An Assistive Technology for Cognition to Support Meal Preparation:

The Concept Map of a User-centred Design Process and Procedure

Sareh Zarshenas

1,2 a

, Nathalie Bier

1,3 b

, Helene Pigot

, Sylvain Giroux

Patricia Briskie Semeniuk

, Melanie Couture

and Carolina Bottari

1,2

Occupational Therapy Program, School of Rehabilitation, Universite de Montreal, Montreal, Canada

Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal, Canada

Centre de Recherche de’Institut Universitaire de Geriatric de Montreal, Montreal, Canada

Universite de Sherbrooke, Sherbrooke, Canada

{helene.pigot, sylvain.giroux, melanie.couture}@usherbrooke.ca

Keywords: User-centred Design, Assistive Technology, Cognition, Activity of Daily Living, Meal Preparation, Acquired

Brain Injury, Concept Map.

Abstract: In response to the long-lasting effects of cognitive impairments following acquired brain injury (ABI) on

performing meal preparation safely and independently, our team has been working on developing a Cognitive

Orthosis for coOKing (COOK) to meet these needs. In this paper, the concept mapping method was used to

describe the processes and procedures of employing a user-centred design approach to develop this novel

technology. For this purpose, a mixed methodology including qualitative and quantitative studies was

conducted for needs analysis, prototype design, prototype evaluation, and technology validation via the

examination of the usability and feasibility of COOK within real-life contexts. Our comprehensive studies

have shown that COOK is a promising technology for meal preparation by individuals with severe ABI.

Further study is warranted/in progress to develop a therapist’s interface to tailor the required type and level

of assistance to a broader population with cognitive deficits of varying severity.

1 INTRODUCTION

Cognitive impairments following acquired brain

injury (ABI), may significantly affect cognitive

domains such as executive functions (Funahashi S &

Andreau JM, 2013). Executive functions are higher-

level cognitive functions necessary for directing

actions to perform instrumental activities of daily

living (IADL) (Blomgren C, & et al., 2019; Crichton

SL, & et al., 2016; Diamond A, 2013; Zinn D, & et

al., 2004). Meal preparation is a complex IADL that

heavily draws on executive functions and is essential

for living independently (Doherty TA, & et al., 2015;

Godbout L, & et al., 2004; Tanguay AN & et al.,

2014). Long-lasting effects of executive function

deficits in individuals with ABI may contribute to

difficulties in the meal preparation process, including

https://orcid.org/0000-0002-2872-3257

https://orcid.org/0000-0002-2440-694X

https://orcid.org/0000-0003-0602-5957

https://orcid.org/0000-0003-2242-8369

setting goals, planning steps, initiating meal

preparation, monitoring actions, and inhibiting

inappropriate behaviors (Bottari C, & et al., 2009;

Doherty TA et al., 2015; Tanguay AN et al., 2014).

With the evolution of smart technologies,

assistive technologies for cognition (ATC) are

strategically positioned to enhance healthcare

services and enable people with cognitive

impairments to be more independent in their daily

living activities such as meal preparation (Jamieson

M & et al., 2020; WHO, 2015). ATCs refer to

“technologies that enable, enhance, or extend

cognitive function in which the human user is an

autonomous agent using tools to facilitate their

cognition” (O'Neill B & Gillespie A, 2014). Over the

last decade, there has been a growing body of

evidence about the potential of ATCs in enabling

Zarshenas, S., Bier, N., Pigot, H., Giroux, S., Semeniuk, P., Couture, M. and Bottari, C.

An Assistive Technology for Cognition to Support Meal Preparation: The Concept Map of a User-centred Design Process and Procedure.

DOI: 10.5220/0010933900003123

In Proceedings of the 15th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2022) - Volume 5: HEALTHINF, pages 921-928

ISBN: 978-989-758-552-4; ISSN: 2184-4305

921

individuals with ABI to actively engage in daily

activities while supporting formal and informal

caregivers (Jamieson M, et al., 2020; Kettlewell J, &

et al., 2019; Leopold A, & et al., 2015; Nam J, & Kim

H, 2018; Vaezipour A, & et al., 2019; Wang J, & et

al., 2016; Widehammar C, & et al., 2019). Among

different categories of ATCs that focused on

executive functions, most are designed to help with

time management (i.e., reminding, and scheduling

technologies) or developed to assist with guiding

people through tasks (i.e., micro-prompting systems

that support multi-step task performance) (Mihailidis

A, & et al, 2008; O'Neill B & Gillespie A, 2014;

Rudzicz F, & et al., 2015). However, very few of

these technologies include a consideration of

assisting with the multiple aspects of executive

functions in complex tasks (e.g., setting a goal,

organization and problem-solving, preventing

hazardous behaviors, completing the task, and

evaluation of the outcome), which are inherent to

meal preparation (Wang J, & et al., 2019).

