Based on the experiences and statements of the Silvia Program users, this exploratory qualitative study yielded findings related to the two research questions that were focused on the benefits and challenges experienced by ALF residents. Two core topics, five main themes and fourteen associated subthemes have been identified that are related to cognitive benefits, positive psychological experiences, health-related behavior management, and challenges associated with the Silvia Program use such as technology usability and content issues (See Table 1). Our findings suggest that the Silvia program can serve as a technology tool to improve the cognitive and psychological health and health management skills of ALF residents. The few challenges identified suggest further avenues of investigation for researchers in refining this approach.
Health Benefits
Cognitive Health. Improving cognitive function
was identified as the most salient theme from the data. All participants identified several cognitive functions that they believed had improved including calculation, attention, and memory. In addition, cognitive training included activities for memory, visuo-spatial abilities, language, executive function, and attention and each activity provided participants with scores that enabled them to monitor their progress and encourage their participation. It appears that cognitive training can be instrumental in improving these cognitive domains by improving mathematical abilities and memory retention and strengthening critical thinking and attention skills. While some cognitive activities were found to be challenging for participants due to different degrees of difficulties in tasks, they mentioned that they adapted to the features, usage, and rules, and as a result improved their concentration and attention skills.
Most participants experienced improvements in mathematical skills and recall of contents after engaging in cognitive exercises. Though they mentioned that they occasionally felt frustrated by challenging mathematical questions, they reported being determined to solve the questions to achieve higher scores on each activity. By engaging in different types of cognitive exercises, participants were actively involved with cognitive activities and felt that they improved their scores on algebraic calculations by improving their mathematical skills. For example, Lily said,
I like the Farmers Market game. That really makes your brain think because you need to calculate how much all those things are together. I haven’t done math for a while, and I hate math, but in this game, I really enjoyed it. I think I like challenging myself with it, because it’s a fun way to practice my math skills.
She also indicated that she improved her scores on the Farmers Market game and was able to proceed to levels of higher difficulty.
Similarly, Mary shared how she used her mathematical skills to engage in cognitive activities. Among various cognitive activities, she stated that calculating the numbers through the activity was helpful to her cognitive function. Also, she stated,
The second one I liked was the one where the vegetables were priced, and you had to add the prices. And if you wanted eggs and yeah.
Participants believed that they enhanced attention and concentration on various activities. Especially, they identified some activities such as animal features in the 'Friends in the Woods' and “Finding Poppy” activities as a tool in enhancing attention and concentration because of different levels of difficulties in activities. They used similar expressions such as ‘I was fully focused on this activity’ ‘I was able to fully concentrate on them’ and ‘I enjoyed focusing and completing these activities. According to Amy,
When I engaged in this activity, I concentrated solely on the task at hand. Engaging in activities such as solving puzzles and searching for puppies and kittens brought me a sense of pleasure.
John who enjoyed animal-based activities stated,
You should stay pretty fast because sometimes they just make those land there quick, and they'll you got to watch them because they'll sometimes do four and five at a time. Same thing. So, you got to just kind of keep getting that squirrel.
These statements indicate that participants concentrated on their activities well and enhanced their attentive skills.
Several participants reported that their memory was enhanced through Silvia Program participation. They indicated that various cognitive activities stimulated their brain to memorize numbers, colors, figures, objects, and language. As previously noted, participants embraced the challenges necessary to complete tasks related to memory, which resulted in memory enhancement. Paul who enjoyed color matching activities said,
I struggled with selecting the correct colors, but I found that trying to recall the sequence and keep track of the colors was challenging and very fun. I believe it helped me improve my memory, and it's a positive and enjoyable challenge.
Amy shared similar experiences by stating that the programs helped her refresh her mathematical skills and improve her memory. She also mentioned that practicing adding and subtracting numbers, matching colors, and recalling letters helped improve her memory.
Several participants shared their memories with their family members and pets through cognitive activities that were designed with animals, nature, and locations. By engaging in cognitive activities, they shared their life stories by recalling personal events and thus contributed to strengthening their memory.
Overall, these examples and statements provide qualitative evidence that participants benefited by engaging in the cognitive training activities of the Silvia Program such as calculation, attention, and memory. This finding suggests that the Silvia Program can be beneficial for cognitive health of users.
Psychological Wellbeing. Most participants shared that they experienced mental relaxation and a sense of enjoyment and accomplishment while they participated in the Silvia Program. When they participated in the home-based exercise, relaxation/mindfulness, and cognitive training programs, they immersed themselves in each activity/program and felt relaxed and comfortable. They mentioned that these programs enabled them to experience a sense of happiness and enjoyment because there were fun, challenging components of each activity/program. For example, John stated,
I found it (the activity) relaxing. I am always searching or looking for information, so to sit down and play games was very relaxing.
