Digital Inclusion of Nursing Home Residents: A Usability Evaluation

of the Digital Kiosk siosLIFE™

Carla V. Leite

1,2,3 a

, Daniel Carvalho

1,2,4

, Ivone Almeida

1,3,5

, Sofia Nunes

1,2,4

and

Ana Margarida Almeida

1,2 b

Department of Communication and Art, University of Aveiro, Aveiro, Portugal

Digital Media and Interaction Research Centre (Digimedia), University of Aveiro, Aveiro, Portugal

Department of Education and Psychology, University of Aveiro, Aveiro, Portugal

Faculty of Arts and Humanities, University of Porto, Porto, Portugal

Research Centre on Didactics and Technology in the Education of Trainers (CIDTFF),

University of Aveiro, Aveiro, Portugal

Keywords: Digital Inclusion, Elderly Population, Active Ageing, Usability.

Abstract: The fast demographic ageing and technological progress are leading to a greater demand to develop digital

solutions that can foster communication, information, and socialization of the elderly population. In the past

decade, kiosks have been used to prevent digital exclusion and to promote the quality of life of this age group.

This paper analyses siosLIFE™, a digital kiosk that is gradually getting attention from the public. The

methodology adopted consisted in a usability test with guided tasks, using a cognitive walkthrough and think

aloud protocol, with participants being residents from a nursing home. The results show that siosLIFE™

complies with some usability recommendations, but there are several improvements regarding the interface,

contents, integration of support systems, and assistive technologies that can be made.

1 INTRODUCTION

The use of digital services has changed drastically

since the early nineties, focusing on personal

entertainment, leisure and social contexts, instead of

being used solely for professional tasks (Lowgren,

2008). On the one hand, it allows and promotes new

sociability; on the other hand, it can lead to the

development of stereotypes and lead to exclusion

(Hamelink, 2000; Gorman and McLean, 2009). This

informal adoption plays an ever-increasing role, in

such a way that the global digital inclusion of all age

groups is currently viewed as a societal challenge.

The elderly population constitutes the age group with

the lowest usage of digital media (Keränen et al.,

2017), with this fact being attributed to different

factors, such as: the lack of opportunities to access

and becoming familiar with it, as a consequence of

economic, cultural and educational variables, the

inadequacy of digital platforms regarding

impairments, needs, and motivations of to this

https://orcid.org/0000-0001-5803-2775

https://orcid.org/0000-0002-7349-457X

particular age group and the physical and psycho-

sociological changes resulting from the ageing

process (Pfeil et al., 2009).

One of the main accomplishments of humanity,

strictly related to the progress in the health, education,

economic, political and social fields: the increase of

longevity; along with the decrease of the birth rate in

the last decades, are generating a worldwide

demographic aging phenomenon (Cabral et al, 2013;

Chau et al, 2012), especially noticeable in developed

countries (Nazareth, 2009). The World Health

Organisation estimates that, until 2050, the

proportion of people aged 60 or over will exceed 30%

in many countries (WHO, 2015).

Despite the fact of the aging process being

naturally universal, instigating changes in several

human dimensions, it is also individual, determined

by the unique experiences and particularities of each

individual, thus the very definition of the elderly

person becomes imprecise (Rocha, 2007). Three

relevant components can be highlighted in this

Leite, C., Carvalho, D., Almeida, I., Nunes, S. and Almeida, A.

Digital Inclusion of Nursing Home Residents: A Usability Evaluation of the Digital Kiosk siosLIFE

DOI: 10.5220/0010349906930700

In Proceedings of the 14th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2021) - Volume 5: HEALTHINF, pages 693-700

ISBN: 978-989-758-490-9

693

process: physiological, social and psychological

ageing (Ferreira, 2013; Paúl, 2005).

Interactive systems should be able to respond to

different settings and support the behaviour of the

users, considering their struggles and needs; in

particular touch screen systems, widely used in kiosks

may constitute a promising and viable option

considering its capabilities (Moti et al., 2014;

Fonseca, 2011), for the elderly population. The

research regarding this subject, faces the elderly

population as part of the network society, promoting

their digital empowerment and inclusion (Wu et al,

2015).

