All interviews were approximately 30 minutes in duration. Baseline participant demographics is presented in Table 1. Participants were aged 65 to 79 years (mean ± SD age 70.3 ± 4.3 years). Sixty per cent (9/15) of the participants were women, 53% (8/15) reported that both their parents were born in Australia and the same proportion (53%) had been educated at university level or similar, while two-thirds (10/15) were retired. Fifty-three percent (8/15) of participants reported having hypercholesteraemia, 47% (7/15) hypertension, and 40% (6/15) diabetes and osteoarthritis. All participants reported the presence of at least one chronic disease. No participant declined to participate in the semi-structured interviews.
Figure 1 depicts enablers and barriers of using Alexa for the delivery of a home-based pragmatic exercise program.
Theme 1: Enablers of interacting with the Alexa to participate in the exercise intervention
Generally, participants reported several enablers to a home-based exercise program delivered and monitored by an Alexa supporting conversation-based interactions.
Voice interaction
Participants reported that using voice interactions to engage in the exercise program was user friendly.
“I particularly like the voice thing if you can just say it without having to go and sort of manually touch the screen, yeah. That’s good, yeah.” (Participant 14, male, age74)
“ Yeah no, it’s good. You don’t have to touch it.” (Participant 9, female, age 65)
“A phone would probably do something similar…, but I mean it’s still you have to then go and dive into the app and all that sort of stuff, I guess.” (Participant 14, male, age 74)
“Oh yes, I didn’t need to be close to it to do the exercises. I could do it from a distance and it responded to my answers.” (Participant 8, female, age 67)
Alexa device design
Participants identified that aspects of the Alexa device’s design made it convenient to access the program.
“Anyway, it can stay where it is, you know what I mean? I don’t have to transport it around the house and the volume is important that you can adjust the volume. It is kind of like a more-or-less permanent fixture in the house. So that was good- it was inobtrusive and small enough but usable enough if you know what I mean.” (Participant 3, female, age 67)
“The positive is it’s there, you can use it as many times as you want, it’s handy, it’s close by.” (Participant 1, male, age 70)
“Yeah. I went away to Byron Bay and I only took carry on. I squashed it in there, so it was all right.” (Participant 14, male, age 74)
Ease of use and enjoyability
Participants also found Alexa and Buddy Link enjoyable and simple to use:
“It’s easy to use. There is a lot of exercises. You can skip what you don’t want. You do what you want and what you need. Those are all pluses.” (Participant 1, male, age 70)
“I enjoyed using it. I found Alexa (and the Buddy Link software program) very easy to use.” (Participant 7, female, age 67)
Motivation to participate in the exercise program
The conversation-based functionality of the Alexa device provided motivation to participate in the exercise program.
“(An exercise program is difficult) to do... because sometimes you get lazy and you don’t really want to do things. But if you’re getting directions and instructions (from the Alexa) along the way, you’re doing it without an effort because it’s gentle.” (Participant 9, female, age 67)
“No. I think the thought behind it is good and I can only speak personally for myself that it made me more interested and motivated to do (the exercise program). Because if you’re by yourself all the time and you're not mixing with other people, or in a group situation, and I used to go to group exercises, to keep yourself motivated to do exercises several times a day when you get to the age range that I'm in” (Participant 5, female, age 79)
“I did the exercise because she (Alexa) always asks me (do you) want to do it again? So, I did it again, but all the other times when I said I’ll do it again it’s because I was not happy with myself and I wanted to improve it. It’s a really thought through program” (Participant 3, female, age 67)
Social engagement with Alexa
Some participants reported a level of social “human” engagement with the Alexa that supported conversation-based interactions.
“I would use that device. …I really like this because she’s always asking.., “Are you ready?” So, you always have to give a response. You can’t just say oh well, I’d like to quickly go and get the bin out or what. You just can’t.” (Participant 3, female, age 67)
“(I enjoyed) that someone was talking to me when you live on your own.” (Participant 8, female, age 67)
Using the Alexa provided a feasible means of engaging with an asynchronous telehealth platform for participants with visual issues.
“Yes, that’s convenient. Especially now that I’ve had the cataract operated on, it’s quite hard for me to read small print so I’ve got to find glasses which are never far away.” (Participant 15, female, age 74)
Screen and voice compatible reminders
The reminder functionality of the Alexa device delivered using screen and conversation-based interactions provided motivation to participate in the exercise program.
