The aim of this study was to assess to which extent a customised Kinect system is 1) a credible tool to increase PA in aged persons, 2) motivating to perform PA by aged persons, and 3) easy to be used in aged persons.
In general, participants liked using the i-ACT system, as stated by the participants themselves during exercises. The positive perceived experience that the aged persons had during and after use of the i-ACT systems, as supported by the quotes, is also visual in the results of the questionnaires. From the results of the CEQ, it can be concluded that the participants have moderate belief that they will improve in PA by exercising with i-ACT, but also that they highly belief that exercising with i-ACT can support them in performing PA. It is assumed that credibility is more connected with the logical thought processes of patients while expectancy is more related to the affective processes (36). Therefore, from the results of credibility and expectancy towards use of i-ACT, we can assume that aged persons are convinced that i-ACT is a system that can help them to perform PA, but that they still need more convincing that i-ACT can improve their physical functioning and thus help them to age successful. This latter can be done by providing older adults with more information (36) about the i-ACT, why PA is important and increase the length of the use of i-ACT. When providing people with more information, more knowledge about the i-ACT, people will increase their use and thus their experience with i-ACT (39). Furthermore, by providing more information about the i-ACT, aged persons might become more at ease with using i-ACT. As seen in the results of the IMI, the results on the subscale “felt pressure/tension”, were the lowest (i.e. 3.40/7.00). While this is low, we can still consider this a good outcome as this score indicates that the aged persons felt some level of pressure or tension while performing exercises, but the pressure was not so high that it withheld them from performing the exercises. The same range of results were shown in the pilot study of i-ACT when used in neurorehabilitation (27). Participants in both studies declared to feel a sort of pressure to perform good on the exercises, i.e. they wanted to hit the targets as best as possible, without compensational movements (27). Together with the other results on the IMI, it can be suggested that both groups, aged persons and persons with central nervous system diseases, are motivated by the i-ACT system to perform good to very good on the exercises provided. Another possible explanation why aged persons felt some pressure or tension, might be the fact that aged persons have less experience with technology, computers, etc. which can make them anxious, and thus need more information beforehand:
I’m not used to working with computers, so I was a bit tensed and anxious to use it beforehand. Luckily the nice girl (i.e. student occupational therapy) comforted me and told me she would stay with me to explain everything.
(Participant from day care facility).
As for the feasibility and usefulness of i-ACT as a tool for successful aging, we can assume that i-ACT is feasible and useful, based on the results from the mixed-method study. The statements of the users where generally positive, such as “I tried it, and I was actually happy that I could do it, you know, make those balloons explode and stuff”, “I liked it. Maybe not in the beginning because you don’t know what to do. But when you told me to hit those balls, I was on a roll!”, “I never saw X (person’s name) engaged so much in an activity”, “You see that people get more involved the longer they play with it”, etc. These statements are supported by the results of the SUS (mdn 72.50 (67.50–85.00)), which suggests that the usability of i-ACT is good. According to Chen et al (2017), who used the Technology Acceptance Model (TAM), perceived usefulness is a valid and reliable predictor of technology use, intentions and attitudes towards working with technology (40). Furthermore, these results correspond with the findings of the review of Webster and Celik (2014). They found that the Kinect is a promising technology to use in aged care (17). The first reason is because the Kinect provides the most natural form of human-computer interaction. Secondly, the Kinect is the most feasible technology for a widely dispersed system of elderly exergaming. It uses a vision-based data capture and therefore does not require extraneous hardware (17). These reasons are in correspondence with the feedback of aged persons received during the tests.
“Hey, that guy is doing what I’m doing. How’s that possible? I’m not connected with the tv or anything”. After explaining that there is a camera in front of him, the person stated, “how funny. How amazing is technology nowadays. Almost scary! …. So the camera sees me, but he doesn’t really see me because I’m not the person on the screen?” (Participant from day care facility).
The last reason mentioned by Webster et al (2014) is that the Kinect platform is easy to access by developers to create novel and high quality rehabilitation systems and exergames or serious games together with the freedom of controller-free data acquisition (17).
Although the scores were positive on the assessments (i.e. IMI, SUS and CEQ), these scores have to be interpreted with caution as some participants gave socially desirable answers. So the results might be an overestimation of the real thoughts of the participant. Working with persons’ perceptions can have this bias, it is human to try to give the socially desired answers instead of being completely honest. And although these socially desired answers might be given by the participants, the therapists and researchers who attended the participant during the exercises, saw involvement of participants, they observed happiness, competition within the participant themselves to reach the targets, etc.
Participants liked using the i-ACT but also suggested some adaptations, such as creating a more attractive context by adding more visualisations of targets or the context of the movement, but still keep it simple. They would have like a more game-like environment such as catching flying birds out of the sky, taking a cup out of the cupboard or even kick against a football. This is in accordance with other systems that work with exergames or serious games in older adults with physical limitations (15, 17–19, 41, 42). The most research in this area is done in persons with Parkinson’s disease (19, 41, 42). In these researches it is suggested that persons with Parkinson’s disease are motivated to exercise with virtual reality applications, as well as some positive benefits like increased gait strategies (19, 41). Also, a multiplayer option should be present. The participants wanted to play against other people, sort of like a competition. It has already been proven that a multiplayer feature motivates people more (43). Furthermore, in other research it is also suggested to combine a virtual environment with auditory and visual cues to increase exercise intensity and consequently promote fitness in older adults (42). Although these are good suggestions and they will be considered when developing the i-ACT further with the focus towards aged persons, the first focus of i-ACT is still to work as client-centred as possible, as this will also positively influence the motivation of users (43). Therefore a good combination of working as client-centred as possible, but with more game-like features and implementation of auditory cues, should be taken into account during the following steps in the development of i-ACT for use in aged care.