To propose a technological solution to target

various aspects of executive dysfunctions while

simultaneously improving independence and safety

in meal preparation, our interdisciplinary team has

been working on developing an ATC called

“Cognitive Orthosis for coOKing” (COOK) (Giroux

S, & et al., 2015; Olivares M, & et al., 2019;). COOK

is a web-based and context-aware system that was

developed based on the user-centred design (UCD)

approach in the context of a living lab (Pinard S, & et

al., 2019). COOK has three main components: 1) a

sensor-based security system to monitor safety

incidents via different types of sensors such as motion

detectors, pressure and infrared sensors, developed

based on a preventive assistance model (Olivares M,

& et al., 2016); 2) a cognitive assistance application

to increase independence providing step by step

instruction in the process of meal preparation via a

touch screen tablet and supporting executive function

sub-skills of setting a goal, planning steps, choosing

a recipe, following instructions, adjusting a reminder,

completing a task, and goal attainment evaluation;

and 3) a configuration system that makes it possible

to tailor COOK’s features to the individuals’ needs

while also providing accessibility to COOK’s activity

log (e.g., type of errors that occurred in conforming

safety rules) by expert clinicians, ideally occupational

therapists (OTs) (figure 1). Also, an extra screen can

be installed in the caregivers/ therapists’ room to

inform them of the stove’s/oven’s status (on/off) and

possible safety issues occurring while in use

(dashboard). In this manuscript we aimed to provide

a comprehensive overview of our projects to develop

and validate COOK.

2 METHODS

To meet the objective of this study, we used concept

mapping as a structured methodology for illustrating

steps and employed procedures within the UCD

process to explain the whole procedure of designing,

examining COOK’s usability, and implementing of

COOK within real life contexts (figure 2) (Kane,

2007). This method includes an integrated mixed

method of qualitative and quantitative data collection

that enabled us to access in-depth knowledge from

various stakeholders. Comprehensive information on

the methodologies used for conducting studies at the

different steps of the USD process are provided in the

following sections.

Figure 1: COOK Hardware Components.

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Figure 2: User-Centred Design Concept Map.

3 USER-CENTRED DESIGN

PROCESS, PROCEDURES, AND

RESULTS

UCD is an evidence-based and iterative approach that

incorporates the needs and context of a specific end-

user group and helps ensure that an invented and

novel technology is acceptable and effective (User-

Centered Design Basics, accessed October 2021).

3.1 Needs Analysis

To design an ATC that facilitates meal preparation for

individuals with ABI, one of the imperative steps is

to explore the main requirements and difficulties of

these individuals and other stakeholders in various

processes of meal preparation considering the

interaction of personal, environmental, and task

related factors (Dubuc E, & et al., 2019; Gagnon-Roy

M, & et al., 2020; Pinard S & et al., 2019; Zarshenas

S, & et al., 2020, 2021). For this purpose, descriptive

qualitative studies were conducted by carrying out

interviews and focus groups with individuals with

ABI (n=20) particularly traumatic brain injury

(n=14), their caregivers (n=13), and health care

providers (n=30) and assessing individuals’ level of

independence in meal preparation using the IADL

Profile (n=3) (Dubuc E & et al, 2019; Gagnon-Roy M

et al., 2020; Pinard S & et al., 2019; Zarshenas S et

al., 2020, 2021). Also, as another component of need

analysis, clinical reasonings to provide various levels

of verbal assistance by OTs (n=3) were investigated

via performing IADL Profile to inform the computer

scientists regarding the process of integrating the

verbal assistance within the design of COOK’s

cognitive assistance (Gagnon-Roy M, & et al., 2021).

Findings of these studies revealed various needs and

difficulties in four main areas regarding meal

preparation including psychosocial, cognitive, and

physical abilities, and environment characteristics.

