must reward the

participant for achieving goals or for making

progress. That can be in terms of collecting points that

are shared among a groups’ members that go through

similar intervention, using the same e-coaching

system. In elderly population a common practice for

maintaining dedication to a goal, is to inform their

ICT4AWE 2018 - 4th International Conference on Information and Communication Technologies for Ageing Well and e-Health

260

family, friends, spouse or a special selected person for

their progress. The e-coaching system facilitates and

plan this social support based on the participant’s

desire and encourage social comparison. However,

the reward must be proportionate to the progress and

each time an anticipation must be created for future

rewards. Feedback is provided in each separate task,

on general performance as well as demonstration and

suggestion to achieve better results. Especially in

elderly the instruction must be simple, supported with

audiovisual content and do not assume that the

directions are clearly remembered every time.

Throughout the whole process, the system must

take into consideration to prevent new physical

activities to be abandoned. Stress and time

management is also crucial for the participant’s health

and must be taken into account (Abraham and Michie,

2008).

3.2 BCTs Implementation

The wFFA exrgames are a well-established solution

that has been widely tested and the results are

scientifically documented and supported. In the

starting phase the system should exhibit the benefits

that people in the pilots of wFFA had related to

physical condition and overall QoL. More precisely,

the system compares the user’s profile and presents

charts and images of the progress of people with

similar profiles in the database. The presentation of

real statements will empower the reliability of the

system. Also, statistics for the value of physical

exercise in the elderly population must be presented

in a comprehensive way e.g. charts and images.

Our exergame platform incorporates a default

protocol of four difficulty levels but it also provides

the option to manually modify the intervention. The

design phase aims at individualizing the sessions of

wFFA based on the overall goal and participant’s

preferences. However, the e-coaching system can

also motivate the user to do other physical activities

besides wFFA, if her/his character and environment

allow. For example, the user can agree to take a walk

outside instead of the hiking game of wFFA (Figure

1) once a week. The agreed plan will be forwarded in

a familiar person, given the participant’s consent.

Before each game in the wFFA platform there are

audiovisual instructions accompanied by a simple

text (Figure 2). In the current form, the user collects

points e.g. number of balls in the hole (Figure 1). In

addition a scoring functionality has been designed

and is under development. The score for every game

will be calculated depending on the in-game metrics

that the system collects during the intervention and

will reflect the actual improvement in physical and

cognitive cognition. To do so, wFFA correlates in-

game metrics (users’ gaming performance

measurements) with neurophysiological assessment

test of previous users and compares them with the

current users. wFFA is a web-based application

which can easily support social interaction between

users. The achievement of a goal or the augment of a

score will be shared among desired users to promote

competition. Concluding, the system can provide

additional instructions, when an exercise is being

executed, correcting possible mistakes.

Figure 2 Visual and text instructions before an exercise.

4 DESINING THE E-COACHING

ENVIRONMENT

There are two aspects that should be considered when

designing the framework of an e-coaching

environment: what are the suggestions that the system

would do and how these should be addressed to the

user. The former is based on option generation

techniques and effective counseling dialogue system

development, while the latter is about defining the

most appropriate interface and information gathering

technique, taking into consideration the target group.

The options that the system proposes to the user

can have two possible implications. Firstly, they can

affect the decision making process and influence the

final decision (Fogg, 2003). As mentioned

previously, coaching is an ongoing process that

encapsulates BCTs so, in fact it intervenes with

people’s decision. Consequently, the suggestions

must be carefully studied. Secondly, if the system

repeatedly make suggestions and indications that a

person rejects, because they are not contingent on his

character, may harm the system’s reliability. The

proposals must in general agree with what a person

consider as an option (Kamphorst and Kalis, 2014). If

a suggestion is rejected or not followed by the

coachee, the system must produce a dialogue

explaining its importance and making questions to

identify the reasons of its rejection. The new

Designing an E-coaching System for Older People to Increase Adherence to Exergame-based Physical Activity

261

information provided by the user will help the system

learn more about his character. In case of an option is

accepted and successfully carried out, the system

encourages and praises the participant. Obviously, an

holistic dialogue ontology must be created to support

counseling and enhancement of physical activity,

taking into consideration the specific needs of older

adults.

Vision impairment and reduction of precision in

motor skills are frequently encountered as normal

consequences of aging. These difficulties can prevent

elderly from using conventional computer interfaces

like mouse, keyboard, small buttons or gestures

requiring slick movements. The user interface must

be clean, friendly and not include redundant material.

From our point of view, three points that a user

interface for elderly must have are: usability,

acceptability and reliability. That means that the

elderly can easily interact with the technology, accept

it in their everyday life and last but not least be sure

that the system effectively interacts with them.

A proposed technology, which has not yet been

used in e-coaching, is augmented reality through

projections. This means that the system could project

contextualized information, wherever needed,

without the use of devices like mobile phones or

tablets. The user could interact with the system by

touching or moving actual objects, without the need

of a specific skills and preexisting knowledge. This

way the e-coaching environment will blend in the real

life environment, making it easier for older people to

accept it. Furthermore, the absence of buttons or

touch screens will reduce the stress of touching or

pushing the “wrong” button as the interaction will be

done by real life movements (Steele et al., 2009).

The wFFA games are controlled by the user’s

movement using information from a 3D sensor

camera that detects human body joints. Projection

technology can be exploited in order to replace

computer screen. It can also be used for direct

instruction when using technical equipment like

blood pressure meter. Audiovisual direction on how

to place the device and take the measurement would

be projected near the device.

It is also of vital importance for the system to

gather behavioral, physiological as well as emotional

information about the user. This can be done

unobtrusively with the use of 3D sensing systems.

The potential uses are of great amount, including

facial image technologies to capture emotional state,

gait analysis, communication with traditional devices

like blood pressure meter and pulse oximeter and

physical and cognitive state indicators through

serious games in-game metrics.

5 DISCUSSION

The current work presents the main issues that have

to be studied during the design process of an e-

coaching system aiming to promote physical activity

in older adults. This system will be based upon wFFA

exergame platform which is an effective way to

improve physical condition, specially designed for

older people and already widely tested. This work

tries to indicate the basic components of an e-

coaching system and address the necessities in its

outline.

Although the e-coaching systems are, fairly, an

emerging trend, questions have been raised on the

exclusion of the human specialists. The current

system aims at the inclusion of human

therapists/doctors or a familiar person chosen by the

user who can have access to the stored data and

involve or interfere in the coaching process (Geissler,

H. Hasenbein, M., Kontouri, S., Wegener, 2014).

In conclusion, the construction of an e-coaching

system must not be confronted with naivety. It is a

complicated process that demands careful planning

and cooperation of many scientific domains like

psychology, computer science, and medical science.

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