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Exposure to “Exergames” Increases Older Adults’ Perception of the Usefulness of Technology for Improving Health and Physical Activity: A Pilot Study

Exposure to “Exergames” Increases Older Adults’ Perception of the Usefulness of Technology for... Background: High rates of sedentary behaviors in older adults can lead to poor health outcomes. However, new technologies, namely exercise-based videogames (“exergames”), may provide ways of stimulating uptake and ongoing participation in physical activities. Older adults’ perceptions of the use of technology to improve health are not known. Objective: The study aimed to determine use and perceptions of technology before and after using a 5-week exergame. Methods: Focus groups determined habitual use of technology and the participant’s perceptions of technology to assist with health and physical activity. Surveys were developed to quantitatively measure these perceptions and were administered before and after a 5-week intervention. The intervention was an exergame that focused on postural balance (“Your Shape Fitness Evolved 2012”). Games scores, rates of game participation, and enjoyment were also recorded. Results: A total of 24 healthy participants aged between 55 and 82 years (mean 70, SD 6 years) indicated that after the intervention there was an increased awareness that technology (in the form of exergames) can assist with maintaining physical activity (P<.001). High levels of enjoyment (Physical Activity Enjoyment Scale [PACES-8] score mean 53.0, SE 0.7) and participation rates over the whole study (83%-100%) were recorded. Conclusions: Older adults’ have low perception of the use of technology for improving health outcomes until after exposure to exergames. Technology, in the form of enjoyable exergames, may be useful for improving participation in physical activity that is relevant for older adults. (JMIR Serious Games 2015;3(2):e8) doi: 10.2196/games.4275 KEYWORDS health care reform; postural balance; pleasure; exercise; perception reported in as much as 62% of the older population (ie, not Introduction meeting the recommended guidelines of 30 minutes moderate activity on most days of the week) [4]. As well, they also Adequate levels of physical activity are a primary factor reportedly spend a major proportion of their day in activities contributing to the maintenance of physiological and that use very little energy expenditure and would be classified psychological health, yet many older adults are physically as sedentary. Sedentary behavior levels in Australia are reported inactive [1-3]. Insufficient levels of physical activity have been http://games.jmir.org/2015/2/e8/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e8 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Bird et al to be as high as 40% for adults aged between 65 and 74 years [21]. Although balance training has been recently included in [3,5]. The magnitude of this health issue is set to increase with guidelines for exercise for adults older than 65 years [22], many the changing demographics of our population with the Australian older adults do not participate in balance training as part of their Bureau of Statistics [6] predicting that the portion of the habitual exercise, with only 6% performing balance training population aged 65 years and older will increase to 29% by and 27% undertaking balance-challenging activities [23]. A 2051. recent review of exergames to improve balance in older adults found improvements in at least one facet of postural balance The health benefits of adequate levels of physical activity and occurred in 10 of 13 of them [24]. Although many of these regular exercise include improvements in lower limb strength, studies were small, this provides some evidence that balance, and mobility, which may provide a reduction in the balance-related exergames may be useful in assisting older risk of accidental falls in older adults. As well, a reduction in adults meet this component of the exercise guidelines. incidence in a range of chronic health conditions is seen with changes from sedentary behaviors to more active behaviors. The primary aim of this study was to determine the perceptions Overcoming barriers and identification of facilitators that will of the use of technology for health before and after the use of improve uptake of positive health behaviors and encourage an exergame intervention designed to improve postural balance long-term participation of such behaviors forms the thrust of and to record perceptions of enjoyment after the intervention. current population-based health research. Methods Advances in technology, both hardware and software, has enabled increased accessibility of technology-based exercise The small number of participants involved in this pilot project interventions to a vast number of consumers [7]. The design of and the exploratory nature of the research lent itself to a exercise-based videogames (“exergames”) provides activities methodology that enabled researchers to explore participant that balance enjoyment, ability, and intensity levels to a large responses in some depth. Heinz et al [25] suggested that opinions market audience [8]. Enjoyment of an activity has been of technological developments can be achieved through focus identified as one of the predictors of the effectiveness of an group research, where researchers can relatively easily gain exercise program and, because of this, interactive exercise-based information from older adults. Therefore, a qualitative technology, or exergaming, is becoming an increasingly popular descriptive study was utilized based on data analysis from 3 strategy for the implementation of physical activity [7-9]. focus groups [26]. Incorporating the use of interactive games into home-based Participants exercise programs addresses several access barriers around transport and leaving the home, while at the same time providing Eligibility criteria of the participants included targeting older enjoyable activities may improve ongoing participation in adults (>50 years), classified as low risk according to the physical activities [7]. The feasibility of trialing exergaming American College of Sports Medicine guidelines, and currently interventions in an older population will rely on acceptance of participating in a previously established Pilates program this type of technology, but evidence about older adults’ established at the Exercise Physiology Clinic at the Newnham attitudes toward using technology to improve physical activity campus of the University of Tasmania. No participants were and health more generally is mixed. excluded. The