With respect to the psychosocial aspect,

motivation to initiate the task, ability to maintain the

energy level required to engage in the task following

the onset of fatigue, need to change old habits in meal

preparation that may no longer be adapted to the

person’s abilities, managing impulsive behaviors, and

availability of caregiver’s support were all considered

necessary to engage in the meal preparation task

(Dubuc E, & et al, 2019; Zarshenas S, & et al., 2020,

2021).

Regarding cognitive and executive function,

difficulties in formulating a goal, planning, and

carrying out the task, problem solving, tailoring the

meal preparation process to the person’s cognitive

abilities were mentioned as important factors that

may limit the ability to complete the task safely and

independently (Dubuc E, & et al, 2019; Gagnon-Roy

An Assistive Technology for Cognition to Support Meal Preparation: The Concept Map of a User-centred Design Process and Procedure

923

M, et al., 2020; Pinard S, & et al., 2019; Zarshenas S,

et al., 2020, 2021).

Further, adaptation of the meal preparation task to

individuals’ fine and gross motor abilities were

mentioned as another necessary element to carrying

out the meal preparation task in a safe manner (Dubuc

E, & et al, 2019; Gagnon-Roy M, et al., 2020; Pinard

S, & et al., 2019; Zarshenas S, et al., 2020, 2021).

Finally, the level of support that could be provided

within a living environment (home vs. supported

residence) was considered as a determining factor to

perform the meal preparation task successfully

(Dubuc E, & et al, 2019; Gagnon-Roy M, et al., 2020;

Pinard S, & et al., 2019; Zarshenas S, et al., 2020,

2021). Stakeholdrs also expressed that available

commercial products have not been designed

specifically to meet the needs of individulas with

ABI which imposes a significant burden on

caregivers who have to provide personalized

cognitive assistance (e.g., verbal and visulal) to

compensate the cognitive and excecutive

impairments for their loved ones (Zarshenas S, et al.,

2020, 2021). Also, our findings showed that four

factors may affect providing verbal assistance

including presence of safety and emotional issues,

lack of progress in the task, requests for support, and

off-task discussions (Gagnon-Roy M, & et al., 2021).

3.2 Ideation

After obtaining in depth knowledge regarding the

needs and preferences of stakeholders, an

interdisciplinary team including rehabilitation (n=4)

and computer scientists (n=2), clinicians (n=3, OTs),

and potential end-users (n=3) collaborated to

brainstorm ideas to design different components of

COOK (Pinard S & et al., 2019;). Various strategies

were used to facilitate this step comprising persona

and scenario creation, ideation workshops, and co-

designing workshops (Olivares M, & et al., 2020;

Pinard S & et al., 2019).

As part of the UCD process, persona and scenarios

were used to characterize archetypes of various end

users to facilitate the interdisciplinary collaboration

between clinicians, computer scientists, and other

stakeholders. Personas and scenarios were created

through interdisciplinary workshops and video

analysis of individuals with traumatic brain injury

(n=4) being tested with the IADL Profile evaluation

by an OT.

As a result of this study, personas and scenarios

were created including individuals’ demographic and

clinical profiles and the types and levels of cognitive

assistance provided by OTS to facilitate the meal

preparation task for these personas. In total, three

personas were developed for mild, moderate, and

severe traumatic brain injury (TBI).

These personas were used in co-designing

workshops with various stakeholders to inform how

certain features should be designed or integrated to

meet end-user’s needs particularly in the client’s

interface of COOK. As part of the ideation and co-

designing workshops, several multidisciplinary team

meetings were held regarding strategies to maximize

safety and facilitate cognitive difficulties during meal

preparation that helped with the COOK mock-up

ideas (Pinard S, & et al., 2019).

3.3 COOK Iterative Prototype Design

The design process of COOK was iterative and

incremental with new features added gradually over

the course of several different studies. The design

team that remained stable throughout all stages of the

design process included computer scientists, OTs, a

psychologist, an implementation science expert, and

potential end-users including individuals with a

moderate to severe TBI (Pinard S, et al., 2019).

The interactive prototype was designed

progressively through simulating features and

functions via an interdisciplinary collaboration and

applying qualitative feedback from end-users

regarding their interaction with features and functions

to improve simulated features. During these sessions,

various strategies such as interviews, storyboarding,

scenario testing, and Wizard of Oz were used for the

iterative and incremental development process to

design the COOK interface for individuals with ABI

(Pinard S, & et al., 2019).