In this study, an interactive touch kiosk was

analysed – siosLIFE™, composed of a multimedia

screen, a Kinect sensor, and a card reader, designed

to be used in nursing homes.

Its main goal is to promote cognitive stimulation

and physical exercise to the elderly population,

through games, video calls, music, and drawing

(ScaleUpPorto, 2016). A usability study was

conducted in order to analyse the digital inclusiveness

of this platform.

2 CONTEXTUALISATION

In the Portuguese context, there is a statistical rise of

the population over 65 years’ old which, at the

moment, which is the reference for the chronological

age of the elderly population (WHO, 2002). In 2015,

amongst the Portuguese from 65-74 age group the

average of the computer and Internet usage was 29%

(INE, 2015). It should be noted that this official report

does not present data for people aged 75 or over.

However, it is possible to conclude from other

international studies, that this age group uses digital

media even less (Keränen et al, 2017). In addition to

the exclusion factors felt by the younger peers, they

are presented as barriers: the difficulty felt and the

lack of access skills, even if the technology is at their

disposal (Ferreira, 2013; Friemel, 2016). When a

population is deprived of digital literacy, there is a

gap in the appropriation of the language, tools and

conceptual models, which are important to

understand and to use digital media (Ferreira, 2013).

Moreover, changes resulting from the ageing process

may interfere with the ability to use digital media, so

it is mandatory to properly consider the specific needs

of the elderly population during the survey of

requirements and design of a digital system (Ferreira,

2013). The benefits of using digital media by the

elderly seem to focus mainly on social interaction.

According to Dias (2012), the elderly population

value communication with family and friends, along

with interaction between different age groups. The

promotion of intergenerational relationships can

occur through discussion groups, chat or email, as

well as recreational activities such as interactive

games. The opportunities for communication, access

to information and entertainment generated by digital

media, may motivate the elderly to leave home and

participate in society (Chaumon et al, 2014). They

can also help them to focus on the future and develop

and invest more in their own life projects, and also

support the performance of daily life activities, health

monitoring and safety (Azevedo, 2013; Ashok and

Jacko, 2009; AGE, 2008; Dickinson and Gregor,

2006; Blit-Cohen and Litwin, 2004).

The elderly population can be involved in the

development of these technological solutions, just as

it already happens with other age groups. Those tools

should be oriented towards respect for the individual,

protection and fulfilment of human rights, following

principles of universality, non-discrimination and

equality, in order to achieve participation and

inclusion (AGE, 2008).

3 siosLIFE

DIGITAL KIOSK

As stated previously, digital platforms can help

fighting limitations resulting from ageing (Blaschke

et al., 2009), contributing to a better quality of life of

the elderly (Czaja and Lee, 2007). These are the two

aims of the siosLIFE

™ platform, through the

promotion of cognitive stimulation and physical

exercise with games, contact with family and

relatives, music broadcasting, drawing and painting,

access to news and religious contents, contextualized

with the preferences of the Portuguese audience

(ScaleUpPorto, 2016).

The project was born in 2014 as a result of the

efforts of two graduate students who applied for a

business ideas competition (ScaleUpPorto, 2016). In

2016, siosLIFE

™ won the “Health and Wellbeing”

category in the project Porto 3i, which allowed the

company to work directly with some institutions in

Porto, so as to validate the system, and since then, the

impact of siosLIFE

™ is being measured and followed

by an evaluation commission from School of Health

Sciences - Polytechnic of Porto (ScaleUpPorto,

2016). The creators provided the data needed to the

authors of this paper, and the conclusions of this study

contribute for the new versions that will be released.

Bearing in mind the particularities of the siosLIFE

™

system, it was designed to be integrated mainly in

institutions such as nursing homes, day care and

HEALTHINF 2021 - 14th International Conference on Health Informatics

694

social centres. However, we consider that its

integration may be relevant in other places and

services, such as libraries, parish councils and other

areas where the elderly population is likely to use it.