assumption that interest in technology decreases with age Procedure is misleading [10] and the small amount of literature available Potential participants were invited to participate in a focus group in this area is conflicted. Several studies report negative attitudes held 1 week before initiation of the 5-week exergame and limited use of technology by older people [11,12], whereas intervention. From this focus group, a survey was developed others report that older people are enthusiastic about the and administered before and after the intervention. potential for eHealth and are increasingly adopting these technologies [13-15]. Despite this diversity in findings, there Focus Group is strong evidence to suggest that older adults are more likely The focus group was run as an open discussion forum with one to use applications that they perceive as being user-friendly, experienced researcher directing the group and asking questions, engaging, and meeting a current need [13,15]. Miller et al [16], while another trained research assistant took notes and recorded in their review of the literature focusing specifically on the session for later analysis. Structured open-ended questions home-based exergaming systems used by older adults, suggest were used in the focus groups to elicit information regarding that the evidence supporting positive benefits is “relatively current use and access to technology and the types of technology weak, with a high risk of bias.” However, older adults have that this cohort currently engaged with. The whole team was been reported to find exergaming appealing [17] and that it involved in the development of the questions; this has been provides improved motivation for activity [18]. As well, shown to enhance the validity of the research in the design stage perceived enjoyment has been correlated to improved physical [27]. Current physical activity and perceptions of the impact on well-being during an exergame intervention [19]. physical activity when using technology were explored. The forum was designed to gather qualitative information regarding From the age of 45 years onward, balance control function each person’s current health and physical activity levels, their declines [20]. Exercise has been shown to improve balance and reasons for exercise, and their technology use and knowledge. exercise programs that include a high dose of balance training This included perceptions and awareness of using technology (without a walking component) reduce fall rates by up to 38% http://games.jmir.org/2015/2/e8/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e8 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Bird et al for health. This information was used to develop a questionnaire The exergame was introduced as an individual 2-minute station by the research team that quantitatively assessed perception of in a circuit class (see Multimedia Appendix 1). This allowed how useful technology can be for a range of health parameters for maximum engagement of the exergame, but did not require and physical activity: the Technology Engaging Activity (TEA) any extra effort from the participants. Research assistants questionnaire. Pretesting of questions was undertaken to ensure implemented the program, which was the game “stack ’em up” validity of survey questions. Before commencing the contained within the “Your Shape: Fitness Evolved 2012” intervention, this questionnaire was administered and (Ubisoft) exergame package for the Microsoft Xbox 360 Kinect participants were invited to familiarize themselves with the game console. The level of difficulty throughout the intervention intervention. was set at easy and was not adjusted throughout the study. Game scores were collected for each participant after the game was Throughout the study, the intervention was set up as a 2-minute completed. Comments while performing the game were station during the Pilates classes for voluntary and independent collected by the researchers. access by the participants at any time throughout the hour-long timeframe supervised by 2 research assistants. The technology Ethics approval from the Social Science Human Research Ethics was available for 5 weeks, which included a total of 10 Pilates Committee (H0013878) was gained before commencement of sessions. After the conclusion of the intervention, participants the study. Participant flow through the study and data collection were invited to complete the same questionnaire and the 8-item time points are outlined in Figure 1. Physical Activity Enjoyment Scale (PACES-8) questionnaire. Figure 1. Study flow diagram. participants’ responses in the focus group. Two research Measures assistants administered the survey. Specifically, the questionnaire asked participants to rate their level of Perceptions of Technology Enhancing Physical Activity agreement/disagreement with the following statements: Participant’s perceptions of technology usage were gauged through the TEA questionnaire. This questionnaire was I think technology can keep me active. composed of 5 questions and responses were measured on a I think technology is useful in my life. Likert scale of 1 to 5, in which a score of 5 represented a strong I think technology is enjoyable. agreement and a score of 1 indicated a strong disagreement. I think technology helps me be more active. This was developed by the research team and established from I think technology can improve my postural balance. http://games.jmir.org/2015/2/e8/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e8 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Bird et al majority indicated little exposure to using technology for Exergame Enjoyment enjoyment (23/24) or games (18/24). In fact, the game-based The PACES-8 [28] is a validated and reliable modified version technology that they currently engaged in encouraged sedentary of the original 18-item PACES questionnaire, which describes behaviors. enjoyment of physical activity within the older adult population. For each of the 8 questions, a score of 7 represents maximal The focus group established that, before exposure to the enjoyment and a score of 1 represents minimal enjoyment for intervention, the majority (23/24) of participant’s engagement each subsection, resulting in a total possible score of 56. with technology was for mainly pragmatic reasons, such as communication (eg, mobile phones, email, and use of Skype to Data Analysis communicate with family members) and simple information The data analysis drew on semantic thematic analysis to identify gathering (eg, timetables and location of services). Although explicit surface meanings within the data. Thematic analysis is this