3.4 Evaluation of the COOK Prototype

To evaluate the prototype, different techniques were

used including cognitive walk-through, lab testing of

usability, and field testing of usability.

3.4.1 The Cognitive Walk-through

The cognitive walk-through method is “a usability

evaluation method in which one or more evaluators

work through a series of tasks and ask a set of

questions from the perspective of the user” (Usability

Body of Knowledge, accessed December 2021). For

this purpose, we carried out interviews and focus

groups with various stakeholders including

individuals with moderate to severe ABI (n=20),

caregivers (n=13), and health care providers (n=30).

They were provided a short demo of COOK’s

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features and functions to enable them to provide

feedback on the perceived advantages, barriers, and

facilitators to implementing COOK within living and

clinical contexts (Gagnon-Roy M, & et al., 2020;

Zarshenas S, & et al., 2020, 2021).

Findings showed that participants perceived

COOK as a promising technology to improve

independence and safety in meal preparation in the

ABI population while addressing caregivers’ burden

of care. For instance, availability of various types of

recipes with different levels of complexity, lists of

ingredients for each recipe, weekly meal, and grocery

planner, step by step instructions, portability, and

possibility of installing COOK on various electronic

stoves were all reflecting the positive potential of this

technology. However, limited access to financial

resources or funding to cover the cost of purchasing

technology, being trained on, and using COOK,

severity of injury, cognitive impairments and

psychosocial deficits, absence of supportive

caregivers, and some gaps in COOK’s software (e.g.,

not designed for multiple users, not accessible in all

languages) and hardware (e.g., not designed for a gas

stove) of the technology were described as the main

barriers that needed to be addressed to scale the

implementation of COOK. Further, raising awareness

about COOK, providing training to end-users and

their caregivers/providers, and availability of

technical support were considered as facilitators to

the eventual widespread implementation of COOK

and address some of the perceived barriers.

3.4.2 The Lab Testing of Usability

The primary version of technology was evaluated by

conducting two rounds of usability and user

experience (UX) evaluations which were completed

in a laboratory context including 3 sessions with 5

experts and 2 sessions with 10 TBI participants. Lab

usability tests measure a user's ability to complete

tasks (Usability Body of Knowledge, accessed

December 2021). Examination of the usability in the

lab, provided us with an opportunity to involve more

participants to ensure the reliability of the results

(Gagnon-Roy M, & et al, 2021, submitted).

Each session included the use of scenarios and

questionnaires regarding the users’ experience and

the technology’s usability. The UX and usability

evaluations of the user interface components of

COOK were completed via three steps: 1) a general

presentation of COOK, 2) simulating the use of the

technology via scenarios, and 3) administration of

two questionnaires; the System Usability Scale and

the Attrak-Diff Scale (Brooke J, 1996; Lallemand C,

& et al., 2015). During each simulation, participants

were asked to describe their thoughts using a think

aloud process, explaining their understanding of the

task and the technology, and comment on the

technology’s ease of use and potential. Both rounds

demonstrated good usability outcomes and good

hedonic qualities. Various usability issues were

identified by participants, such as navigation

inconsistencies and technical bugs. Factors to

consider in the future implementation of COOK were

also mentioned by TBI participants, including

environmental and personal factors (e.g., level of

comfort using the technology, and possible impact of

visual deficits on use of the technology).

3.4.3 The Field Testing of Usability

To test a product in the actual context, we used field

usability testing (Usability Body of Knowledge,

accessed December 2021). Considering the lessons

learned from the lab testing of COOK, we continued

to evaluate the usability of a modified version of

COOK over a 6-month period for 3 individuals with

severe TBI, with an average of 22 years post-injury,

through evaluating effectiveness, efficiency, and

satisfaction. This study took place at a community

residence in Sherbrooke where we made a partnership

to run the COOK project and expand our study scope.

Results of effectiveness and efficiency evaluation

revealed that the number of meals prepared with

COOK’s support increased significantly over time

while safety warnings and automatic stove shot

downs by the autonomous safety system decreased

over time. As part of the design process, technology

bugs and malfunctions (e.g., false alarms, sensitivity

of sensors) were precisely documented and prototype

modifications and refinements were made (Pinard S,

& et al., 2019). Further, findings highlighted the

importance of considering training as an imperative

complementary component to use COOK over

extended period by individuals with TBI.