When carrying out this study, the project was

available in 91 institutions, reaching around 1200

elderly people.

The terminal of the user platform consists of a

touchscreen, a card reader and a Kinect, which are

portable and resistant, as shown in Figure 1. Each user

owns a numbered card to log into their account. The

institution provides the cards and fills in their data

online. The software entirely depends on the internet

connection and has artificial intelligence, adapting the

level of the games to the user’s performance.

Figure 1: SiosLIFE™ digital kiosk.

4 PROCEDURE

siosLIFE

™

is divided into three user profiles with

specific functionalities: elder user, institution and

family. This study is focused solely on the first profile

created for the elderly people usage, called the ‘user’

profile from now on.

The authors of this study were granted access to

the siosLIFE

™

system, with the most recent software

version at that time, in an institutional context, in the

nursing home that promotes more initiatives of active

aging in Portugal. They had contact with it several

times, in order to analyse, evaluate and gather data.

After analysing the system, it is important to orient

and map out the scope of the study. Formulating the

starting points allows expressing what is intended to

be known, elucidated and better understood, having

in consideration clarity, viability, and relevance

(Quivy and Campenhoudt, 2008). Trying to attend

those criteria, the following question was drawn:

• Does siosLIFE

™

comply with accessibility,

usability and inclusive design for the elderly

population?

A usability test was conducted in December 2017,

with two of the researchers present, one reading a

guideline of seven tasks, and the other observing and

taking notes. The set goal was to test with six

participants - three women and three men, who were

full-time in the facility and aged over 64. The average

age of the group turned out to be 77 years. Moreover,

some clinical conditions could be considered

exclusion criteria, since they were likely to influence

the interaction with the platform, but since the nursing

home is a small institution and only few elderly

individuals were interested and motivated to

participate in the study, their uniqueness were taken

in consideration during the tasks completion to avoid

their frustration. Three participants had visual

impairments, another one had cognitive deficit and

two others had mobility limitations (one of them

being a wheelchair user and with reduced mobility of

the upper limbs).

It was followed a think aloud protocol to be

possible to understand their thinking process and

experience during the interaction (Hartson and Pyla,

2012). Autonomy, Errors, Time and Path to complete

the task were assessed, along with Gestures, Body

posture, Facial expression, Comments and Reported

difficulties caused by motor, sensorial and cognitive

limitations, were the dimensions of the observation

grid.

To complete the first task, participants were asked

to: adjust the monitor, read the instructions showed in

the monitor, log in, confirm who was the user logged

in, and visualise the main menu, as illustrated in

Figure 2.

For the second task, it was requested to select the

Games menu, selecting the required game Smashing

bugs, illustrated in Figure 3, and play until the

objective was completed.

In the third task, participants were asked to go

back to the Main menu, select another game Picking

Figure 2: Part of Task 1.

Figure 3: Part of Task 2.

Digital Inclusion of Nursing Home Residents: A Usability Evaluation of the Digital Kiosk siosLIFE

695

fruit that can be seen in Figure 4, then follow the

instructions to start and play until finishing the round.

Figure 4: Part of Task 3.

In the fourth task, participants needed to go back

again to the Main Menu and select Listen to music

option, then choose a specific artist they were familiar

with, and select a specific song, as shown on Figure

5. Moreover, they were requested to

increase/decrease the sound volume.

Figure 5: Part of Task 4.

To complete the fifth task, the participants were

requested to go back once more to the Main menu and

select the News option. Afterwards they had to

identify the category Sports and read a specific

section of the soccer news, as illustrated in Figure 6.

The sixth task consisted in going back to the Main

Menu once again, but this time to select the Call one,

then pick a specific contact and make the phone call,

as it is possible to observe in Figure 7.

And finally, the user had to log out, removing the card

and check the light changes in the NFC reader.

5 RESULTS AND DISCUSSION

All the participants completed the full set of tasks,

some autonomously and others with the help of the

researcher who was reading the tasks guideline when

requested.

The first and last tasks were related to the

interaction and customisation of the hardware of the

kiosk, so their results are grouped in Table 1.