majority indicated that technology was “not used for appropriate for questions seeking to explore people’s views or enjoyment” and “only do what I need to do,” a few people (2/24) perceptions [29,30]. Because this evaluation sought user identified enjoying interacting with new technology and opinions and perceptions, the methods of thematic analysis were provided positive responses such as “I’m a gadget baby” and considered appropriate. “very useful when needed.” Thematic analysis of focus group data was undertaken from When asked about technology and games, participants only both recordings and notes from the sessions using a identified participating in technology-based games, such as phenomenological approach. Recordings were analyzed in a Solitaire and FreeCell. Generally, participants seemed unaware group session. Each researcher listened to the material and that it was possible to use gamed-based technology for individually noted common responses. These were then improving health outcomes, indicating that the computer-based discussed as a group until consensus about common patterns games they currently participated in reduced activity and were was reached and these were used as a basis for manual coding not positively related to health. Two of 24 participants indicated of data. In addition to identifying common patterns, the range that they had at one time (but did not regularly) played with a of views for each pattern was identified with examples across Nintendo Wii console with their grandchildren. the spectrum recorded as anonymous quotations. Participants indicated strong engagement in a variety of exercise Microsoft Excel was used to analyze the quantitative data from activities over many years. It was established that participants the surveys, which was reported as mean and standard error of engaged in both structured and unstructured exercises daily and means. Pre- and postintervention data were analyzed using mostly of moderate intensity. Many in the group described their paired t tests. preferential involvement toward exercise in a social environment (eg, dancing, swimming, and bushwalking groups), whereas Results other participants focused on more individual activities (eg, gardening, walking, and riding) with each participant indicating Participants that the autonomy of exercise selection enhanced participation. A total of 24 participants (5 male, 19 female) aged between 55 Participants described that they engaged in multiple types of and 82 years (mean 70, SD 6 years) were recruited to participate physical activity throughout the week, including both social in the focus groups and technology engaging intervention for and individual activities regularly. Participants expressed that older adults study. Although the number of attendees exercise in their life was related to being “habitual” and to participating in the exergames session in the circuit class varied maintain or improve their health. over the duration of the intervention, participation rates Perceptions of Technology Enhancing Physical Activity increased from week 1 (20/24, 83%) to all participants in week 4 (24/24, 100%) with a slight drop seen in week 5 back to 21 Pre- and postsurvey data indicated that participants significantly participants (88%). increased their positive perceptions of the use of technology to keep active and improve postural balance (P<.05) (Table 1). Focus Group The focus group identified that this active group of older adults primarily used technology for pragmatic purposes and the http://games.jmir.org/2015/2/e8/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e8 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Bird et al Table 1. Survey responses pre- and postintervention (N=24). Statement Preintervention, mean (SE) Postintervention, mean (SE) P I think technology can keep me active 2.95 (0.21) 4.00 (0.23) <.001 I think technology is useful in my life 3.90 (0.17) 3.94 (0.19) .44 I think technology is enjoyable 3.48 (0.21) 4.00 (0.21) .04 I think technology can help me be more active 3.38 (0.23) 3.78 (0.22) .05 I think technology can improve my postural balance 3.76 (0.17) 4.22 (0.19) .03 Based on a 5-point Likert scale (5=strongly agree, 1=strongly disagree). items on the questionnaire relating to physical activity after the Exergame Enjoyment intervention. After the intervention, participants indicated that The postintervention PACES-8 enjoyment questionnaire focused they thought that technology was able to assist in maintaining solely on the chosen exergame used throughout the intervention. physical activity levels. There was an increase in the perception Participant mean results identified that all the questions received that technology was useful to improve physical activity, but this a score of 6 or higher. From the PACES-8 questionnaire, an difference did not meet statistical significance (P=.05). overall score of 56 signifies the maximal score that can be Specifically, with respect to postural balance, the usefulness of achieved per individual. The mean pooled response from this form of exercise was perceived to increase. The use of participants was 53.0 (SE 0.7). technology to enhance physical activity in older adults is receiving attention in current literature as a motivator for Game Scores improving physical activity, especially to meet the needs of that Game scores increased from week 1 (mean 892, SE 65) to week part of the population. 5 (mean 1579, SE 112). Researchers observed that participants There was a strong response that indicated maintaining health endeavored to increase their scores over the time of the study. was a key reason to exercise. One participant stated they felt that “exercise is a part of life,” with the other 7 people in that Discussion group affirming that concept. Another participant in a different The primary aim of this study was to determine the perceptions group described exercise in their life as “habitual”. Although it of older adults to technology for health before and after was identified that the focus group participants used some form participating in an exergame intervention. This group initially of technology on a daily basis, there was only limited exposure indicated commitment to nontechnology-based physical activity; to any form of exergame activity. The literature suggests that however, a significant change in attitude was seen after the older adults are more willing to use technologies that they intervention with improvements in understanding about the perceive as meeting a current need in a more convenient way health and activity benefits of using technology in the form of than other options [12,14,33-36]. Before the intervention, exergames. High