Lily also mentioned that she felt excited when she played some star or animal-based cognitive exercises and followed some instructions for home-based exercise programs. She felt physically and mentally stronger after doing these activities. In a similar manner, Susan stated,
But just about all of those games were fascinating. I really enjoyed those. They were all good mentally and really exciting. I had a really great time.
Some participants shared personally meaningful stories related to their participation in specific activities within the program such as memories of spending time with family members and beloved pets from the past. They mentioned that these program activities undeniably had a profound and positive impact on their psychological wellbeing. Frank, who enjoyed playing with animals mentioned that he felt a sense of enjoyment and connection with his past with some activities. Also, according to Ashley,
That (Finding My Puppy) was my favorite activity of all the games… a dog like mine. Unfortunately, mine was gone, but those dogs are like my dog.
She shared that she cherished her memory with her pet through this activity and mentioned that she enjoyed playing this activity.
Paul also stated,
I like the games, and I liked putting in our meals and all that kind of stuff too. That made me relive today, it was like a blast from the past because I felt like I was back in my childhood, enjoying simple pleasures and spending time with loved ones.
A few participants mentioned that they experienced a sense of accomplishment by improving their scores on cognitive activities and participating in exercise programs and mindfulness. While they encountered some challenges, they developed the perseverance necessary to persist in various programs that led to a sense of achievement and accomplishment. Thus, based on these examples and statements, participants experienced enhanced psychological wellbeing that resulted in an enhanced sense of enjoyment, accomplishment, and feelings of relaxation and reward.
Health-related Behavior Management. Most participants indicated that the lifestyle management aspect of the Silvia Program helped them pursue a much healthier lifestyle. They identified their daily routines, sleep patterns, dietary habits and nutritional information as the main benefits of the lifestyle management program that contributed to a heightened awareness of their overall health management. By tracking this information and monitoring their lifestyle related behaviors, they reported that they modified their behaviors when needed. They shared that these changes not only enhanced their perception of managing health behaviors but also empowered them to monitor and regulate these behaviors. For example, Tina stated that monitoring her life routines helped her to make better choices for food and exercise and prioritized her health. Similarly, Tiffany stated,
It is good that the app encourages us to think about what we eat and the importance of getting enough protein. And it's not just about eating; it also tracks our sleeping habits.
She also indicated that she was determined to pursue a healthier lifestyle in terms of eating and sleeping.
Several participants also modified their sleep patterns based on data from the Silvia Program sleep tracking system. According to Mary, she maintained and improved her sleep pattern and quality by monitoring her sleep and mentioned that she decided to restrict the use of her own electronic devices to promote better sleep. Also, Mary said,
At first, I didn't think it would make a difference, whether I slept for a certain number of hours or ate a specific way. But now I understand the importance of finding a balance in life.
These examples indicate that the lifestyle management programs offered by the Silvia Program helped participants to make a better choice for their health and pursue a healthier lifestyle.
Challenges
In addition to the positive outcomes of the use of the Silvia Program, participants identified two main challenges: (1) technology anxiety and challenging content. The identification of these challenges can provide practical suggestions for efficacy investigations that involve the technology developer.
One primary challenge that most participants experienced in the first two weeks was technological anxiety caused by unfamiliarity with mobile technologies. Although it took a short time to adjust to and understand how to use the Silvia Program on a tablet device, participants expressed concerns and apprehensions related to technology use, and several participants mentioned that technology anxiety impeded their ability to fully engage with each program in the early stages of their participation. For instance, Velvet stated,
Initially, I was uncertain and apprehensive as I had no prior experience with this type of thing and was concerned about making mistakes or breaking it.
Some participants experienced frustration when they experienced technical glitches (screen frozen), especially in the middle of engaging in activities. Tina indicated that he lost interest in redoing the activities when the program stopped unexpectedly. Tiffany also mentioned that she was frustrated and uneasy when she was not able to continue doing the activities due to technical errors. She said,
I've been frustrated when it didn't work properly, it continuously stopped in the middle of the game. For example, I just did the rainbow melody, and it didn't work, I was worried if I had done something wrong.
While most participants found the programs enjoyable, it is worth noting that some individuals exhibited a reluctance to engage in some activities because of the complexity of the instructions and repetitive program contents. They mentioned that found some activities less than challenging and some instructions too complex (home-based exercises). For example, Frank shared that some activities within the program were so fast paced that at times he was overwhelmed, reporting, “Sometimes I can't read the instructions because it goes too fast.”
Also, John mentioned,
“Because you had to look at the animals. You saw what's coming down. Then you had to change the animal, and sometimes there were three animals, and sometimes there were four, and if I, if you go too fast.
Participants frequently expressed that they became easily bored when they encountered monotonous or overly simplistic activities that failed to challenge and engage them for a sustained period. Additionally, when they perceived limited improvement in their performance over time, they were more prone to lose interest. Consequently, the provision of tangible and meaningful results at the conclusion of each activity emerged as a critical factor in sustaining participant motivation and engagement with these activities.