Table 1: Task 1 and 7 results.

Completed

without

help

Completed

with help

in with car

4 2

Monitor ad

ustment 3 3

out removin

the car

1 5

The participant who stated that uses the computer

and internet daily in the nursing home, found it easy

and quick to log in/out using the card, doing it without

help and faster than the average. On the other hand,

this participant had difficulty adjusting the screen due

to upper limbs mobility limitations and weight of the

screen. The other five participants had to use both

hands to adjust the screen. Two participants who

completed the log in without help removed the card

and placed it back repeatedly, in order to check

changes in the hardware. They showed satisfaction

about the light feedback of the NFC reader. Two

participants, who stated that did not use informatic

systems autonomously, they were unaware that the

hand, one of the participants comment the fact that the

card should keep being personal since it is practical

to log in using it. One of the participants searched for

feedback on the monitor after the log out, mimicking

the log in behaviour.

In the second task, as shown in Table 2, all

participants played until the level was finished. Two

participants, who stated not to be familiar with

informatic systems, continued playing

enthusiastically, even after being asked to exit the

game because the level was already completed. It was

observed that half of the participants did not lean on

the wrist while playing.

Table 2: Task 2 results.

Completed

without help

Completed

with help

Open Games menu 5 1

Select Smashing bugs

ame

2 4

Play and complete the

level

6 0

Figure 6: Part of Task 5.

Figure 7: Part of Task 6.

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The navigation for five participants was done by

selecting page numbers, and requesting help to do it

properly, instead of using the Next page button. Only

one participant with visual impairment could not read

the game information status. Another participant that

is illiterate stated that he could not read the captions,

so it was only possible to identify the game from the

picture since the name was suggestive.

Four of the participants asked for help to change

the game (reach the games menu and select a specific

one - Picking fruit), as can be seen in Table 3.

Table 3: Task 3 results.

Completed

without help

Completed

with help

Change game 2 4

Follow start instructions 4 2

Play and complete 3 3

Furthermore, two participants needed help to

understand the game instructions, since they needed

to stand up and be 3 metres away from the Kinect.

Also, the game instructions did not mention the

interaction needed, i.e. how to pick the fruit that was

dropping from the top of the screen.

Every time this game is selected begins a trial

mode to calibrate the sensor, however it does not

change the interaction input when the user does not

move both hands together as a shell. The participant

with cognitive deficit showed to be unsure how to

proceed and confusion. The acceptance of the game

was high, all the participants enjoyed playing it. Half

of them used both hands since the beginning, with

two of them clapping when the fruit was virtually

close. The participant with severe mobility limitations

did not show frustration and tried different

interactions methods, even tried to stub the fruit with

his head. Half of the participants faced difficulties

because of the parallax effect, not knowing where to

find the apple in real space according to its virtual

representation. Moreover, four participants, including

those with visual limitations, could not read their

performance from a three metres distance.

During the fourth task completion, both

participants with visual impairments and one

illiterate, along with another participant, they all

could not associate the image of the Music menu,

moreover they hesitated between the image and the

caption as selection input of the singer and the song.

Two participants were able to understand how to

navigate in the Music area using the arrows, what may

be explained by their familiarity with the metaphor,

since they are mobile and computer users and the

applications/software/websites to listen to music

commonly follow the same approach, as can be seen

in Table 4.

Table 4: Tasks 4, 5 and 6 results.

Completed

without

help

Completed

with help

Change to

usic menu 2 4

Select artist and son

2 4

Increase-decrease volume 1 5

Chan

e to

ews menu 4 2

Change to Sports menu

and select soccer o

tion

4 2

Chan

e to Call menu 4 2

Do the call and hang up 4 2

When participants were asked to increase the

sound volume, only one managed to do it without

help. Another participant, despite identifying the

icons related to volume, did not differentiate the icon

of increase from the decrease volume. The other

participants approached the corner of the screen

where the volume buttons are located but could not

visualise them. This difficulty may be related to their

visual impairments, as well as due to the icons small

size and buttons location - lower part of the screen.