levels of enjoyment and perceived personal participants did not view the exergame as meeting their need benefit were also identified. This study adds to the evidence for regular exercise. However, this perception changed after supporting the use of exergames as enjoyable and engaging their participation in the program. methods for older adults to improve participation in physical Technology, Enjoyment, and Engagement activity. The high levels of enjoyment recorded by the participants augur Pragmatism to Participation well for the future of this form of technology to improve The responses from the focus group identified strong emerging physical outcomes using this modality. themes associated with attitudes toward the use of technology Enjoyment has been identified as an important implementation for pragmatic purposes and the participants’ attitudes about factor in physical activity programs [37]. As well, the literature life-long commitment toward physical activity. Although there suggests that older adults who find enjoyment in physical are positive health outcomes associated with digital video activities tend to perform them for longer periods of time [19]. gaming for older adults, our participants were not aware of this Overall enjoyment and levels of satisfaction have been shown before the intervention [31]. When initially questioned regarding to be better predictors of physical activity participation and their perceptions about technology and games, all participants adherence than any other factors [38,39]. immediately responded with the idea that these involved limiting physical activity. The impact of sedentary behaviors associated Indication of engagement with this form of exercise is supported with screen-based technology use is a concern across the life by high voluntary participation rates throughout our study. span [32]. Researchers noted that participants strategically challenged themselves to gain a higher overall score and continued to Technology and Activity engage in the exergame over the period of the intervention. The Before the intervention, there was a lack of familiarity in these researchers also identified that scores needed to be monitored older adults with the concept of utilizing technology as a form and recorded for each participant to further challenge the of exercise. There were positive changes to responses on both participants and retain and reinforce enjoyment levels. http://games.jmir.org/2015/2/e8/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e8 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Bird et al The social context of this study design (ie, being part of a group active (ie, attending Pilates classes regularly). This limits the and having the ability to compare scores with others) contributed generalizability of these results and precludes application to to the engagement of this group in the intervention. Future sectors of the community that are more sedentary and perhaps research needs to identify the types of people who would engage a better target for interventions such as these. Future research with this technology in their own home, without face-to-face should endeavor to use higher best practice dosage to improve social contact, if we want to use exergames as part of a postural balance. Because of the short intervention period, it is widespread intervention to overcome many barriers to physical important to note that adherence and enjoyment levels may have activity that older adults have in leaving their home. Technology changed after the 5-week period. that links virtual groups may overcome the potential barrier of Conclusion social isolation and may be of benefit for both improving Exposure to and participation in a balance-focused exergame physical activity within a virtual social network for those people resulted in older adults dramatically increasing their perception unable to mobilize easily outside the home. In the future, of the usefulness of technology for improving several health home-based preventive health care using technology may be outcomes, including physical activity levels and postural leveraged off current research exploring in-home rehabilitation balance. High rates of enjoyment and adherence to this program using motion capture software and technology [40]. were reported. Technology, in the form of enjoyable exergames, A limitation of this study was the selection and use of a may be useful for improving participation in physical activity convenience sample of participants who were currently physical that is relevant for the needs of older adults. Acknowledgments The authors would like to thank the participants of the University of Tasmania Pilates program and the University of Tasmania Clinical Exercise Physiology Lab for allowing the research to be conducted in their clinic. Conflicts of Interest None declared. Multimedia Appendix 1 (A) Screenshot of intervention for training postural balance. (B) Using the game for training postural balance. [PDF File (Adobe PDF File), 397KB-Multimedia Appendix 1] References 1. Australian Institute of Health and Welfare. 2008. Australia's health 2008 URL: http://www.aihw.gov.au/publication-detail/ ?id=6442468102 [accessed 2015-11-16] [WebCite Cache ID 6d4Zquvyw] 2. Dacey M, Baltzell A, Zaichkowsky L. 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Movement-based interaction applied to physical rehabilitation therapies. J Med Internet Res 2014;16(12):e281 [FREE Full text] [doi: 10.2196/jmir.3154] [Medline: 25491148] Abbreviations PACES: Physical Activity Enjoyment Scale TEA: Technology Engaging Activity Edited by G Eysenbach; submitted 22.01.15; peer-reviewed by YY Chao, E Lyons; comments to author 21.05.15; revised version received 31.07.15; accepted 15.10.15; published 27.11.15 Please cite as: Bird ML, Clark B, Millar J, Whetton S, Smith S Exposure to “Exergames” Increases Older Adults’ Perception of the Usefulness of Technology for Improving Health and Physical Activity: A Pilot Study JMIR Serious Games 2015;3(2):e8 URL: http://games.jmir.org/2015/2/e8/ doi: 10.2196/games.4275 PMID: 26614263 ©Marie-Louise Bird, Brodie Clark, Johanna Millar, Sue Whetton, Stuart Smith. Originally published in JMIR Serious Games (http://games.jmir.org), 27.11.2015. This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on http://games.jmir.org, as well as this copyright and license information must be included. http://games.jmir.org/2015/2/e8/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e8 | p. 8 (page number not for citation purposes) XSL FO RenderX http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JMIR Serious Games JMIR Publications

