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Perceived Smart Technology Needs Among Elders with Mobility Impairments

Permanent Link: http://ufdc.ufl.edu/UFE0021599/00001

Material Information

Title: Perceived Smart Technology Needs Among Elders with Mobility Impairments An Ethnographic Approach
Physical Description: 1 online resource (181 p.)
Language: english
Creator: Davenport, Rick D
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2007

Subjects

Subjects / Keywords: activity, ad, adl, aging, assistance, assistive, at, automation, baby, boomer, computer, consumer, decision, designers, development, device, elder, engineering, ethnography, health, home, iadl, icf, impairment, independence, interview, mobility, model, monitoring, need, observation, personal, prediction, prompting, prototype, qualitative, recognition, rehabilitation, reminding, robotic, science, smart, technologies, technology, touchscreen, tree, usability, voice
Rehabilitation Science -- Dissertations, Academic -- UF
Genre: Rehabilitation Science thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: Comparatively little research has been conducted regarding the smart technology needs of the elder population despite the proliferation of smart technology prototypes. The purpose of this study was to explore the perceived smart technology needs of elders with mobility impairments while constructing a preliminary decision tree model of how these decisions are made. An ethnographic research approach, with a decision tree modeling component, was utilized to explore the complex variables surrounding the elder ST need decision process. In-depth individual interviews with 11 elders aged 65 and older with mobility impairments, and their in-home observations, provided insight into how elders perceived smart technology. Audio-taped interviews were transcribed verbatim and then analyzed for key phrases that represented participant decision criteria. Decision criteria concepts were combined to construct an elder smart technology decision tree model. The model identifies that elder participants must first determine if they are satisfied or not satisfied with their current activity performance level. If satisfied with their activity performance level then the elders do not critically consider the ST device. However, dissatisfaction with current activity level is no assurance that elder participants will desire ST to assist with their daily activity needs, due to the numerous other potential barrier criteria identified in the model (i.e., not practical, not easy to use/learn, not reliable, or whether it may add more problems). If any of the other barriers are a concern then elders will not desire the ST device. The model also identifies important facilitator criteria (i.e., decreasing imposition on family/friends, increasing sense of autonomy, assisting with difficult tasks, replacing existing technology in order to perform task safely, providing a safety net, and enhancing the monitoring of their health) that could motivate elders to adopt ST assistance. This decision model adds to the elder ST needs literature and potentially will help future designers create appropriately matched technological devices that will assist in the care of aging baby boomers with mobility impairments.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Rick D Davenport.
Thesis: Thesis (Ph.D.)--University of Florida, 2007.
Local: Adviser: Mann, William C.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2007
System ID: UFE0021599:00001

Permanent Link: http://ufdc.ufl.edu/UFE0021599/00001

Material Information

Title: Perceived Smart Technology Needs Among Elders with Mobility Impairments An Ethnographic Approach
Physical Description: 1 online resource (181 p.)
Language: english
Creator: Davenport, Rick D
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2007

Subjects

Subjects / Keywords: activity, ad, adl, aging, assistance, assistive, at, automation, baby, boomer, computer, consumer, decision, designers, development, device, elder, engineering, ethnography, health, home, iadl, icf, impairment, independence, interview, mobility, model, monitoring, need, observation, personal, prediction, prompting, prototype, qualitative, recognition, rehabilitation, reminding, robotic, science, smart, technologies, technology, touchscreen, tree, usability, voice
Rehabilitation Science -- Dissertations, Academic -- UF
Genre: Rehabilitation Science thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: Comparatively little research has been conducted regarding the smart technology needs of the elder population despite the proliferation of smart technology prototypes. The purpose of this study was to explore the perceived smart technology needs of elders with mobility impairments while constructing a preliminary decision tree model of how these decisions are made. An ethnographic research approach, with a decision tree modeling component, was utilized to explore the complex variables surrounding the elder ST need decision process. In-depth individual interviews with 11 elders aged 65 and older with mobility impairments, and their in-home observations, provided insight into how elders perceived smart technology. Audio-taped interviews were transcribed verbatim and then analyzed for key phrases that represented participant decision criteria. Decision criteria concepts were combined to construct an elder smart technology decision tree model. The model identifies that elder participants must first determine if they are satisfied or not satisfied with their current activity performance level. If satisfied with their activity performance level then the elders do not critically consider the ST device. However, dissatisfaction with current activity level is no assurance that elder participants will desire ST to assist with their daily activity needs, due to the numerous other potential barrier criteria identified in the model (i.e., not practical, not easy to use/learn, not reliable, or whether it may add more problems). If any of the other barriers are a concern then elders will not desire the ST device. The model also identifies important facilitator criteria (i.e., decreasing imposition on family/friends, increasing sense of autonomy, assisting with difficult tasks, replacing existing technology in order to perform task safely, providing a safety net, and enhancing the monitoring of their health) that could motivate elders to adopt ST assistance. This decision model adds to the elder ST needs literature and potentially will help future designers create appropriately matched technological devices that will assist in the care of aging baby boomers with mobility impairments.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Rick D Davenport.
Thesis: Thesis (Ph.D.)--University of Florida, 2007.
Local: Adviser: Mann, William C.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2007
System ID: UFE0021599:00001