“The advantage of having it there, knowing that it was going to remind me to do my exercises was a good thing, because I do have a physio app on my phone, but I have to actually go onto it to use it, where this actually would be reminding me. I feel very guilty if I didn’t do it.” (Participant 9, female, age 65)
“I thought it was a great way to be reminded and would definitely influence me to exercise more. So I thought it was a very good thing from that point of view.” (Participant 7, female, age 67)
“Yeah, I found that it actually made you commit to doing it. Because it would give you reminders, you kind of felt obligated to complete it, you wouldn't just be going …Oh, I'm too busy,…or "I can't be bothered….So I found that was really good. It sort of made you commit to it.” (Participant 2, female, age 66)
Theme 2: Barriers to interacting with the Alexa to participate in the exercise intervention
Technical issues
Some participants reported technical issues, such as poor internet connectivity and accuracy of voice recognition, as barriers to participating in an exercise program delivered by Alexa
“The voice interaction is very problematic. It does not understand a clearly enunciated yes or no, and I think there’s a reason for that. But you’ll see lots and lots of examples where it just refuses to understand a simple yes or no, or any other command, and given that it’s voice-driven that’s a critical failure.” (Participant 6, male, age 77)
“No, the main negative was it may be my (Internet WiFI) connectivity here, I notice on Saturdays it always goes bad for the last three or four weeks, when people have been escaping from Melbourne and bringing their devices down, swamping the bandwidth. Last Saturday it took one session when I waited for it, a good three quarters of an hour. So the “exercise program” doesn't work when your connectivity is not good.” (Participant 11, male, age 71)
Preferences for other existing telehealth modes of exercise delivery
Some participants expressed a preference for their exercise program to be delivered and monitored by other existing telehealth models (such as tablets and smartphones).
“Yeah. I think I might’ve mentioned that such a program could probably be implemented just as easily and alternatively as a web-based solution, which would just avoid all the annoyance of the voice-based program.” (Participant 6, male, age 77)
I've got my old phone, my present phone, an old tablet, on a really old tablet as well, and plus my laptop. I think it's a much better idea to put it onto the web, honestly.
(Participant 11, male, age 71)
Lack of real-time objective feedback in an asynchronous digital health approach
Participants reported the lack of instant feedback and reassurance regarding correct exercise technique that was not provided by the asynchronous Alexa program
“You don’t get feedback, so for somebody who’s not maybe that good at doing their exercises, I don’t know how you would be able to but it would be great if they would get a bit of a feedback on it, whether there’s a physical way you could get somebody to do the exercise on a certain spot and put the camera on a certain spot and then it would be able to measure – or what, I don’t know. Maybe a future version.” (Participant 9, female, age 65)
“Yeah, even if it was saying ‘Too fast. Too fast,’ because that’s what I tend to do, everything too fast. Or you know, it might say ‘Just one more,’ you know, that sort of thing. Yeah, I think that sort of feedback would make it even more engaging for people” (Participant 9, female, age 65)
“I used to do some of these exercises with the exercise physiologist, I know how you’re meant to do them. But for some people, they probably need a little bit more guidance on some of the exercises. Like I know you do say ‘hold your bum in’ or whatever, but some of them it’s quite important that they do it correctly. So it’s tricky because the first time they do it they need the full instruction and then after that you’re just say reminding them what the exercise is, so.” (Participant 9, female, age 65)
Inadequate attention to patient goals in an asynchronous digital health approach
Participants reported a desire for exercise programs to include information on the purpose of exercise, and to explore and address patient goals, that was not met by the Alexa program:
“No, it’s always good to have a real human being to deal with. But as a substitute, I think it’s quite good. The other thing was I did get bored. You brought in some more exercises to give some variety and I suggested explaining why we were doing these. I’m guessing that the balance is good for someone my age because falls can be a problem as you get overzealous, sort of thing. But the explanation of the value of what we were doing would be good, the physical value.” (Participant 15, female, age 74)
“It’s like when I went to the gym, and I have an instructor there, and he said, “Why do you want to be here? What exercises you want to do? Do you want to lose weight? Or you want to just have more agility? Or you want to have fun or whatever it is.” So it can be – then he went and selected five different programs and showed me how to do it. And then every second day I go myself and I do them myself. Some for the leg and the calf, others for the ankles, others for whatever.” (Participant 1, male, age 70)
Privacy concerns
Participants often chose to turn off the Alexa device between exercise sessions due to privacy concerns.
“Well I had the camera turned off, so I’m not sure – and because I live alone, there’s not too many conversations going on around a machine, but if you had a private conversation you probably wouldn’t have it in front of Alexa. But I don’t know. If you haven’t turned her on I don’t know if there’s any recording happening anyway. I don’t know. I don’t know of that privacy.” (Participant 12, female age 68)
“I have turned off the camera except talking to you now. Yes, I suppose with the camera on I would have issues with that, in general, not from Deakin University, but just from Amazon up there in the Cloud, and who else is on it and so on.” (Participant 15, female, age 74)
“ It did concern me, because you don’t want to think that you’re being listened to all the time and watched all the time, however it was alright once I found where to turn off the camera.” (Participant 7, female, age 67)
“Well, I’m a little bit - I mean in terms of the exercise and stuff not really, but if I had to - like, if it was a different kind of program where it’s involving a lot of private things like medical stuff or opinions about things or whatever I might, yeah, think twice about that because the stuff that it’s Alexa or a Google Home thing where they do - you don’t know where your information is and all that sort of thing. Yeah, I mean I’m a bit, not suspicious, but I’m wary of the devices just generally, but in terms of just data for the exercise it’s not an issue for me. It’s only if it’s asking personal information.” (Participant 13, female, age 66)
“Well, I wouldn’t leave it on in between sessions and I wouldn't leave the video on at all.” “It's sort of really amazing when you just have a passing comment to someone during the day, your phone picks it up and then there's an ad about it two hours later.” (Participant 11, male, age 71)