Exposure to “Exergames” Increases Older Adults’ Perception of the Usefulness of Technology for Improving Health and Physical Activity: A Pilot Study

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Abstract

Background: High rates of sedentary behaviors in older adults can lead to poor health outcomes. However, new technologies, namely exercise-based videogames (“exergames”), may provide ways of stimulating uptake and ongoing participation in physical activities. Older adults’ perceptions of the use of technology to improve health are not known. Objective: The study aimed to determine use and perceptions of technology before and after using a 5-week exergame. Methods: Focus groups determined habitual use of technology and the participant’s perceptions of technology to assist with health and physical activity. Surveys were developed to quantitatively measure these perceptions and were administered before and after a 5-week intervention. The intervention was an exergame that focused on postural balance (“Your Shape Fitness Evolved 2012”). Games scores, rates of game participation, and enjoyment were also recorded. Results: A total of 24 healthy participants aged between 55 and 82 years (mean 70, SD 6 years) indicated that after the intervention there was an increased awareness that technology (in the form of exergames) can assist with maintaining physical activity (P<.001). High levels of enjoyment (Physical Activity Enjoyment Scale [PACES-8] score mean 53.0, SE 0.7) and participation rates over the whole study (83%-100%) were recorded. Conclusions: Older adults’ have low perception of the use of technology for improving health outcomes until after exposure to exergames. Technology, in the form of enjoyable exergames, may be useful for improving participation in physical activity that is relevant for older adults. (JMIR Serious Games 2015;3(2):e8) doi: 10.2196/games.4275 KEYWORDS health care reform; postural balance; pleasure; exercise; perception reported in as much as 62% of the older population (ie, not Introduction meeting the recommended guidelines of 30 minutes moderate activity on most days of the week) [4]. As well, they also Adequate levels of physical activity are a primary factor reportedly spend a major proportion of their day in activities contributing to the maintenance of physiological and that use very little energy expenditure and would be classified psychological health, yet many older adults are physically as sedentary. Sedentary behavior levels in Australia are reported inactive [1-3]. Insufficient levels of physical activity have been http://games.jmir.org/2015/2/e8/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e8 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Bird et al to be as high as 40% for adults aged between 65 and 74 years [21]. Although balance training has been recently included in [3,5]. The magnitude of this health issue is set to increase with guidelines for exercise for adults older than 65 years [22], many the changing demographics of our population with the Australian older adults do not participate in balance training as part of their Bureau of Statistics [6] predicting that the portion of the habitual exercise, with only 6% performing balance training population aged 65 years and older will increase to 29% by and 27% undertaking balance-challenging activities [23]. A 2051. recent review of exergames to improve balance in older adults found improvements in at least one facet of postural balance The health benefits of adequate levels of physical activity and occurred in 10 of 13 of them [24]. Although many of these regular exercise include improvements in lower limb strength, studies were small, this provides some evidence that balance, and mobility, which may provide a reduction in the balance-related exergames may be useful in assisting older risk of accidental falls in older adults. As well, a reduction in adults meet this component of the exercise guidelines. incidence in a range of chronic health conditions is seen with changes from sedentary behaviors to more active behaviors. The primary aim of this study was to determine the perceptions Overcoming barriers and identification of facilitators that will of the use of technology for health before and after the use of improve uptake of positive health behaviors and encourage an exergame intervention designed to improve postural balance long-term participation of such behaviors forms the thrust of and to record perceptions of enjoyment after the intervention. current population-based health research. Methods Advances in technology, both hardware and software, has enabled increased accessibility of technology-based exercise The small number of participants involved in this pilot project interventions to a vast number of consumers [7]. The design of and the exploratory nature of the research lent itself to a exercise-based videogames (“exergames”) provides activities methodology that enabled researchers to explore participant that balance enjoyment, ability, and intensity levels to a large responses in some depth. Heinz et al [25] suggested that opinions market audience [8]. Enjoyment of an activity has been of technological developments can be achieved through focus identified as one of the predictors of the effectiveness of an group research, where researchers can relatively easily gain exercise program and, because of this, interactive exercise-based information from older adults. Therefore, a qualitative technology, or exergaming, is becoming an increasingly popular descriptive study was utilized based on data analysis from 3 strategy for the implementation of physical activity [7-9]. focus groups [26]. Incorporating the use of interactive games into home-based Participants exercise programs addresses several access barriers around transport and leaving the home, while at the same time providing Eligibility criteria of the participants included targeting older enjoyable activities may improve ongoing participation in adults (>50 years), classified as low risk according to the physical activities [7]. The feasibility of trialing exergaming American College of Sports Medicine guidelines, and currently interventions in an older population will rely on acceptance of participating in a previously established Pilates program this type of technology, but evidence about older adults’ established at the Exercise Physiology Clinic at the Newnham attitudes toward using technology to improve physical activity campus of the University of Tasmania. No participants were and health more generally is mixed. excluded. The assumption that interest in technology decreases with age Procedure is misleading [10] and the small amount of literature