3.5 Refinement and Development of the

Prototypes

While refinement and modification of the technology

was considered as an ongoing process during the

course of developing COOK, and after lab and field

testing of its usability, the interdisciplinary team

continued working on COOK to advance both French

and English versions of it, removing bugs, setting a

technical support team, and creating a light and

portable version to make it prepare for usability and

An Assistive Technology for Cognition to Support Meal Preparation: The Concept Map of a User-centred Design Process and Procedure

925

feasibility testing within real-life contexts in Quebec

and Ontario.

3.6 Validation

To validate the usability and feasibility of COOK

within real-life contexts, COOK was implemented at

a shared community residence for a 47-year-old

woman with chronic severe stroke (C1) in Ontario

and within the home of a 35-year-old man with

chronic severe TBI in Quebec, Canada (C2) (Gagnon-

Roy M, & et al., 2021, submitted; Zarshenas S, & et

al., 2021).

For both studies we used a mixed-methods single

case design, including a multiple baseline single-case

experimental study and a descriptive qualitative study

(Onghena P, & et al., 2018). C1 received

comprehensive training on using COOK within a

shared kitchen space at the residence. During meal

preparation, independence and safety were evaluated

using three target behaviors: required assistance, task

performance errors, and appropriate responses to

safety issues, which were compared with an untrained

control task, making a budget. Benefits, barriers, and

facilitators were assessed via three individual

interviews with the client and three focus groups with

the care team before, during and after the COOK

implementation. For C2, target behaviors included

the number of meals prepared each week using

COOK, and indicators of performance during both a

meal preparation task and a control task, obtaining

information. Both quantitative and qualitative

analyses of C1 data showed that COOK significantly

increased independence and safety during meal

preparation. No changes were observed in the control

task. Stakeholders suggested that the availability of a

training toolkit would facilitate the involvement of a

greater number of therapists at the residence and the

installation of COOK within the client’s own

apartment would help with the successful adoption of

this technology (Zarshenas S, & et al., 2021). Also,

C2 showed an improved ability to prepare meals

overtime with less assistance being required and a

more efficient preparation of meals using COOK

(Gagnon-Roy M, et al., 2021, submitted). Comparing

the results of these two studies showed that a client

who was surrounded by a team of care at the residence

could receive more support than a client who lived at

home. However, both clients and care

providers/givers comprehended COOK as an

effective technology to increase independence of

clients with ABI (Gagnon-Roy M, & et al., 2021,

submitted; Zarshenas S, & et al., 2021).

4 CONCLUSION AND FUTURE

DIRECTIONS

To our knowledge, COOK is the first assistive

technology for cognition, designed for performing

meal preparation task by individuals with a severe

ABI. Our current studies showed the successful

usability and feasibility examination of this

technology particularly for individuals with severe

ABI. However, considering the variation of ABI

individuals’ needs based on their severity of injury

and cognitive impairments, our team is presently

working on developing the expert interface as part of

the configuration system where therapists will have

the possibility of adjusting the types and levels of

cognitive assistance provided by the technology’s

prompts to expand the usefulness of this technology

for a broader population with ABI with various level

of cognitive functions. In line with this goal, our

interdisciplinary team is also collaborating with OTs

to translate their clinical reasonings regarding types

and levels of cognitive assistance to appropriate

visual and verbal prompts within the configuration

system in COOK to meet the individuals’ needs

during meal preparation (Tekemetieu A, & et al, in

preparation). Finally, to explore application of COOK

to a broader population, we are exploring the

implementation of COOK for older adults with mild

cognitive impairments. Preliminary findings

indicated the potential of COOK for this population

(Yaddaden A, & et al., 2020). Further studies are

warranted regarding the usability and feasibility of

this technology for the aging population.

ACKNOWLEDGEMENTS

We would like to gratefully acknowledge all

participants who assisted in making this work a

reality. This project was funded by Canadian

agencies: Canadian Institute of Health Research,

National Sciences and Engineering Research Council

of Canada, ONF-REPAR, OPHQ-REPAR, AGE-

WELL, and the CRIUGM. N.B. is supported by a

salary award from the Fonds de la recherche du

Quénec – Santé.

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