The fifth task, related to News, was the one

causing less general confusion. Four of them

recognised the categories on the menu and chose

accordingly. Nevertheless, it was noticeable a

common navigation error: returning too many times

on the “back” arrow, since it is always shown in the

same place and has no delay time for the interaction.

Curiously, one of the participants made the

gesture (without touching) to flick through the pages

and comment that would be a satisfactory input to be

developed. Only one participant showed preference

for reading the news in the digital format, instead of

on paper, while the others were neutral or stated they

preferred it on paper.

During the sixth task, related to making the call,

four participants completed the steps requested

without any help. The participant with cognitive

limitations did not recognise the phone icon as

clickable and with the call function, so the participant

looked at the table and searched for a phone. Only

after verbal explanation this participant could

complete the task.

6 CONCLUSIONS

The increase of life expectancy and the demographic

ageing constitute a growing reality, making it

necessary to promote actions focused on active

Digital Inclusion of Nursing Home Residents: A Usability Evaluation of the Digital Kiosk siosLIFE

697

ageing and on the quality of life of the elderly

population. Digital media represent an effective

support for the elderly population, with potential

benefits in regard to the quality of life of this age

group. They can be used as a strategy to compensate

for some alterations that may arise from the ageing

process; thus, it becomes necessary to assess and

adjust them in order to meet the needs and skills of

the elderly population (Arch et al., 2009; Ferreira,

2013). It is therefore necessary to adopt an

interdisciplinary, innovative, and integrative

approach, such as gerontechnology, a field of study

that aims to develop and distribute products,

environments and technological services that

contribute to a better quality of life during the ageing

process, promoting health, social participation, and

independence of the elderly population (Fozard,

2001).

As societies have evolved, ageing has been the

object of several studies, with a clear investment in

policies that advocate it as an active and positive

experience. These predict continuous opportunities

and promote a lifestyle that maintains a healthy body

and mind, through good habits of nutrition,

involvement in interesting and intellectually

stimulating activities, maintenance of self-concept,

and maintenance of a social support system,

throughout the life cycle (Lima, 2004). It is also

relevant to mention that facilitated access to

interaction, information and communication,

informal learning through the exchange of

experiences and the confrontation of opinions should

be guaranteed (Rogers, 2004).

In this contexts, it was considered important to

analyse and assess the siosLIFE

™ platform, in terms

of usability and inclusive nature, so this study could

contribute to raise awareness to a set of problems

regarding the interface, interaction, content and

terminals so this pioneer project could be more

successful in its mission of promoting active ageing,

contribute for health and wellbeing of the elderly

population in nursing homes. The short time and

location set made it difficult to gather participants

with similar limitations into specific groups, so the

study could only gather results from a single, small

and heterogeneous group. A complementary

approach will be considered to help determine if the

results observed would also occur among users

presenting no or less severe limitations.

All participants managed to complete the tasks

and were very enthusiastic. On the whole, being aged

did not hinder their interaction with this technology

but it limited their performance, increasing the time

to fulfil the tasks. Further research related to active

aging through digital devices should be encouraged

and carried out, since it can benefit a wide number of

people.

ACKNOWLEDGMENTS

All authors would like to thank: the nursing home

Centro Comunitário da Gafanha do Carmo for

providing the opportunity for the data collection, and

all its residents who showed interest in participating

in the study; siosLIFE

™ entrepreneurs for the

technical support and the information provided; Paulo

Silva for his careful text revision; the two anonymous

reviewers for the most helpful comments; and the

HEALTHINF 2021 organisation committee for the

registration grant provided, and the Secretariat for

their diligent work; and, the University of Aveiro and

António Moreira in particular, for all the support

provided.

CVL and IA would like to acknowledge the fund

support through the Doctoral Programme in

Technology Enhanced Learning and Societal

Challenges (PD/00173/2013) by FCT, through their

research grants PD/BI/135241/2017 and

PD/BI/135221/2017, followed by doctoral grants

PD/BD/143077/2018 and PD/BD/143054/2018,

respectively.

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