available Potential participants were invited to participate in a focus group in this area is conflicted. Several studies report negative attitudes held 1 week before initiation of the 5-week exergame and limited use of technology by older people [11,12], whereas intervention. From this focus group, a survey was developed others report that older people are enthusiastic about the and administered before and after the intervention. potential for eHealth and are increasingly adopting these technologies [13-15]. Despite this diversity in findings, there Focus Group is strong evidence to suggest that older adults are more likely The focus group was run as an open discussion forum with one to use applications that they perceive as being user-friendly, experienced researcher directing the group and asking questions, engaging, and meeting a current need [13,15]. Miller et al [16], while another trained research assistant took notes and recorded in their review of the literature focusing specifically on the session for later analysis. Structured open-ended questions home-based exergaming systems used by older adults, suggest were used in the focus groups to elicit information regarding that the evidence supporting positive benefits is “relatively current use and access to technology and the types of technology weak, with a high risk of bias.” However, older adults have that this cohort currently engaged with. The whole team was been reported to find exergaming appealing [17] and that it involved in the development of the questions; this has been provides improved motivation for activity [18]. As well, shown to enhance the validity of the research in the design stage perceived enjoyment has been correlated to improved physical [27]. Current physical activity and perceptions of the impact on well-being during an exergame intervention [19]. physical activity when using technology were explored. The forum was designed to gather qualitative information regarding From the age of 45 years onward, balance control function each person’s current health and physical activity levels, their declines [20]. Exercise has been shown to improve balance and reasons for exercise, and their technology use and knowledge. exercise programs that include a high dose of balance training This included perceptions and awareness of using technology (without a walking component) reduce fall rates by up to 38% http://games.jmir.org/2015/2/e8/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e8 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Bird et al for health. This information was used to develop a questionnaire The exergame was introduced as an individual 2-minute station by the research team that quantitatively assessed perception of in a circuit class (see Multimedia Appendix 1). This allowed how useful technology can be for a range of health parameters for maximum engagement of the exergame, but did not require and physical activity: the Technology Engaging Activity (TEA) any extra effort from the participants. Research assistants questionnaire. Pretesting of questions was undertaken to ensure implemented the program, which was the game “stack ’em up” validity of survey questions. Before commencing the contained within the “Your Shape: Fitness Evolved 2012” intervention, this questionnaire was administered and (Ubisoft) exergame package for the Microsoft Xbox 360 Kinect participants were invited to familiarize themselves with the game console. The level of difficulty throughout the intervention intervention. was set at easy and was not adjusted throughout the study. Game scores were collected for each participant after the game was Throughout the study, the intervention was set up as a 2-minute completed. Comments while performing the game were station during the Pilates classes for voluntary and independent collected by the researchers. access by the participants at any time throughout the hour-long timeframe supervised by 2 research assistants. The technology Ethics approval from the Social Science Human Research Ethics was available for 5 weeks, which included a total of 10 Pilates Committee (H0013878) was gained before commencement of sessions. After the conclusion of the intervention, participants the study. Participant flow through the study and data collection were invited to complete the same questionnaire and the 8-item time points are outlined in Figure 1. Physical Activity Enjoyment Scale (PACES-8) questionnaire. Figure 1. Study flow diagram. participants’ responses in the focus group. Two research Measures assistants administered the survey. Specifically, the questionnaire asked participants to rate their level of Perceptions of Technology Enhancing Physical Activity agreement/disagreement with the following statements: Participant’s perceptions of technology usage were gauged through the TEA questionnaire. This questionnaire was I think technology can keep me active. composed of 5 questions and responses were measured on a I think technology is useful in my life. Likert scale of 1 to 5, in which a score of 5 represented a strong I think technology is enjoyable. agreement and a score of 1 indicated a strong disagreement. I think technology helps me be more active. This was developed by the research team and established from I think technology can improve my postural balance. http://games.jmir.org/2015/2/e8/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e8 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Bird et al majority indicated little exposure to using technology for Exergame Enjoyment enjoyment (23/24) or games (18/24). In fact, the game-based The PACES-8 [28] is a validated and reliable modified version technology that they currently engaged in encouraged sedentary of the original 18-item PACES questionnaire, which describes behaviors. enjoyment of physical activity within the older adult population. For each of the 8 questions, a score of 7 represents maximal The focus group established that, before exposure to the enjoyment and a score of 1 represents minimal enjoyment for intervention, the majority (23/24) of participant’s engagement each subsection, resulting in a total possible score of 56. with technology was for mainly pragmatic reasons, such as communication (eg, mobile phones, email, and use of Skype to Data Analysis communicate with family members) and simple information The data analysis drew on semantic thematic analysis to identify gathering (eg, timetables and location of services). Although explicit surface meanings within the data. Thematic analysis is this majority indicated that technology was “not used for appropriate for questions seeking to explore people’s views or enjoyment” and “only do what I need to do,” a few people (2/24) perceptions [29,30]. Because this evaluation sought user identified enjoying interacting with new technology and opinions and perceptions, the methods of thematic analysis were provided positive responses such as “I’m a gadget baby” and considered appropriate. “very useful when needed.” Thematic analysis of focus group data was undertaken from When asked about technology and games, participants only both recordings and notes from the sessions using a identified participating in technology-based games, such as phenomenological approach. Recordings were analyzed in a Solitaire and FreeCell. Generally, participants seemed unaware group session. Each researcher listened to the material and that it was possible to use gamed-based technology for individually noted common responses. These were then improving health outcomes, indicating that the computer-based discussed as a group until consensus about common patterns games they currently participated in reduced activity and were was reached and these were used as a basis for manual coding not positively related to health. Two of 24 participants indicated of data. In addition to identifying common patterns, the range that they had at one time (but did not regularly) played with a of views for each pattern was identified with examples across Nintendo Wii console with their grandchildren. the spectrum recorded as anonymous quotations. Participants indicated strong engagement in a variety of exercise Microsoft Excel was used to analyze the quantitative data from activities over many years. It was established that participants the surveys, which was reported as mean and standard error of engaged in both structured and unstructured exercises daily and means. Pre- and postintervention data were analyzed using mostly of moderate intensity. Many in the group described their paired t tests. preferential involvement toward exercise in a social environment (eg, dancing, swimming, and bushwalking groups), whereas Results other participants focused on more individual activities (eg, gardening, walking, and riding) with each participant indicating Participants that the autonomy of exercise selection enhanced participation. A total of 24 participants (5 male, 19 female) aged between 55 Participants described that they engaged in multiple types of and 82 years (mean 70, SD 6 years) were recruited to participate physical activity throughout the week, including both social in the focus groups and technology engaging intervention for and individual activities regularly. Participants expressed that older adults study. Although the number of attendees exercise in their life was related to being “habitual” and to participating in the exergames session in the circuit class varied maintain or improve their health. over the duration of the intervention, participation rates Perceptions of Technology Enhancing Physical Activity increased from week 1 (20/24, 83%) to all participants in week 4 (24/24, 100%) with a slight drop seen in week 5 back to 21 Pre- and postsurvey data indicated that participants significantly participants (88%). increased their positive perceptions of the use of technology to keep active and improve postural balance (P<.05) (Table 1). Focus Group The focus group identified that this active group of older adults primarily used technology for pragmatic purposes and the http://games.jmir.org/2015/2/e8/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e8 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Bird et al Table 1. Survey responses pre- and postintervention (N=24). Statement Preintervention, mean (SE) Postintervention, mean (SE) P I think technology can keep me active 2.95 (0.21) 4.00 (0.23) <.001 I think technology is useful in my life 3.90 (0.17) 3.94 (0.19) .44 I think technology is enjoyable 3.48 (0.21) 4.00 (0.21) .04 I think technology can help me be more active 3.38 (0.23) 3.78 (0.22) .05 I think technology can improve my postural balance 3.76 (0.17) 4.22 (0.19) .03 Based on a 5-point Likert scale (5=strongly agree, 1=strongly disagree). items on the questionnaire relating to physical activity after the Exergame Enjoyment intervention. After the intervention, participants indicated that The postintervention PACES-8 enjoyment questionnaire focused they thought that technology was able to assist in maintaining solely on the chosen exergame used throughout the intervention. physical activity levels. There was an increase in the perception Participant mean results identified that all the questions received that technology was useful to improve physical activity, but this a score of 6 or higher. From the PACES-8 questionnaire, an difference did not meet statistical significance (P=.05). overall score of 56 signifies the maximal score that can be Specifically, with respect to postural balance, the usefulness of achieved per individual. The mean pooled response from this form of exercise was perceived to increase. The use of participants was 53.0 (SE 0.7). technology to enhance physical activity in older adults is receiving attention in current literature as a motivator for Game Scores improving physical activity, especially to meet the needs of that Game scores increased from week 1 (mean 892, SE 65) to week part of the population. 5 (mean 1579, SE 112). Researchers observed that participants There was a strong response that indicated maintaining health endeavored to increase their scores over the time of the study. was a key reason to exercise. One participant stated they felt that “exercise is a part of life,” with the other 7 people in that Discussion group affirming that concept. Another participant in a different The primary aim of this study was to determine the perceptions group described exercise in their life as “habitual”. Although it of older adults to technology for health before and after was identified that the focus group participants used some form participating in an exergame intervention. This group initially of technology on a daily basis, there was only limited exposure indicated commitment to nontechnology-based physical activity; to any form of exergame activity. The literature suggests that however, a significant change in attitude was seen after the older adults are more willing to use technologies that they intervention with improvements in understanding about the perceive as meeting a current need in a more convenient way health and activity benefits of using technology in the form of than other options [12,14,33-36]. Before the intervention, exergames. High levels of enjoyment and perceived personal participants did not view the exergame as meeting their need benefit