As stated above, i-ACT is developed to be able to provide a client-centred exercise program to users (26). The advantages of a client-centred approach are discussed in several clinical fields, e.g. rehabilitation in spinal cord injury (21, 22, 28, 29, 44–46). One of the most important outcomes is that persons with disabilities are more motivated to exercise (21, 22, 28, 29, 44–46). Although a full client-centred approach is, to the authors’ knowledge, not yet investigated in aged persons, Vanroy et al (2019) indicated that aged persons can be motivated to exercise when the needs for autonomy, competence and relatedness are satisfied (25). These needs can be addressed by using the client-centred approach. In this study, however, various exercises were implemented considering the possibilities of the participants. So no goals were set up beforehand or even assessed after using i-ACT. In future research, this should preferably be implemented in the process. To discover a person’s own goals, one can use many assessments. In another study of i-ACT, the Canadian Occupational Performance Model (COPM) is used (7, 24, 27, 47). This tool is developed to set occupational performance goals, based on a person’s perception. It can also be used to measure progress objectively concerning the performance goals defined by the person. Even in aged persons it is important to define certain goals (24, 48), especially to stimulate physical activity and focus on regaining and/or maintaining engagement in ADLs that the person finds meaningful and purposeful, even at an older age (3, 7, 49).
After the full trial, the supervisors (i.e. occupational therapists and students) reported that they think/feel that i-ACT could be better implemented in day care centres and not so much in nursing homes. The main reason is that people who go to day care facilities have better cognitive and physical functions than people in nursing homes. Furthermore, the sooner people maintain or initiate moderate to vigorous PA, the more likely they will age successfully, and the better quality of life these people will have when aging (1, 3, 5, 6, 8, 10, 13). Therefore, there should not only be general guidelines for the general population as generated by the WHO, but also general guidelines for nursing homes and day care facilities regarding the minimum amount of PA training per day or week. Although the benefits of PA in aged persons have already been well documented (3, 13), using technology while exercising has the benefits of gathering quantitative data related to physical progress, amount of PA, etc. This is also implemented in i-ACT as not only the time of the execution is stored, but also the amount of targets reached, and the amount of compensational movements (26). Although the latter might not be the primary goal in aged care, the other features are also important for future purposes when the system might be used at home in aged persons, i.e. caregivers, doctors, or other supervisors can see whether, how much and how well the aged person is performing PA. Furthermore, a Kinect-based system has the advantages of being low-cost, easy to use and controller-free exercises (17, 26, 39, 43). These advantages are also beneficial when i-ACT is introduced as a PA tool in the home environment of aged persons. The physical risks are limited as users are not connected to wires or have to handle a controller. Also, i-ACT is easy to use by the person who performs the exercises, i.e. they have to follow the example avatar in his movements and have to copy them (26).
Methodological considerations also have to be made. This is a feasibility study so only descriptive statistics are performed. Therefore no conclusions can be made to the general aged population. Findings have to be handled with the upmost care and seen in the light of a feasibility study as a first step to perform a higher level of clinical study.
Limitations of this study is also the sample size and the distribution of the gender. The study sample might be enough for a feasibility study, however, to make vast conclusions towards the general population, a larger sample is necessary and more characteristics of the participants should be gathered, such as education level, level of motor functioning, level of cognitive functioning, experience with technology, etc. Fanning et al. (2016) suggested that people who have at least a college education level, are more likely to provide information and participate in research (5). Furthermore, the majority of the sample was female and all of them were Caucasian. Although women outnumber men in aged population, they are also more likely to engage in health-related endeavours (5). Another limitation is that the i-ACT was mostly used in a one-on-one situation and in a separate (part of the) room. Therefore, we cannot formulate the influence of social interaction. In other settings, where the i-ACT is more integrated in the rehabilitation environment, people are getting interested in the i-ACT by seeing it used by peers and interact with the participants and/or supervisors.
The aim of this study was to assess to which extent the i-ACT could provide a positive contribution towards PA in elderly. The next step would be to adapt the i-ACT towards the wishes and needs of aged persons. For example, a more attractive context or background, implementing some game features so it will become a exergame (e.g. birds as targets), and looking into the possibility of a multiplayer. Also it would be important to evaluate the use of a client-centred approach in aged persons in different settings, i.e. home, day care facility, and nursing home facility. The suggested method for this would be to use a user-centred approach in which the aged persons are involved, but also their caretakers and care professionals. Regarding the PA protocol, there is no evidence of the most optimal amount of exercises, time and/or intensity. But the guidelines of the WHO are clear and feasible in both care facilities and home environment (9). The guidelines suggest 1) at least 150 minutes of moderate-intensity aerobic PA or 75 minutes of vigorous-intensity aerobic PA throughout the week, 2) aerobic activity in bouts of at least 10 minutes, and 3) muscle-strengthening activities involving all the major muscle groups at least two days a week (9). So considering these guidelines, a PA protocol should combine aerobic exercises with muscle-strengthening activities, preferably for at least 30 minutes per day during at least five days per week, preferably in the morning (25). The PA program should take into account the general training parameters such as gradual increase in duration, frequency and intensity over time. Also, the program should continue indefinitely, as aged persons do not continue their PA program after supervision ends (11, 19). The i-ACT system could be a relatively easy solution to stimulate and maintain PA in aged persons in different settings (i.e. home, day care and nursing homes). The PA exercises should be individually set according to the person’s needs and wishes, and by taking into account their preferred occupation/activity in daily life. Regarding outcomes, there should be assessments related to the physical abilities of persons and general health status, and an assessment concerning quality of life and/or life satisfaction.