were also identified. This study adds to the evidence for regular exercise. However, this perception changed after supporting the use of exergames as enjoyable and engaging their participation in the program. methods for older adults to improve participation in physical Technology, Enjoyment, and Engagement activity. The high levels of enjoyment recorded by the participants augur Pragmatism to Participation well for the future of this form of technology to improve The responses from the focus group identified strong emerging physical outcomes using this modality. themes associated with attitudes toward the use of technology Enjoyment has been identified as an important implementation for pragmatic purposes and the participants’ attitudes about factor in physical activity programs [37]. As well, the literature life-long commitment toward physical activity. Although there suggests that older adults who find enjoyment in physical are positive health outcomes associated with digital video activities tend to perform them for longer periods of time [19]. gaming for older adults, our participants were not aware of this Overall enjoyment and levels of satisfaction have been shown before the intervention [31]. When initially questioned regarding to be better predictors of physical activity participation and their perceptions about technology and games, all participants adherence than any other factors [38,39]. immediately responded with the idea that these involved limiting physical activity. The impact of sedentary behaviors associated Indication of engagement with this form of exercise is supported with screen-based technology use is a concern across the life by high voluntary participation rates throughout our study. span [32]. Researchers noted that participants strategically challenged themselves to gain a higher overall score and continued to Technology and Activity engage in the exergame over the period of the intervention. The Before the intervention, there was a lack of familiarity in these researchers also identified that scores needed to be monitored older adults with the concept of utilizing technology as a form and recorded for each participant to further challenge the of exercise. There were positive changes to responses on both participants and retain and reinforce enjoyment levels. http://games.jmir.org/2015/2/e8/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e8 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Bird et al The social context of this study design (ie, being part of a group active (ie, attending Pilates classes regularly). This limits the and having the ability to compare scores with others) contributed generalizability of these results and precludes application to to the engagement of this group in the intervention. Future sectors of the community that are more sedentary and perhaps research needs to identify the types of people who would engage a better target for interventions such as these. Future research with this technology in their own home, without face-to-face should endeavor to use higher best practice dosage to improve social contact, if we want to use exergames as part of a postural balance. Because of the short intervention period, it is widespread intervention to overcome many barriers to physical important to note that adherence and enjoyment levels may have activity that older adults have in leaving their home. Technology changed after the 5-week period. that links virtual groups may overcome the potential barrier of Conclusion social isolation and may be of benefit for both improving Exposure to and participation in a balance-focused exergame physical activity within a virtual social network for those people resulted in older adults dramatically increasing their perception unable to mobilize easily outside the home. In the future, of the usefulness of technology for improving several health home-based preventive health care using technology may be outcomes, including physical activity levels and postural leveraged off current research exploring in-home rehabilitation balance. High rates of enjoyment and adherence to this program using motion capture software and technology [40]. were reported. Technology, in the form of enjoyable exergames, A limitation of this study was the selection and use of a may be useful for improving participation in physical activity convenience sample of participants who were currently physical that is relevant for the needs of older adults. Acknowledgments The authors would like to thank the participants of the University of Tasmania Pilates program and the University of Tasmania Clinical Exercise Physiology Lab for allowing the research to be conducted in their clinic. Conflicts of Interest None declared. Multimedia Appendix 1 (A) Screenshot of intervention for training postural balance. (B) Using the game for training postural balance. [PDF File (Adobe PDF File), 397KB-Multimedia Appendix 1] References 1. Australian Institute of Health and Welfare. 2008. Australia's health 2008 URL: http://www.aihw.gov.au/publication-detail/ ?id=6442468102 [accessed 2015-11-16] [WebCite Cache ID 6d4Zquvyw] 2. Dacey M, Baltzell A, Zaichkowsky L. 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Movement-based interaction applied to physical rehabilitation therapies. J Med Internet Res 2014;16(12):e281 [FREE Full text] [doi: 10.2196/jmir.3154] [Medline: 25491148] Abbreviations PACES: Physical Activity Enjoyment Scale TEA: Technology Engaging Activity Edited by G Eysenbach; submitted 22.01.15; peer-reviewed by YY Chao, E Lyons; comments to author 21.05.15; revised version received 31.07.15; accepted 15.10.15; published 27.11.15 Please cite as: Bird ML, Clark B, Millar J, Whetton S, Smith S Exposure to “Exergames” Increases Older Adults’ Perception of the Usefulness of Technology for Improving Health and Physical Activity: A Pilot Study JMIR Serious Games 2015;3(2):e8 URL: http://games.jmir.org/2015/2/e8/ doi: 10.2196/games.4275 PMID: 26614263 ©Marie-Louise Bird, Brodie Clark, Johanna Millar, Sue Whetton, Stuart Smith. Originally published in JMIR Serious Games (http://games.jmir.org), 27.11.2015. This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on http://games.jmir.org, as well as this copyright and license information must be included. http://games.jmir.org/2015/2/e8/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e8 | p. 8 (page number not for citation purposes) XSL FO RenderX

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JMIR Serious Games – JMIR Publications

Published: Nov 27, 2015

Keywords: health care reform; postural balance; pleasure; exercise; perception

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