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PERCEIVED SMART TECHNOLOGY NEEDS AMONG ELDERS WITH MOBILITY
IMPAIRMENTS: AN ETHNOGRAPHIC APPROACH





















By

RICK DEAN DAVENPORT


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA

2007

































O 2007 Rick Dean Davenport




























To my parents, brother, and all who nurtured my intellectual curiosity, academic interests, and
sense of scholarship making this milestone possible.









ACKNOWLEDGMENTS

I would like to first thank my parents, John and Misako Davenport; and my brother,

George Davenport for being there by my side, and understanding the sacrifices needed for me to

succeed with this milestone. Their support meant the world to me.

I would like to extend my sincere appreciation to my doctoral committee (Dr. William

Mann, Dr. Barbara Lutz, Dr. Linda Shaw, and Dr. Benj amin Lok) whose support, guidance, and

wise counsel kept me on track in my educational endeavors. I also would like to thank the

members of the faculty and staff of the College of Public Health and Health Professions at UF

for their individual insights and broadening of my perspective in academia.

I am also indebted to my RSD family of graduate students, Bhagwant, Jessica, Patricia,

Megan, Pey-Shan, Sande, Leigh, Jia-Hwa, Eric, Cristina, Sandy, Michelle, Inga, Roxanna,

Michael, Dennis, and Arlene who provided friendship, camaraderie, and encouragement for the

last 5 years. Finally, I would like to thank my SGI family who have provided cheerful

motivation, spiritual encouragement, and inspirational human revolution in my life.












TABLE OF CONTENTS


page


ACKNOWLEDGMENTS .............. ...............4.....


LIST OF TABLES ................. ...............8..___ .....


LIST OF FIGURES .............. ...............9.....


AB S TRAC T ............._. .......... ..............._ 1 1..


CHAPTER


1 INTRODUCTION ................. ...............13.......... ......


Introducti on ................. ...............13.................
Problem............... ...............13

Purpose .............. ..... ...............15.
Conceptual Framework............... ...............1
Sum m ary ................. ...............17.......... ......


2 REVIEW OF LITERATURE ................. ...............20.......... .....


Introducti on ................. ...............20.................

Assistive Technology............... ...............2
Smart Technology ................. ...............21.................
Smart Home Technology ................. .......... ...............23......
State of Smart Technology Development ................. ...............23........... ...
Prototype Smart Technology Development............... ..............2
Summary ................. ...............32.................


3 METHODOLOGY .............. ...............44....


Introducti on ................. ...............44.................

Research Approach ................. ............ ...............44.......
Rationale for Research Approach ................. ...............44................
Ethnographic Decision Tree Modeling .............. ...............45....
Ethnography and Technology Development ................. ...............46................
Advantages and Disadvantages of Ethnography ................. ...._._. ............... ....47
Role of Researcher............... ..............4

Sam ple ................ ... ... .... ...... ........4
Inclusion and Exclusion Criteria .............. ...............48....
Recruitment .............. ... ... ...............49
Data Collection Techniques Used .............. ...............49....
Intervi ewing ................. ...............49........... ....
Participant Observation .............. ...............50....
Use of Camera ................ ...............51........... ....












Field Notes ................. ...............51......_.. .....
Data Collection Protocol ......__................. ......._.. .........5
Data Analysis............... ...............53
Bias ...._.. ................ ......._.. .........53
Data Saturation ............... .............. ............5
Ethnographic Decision Tree Modeling .............. ...............54....
Example Analysis Process for Participant Three .............. ...............55....
Background information .............. ...............55....
Activity need decision model ....._.. ................. ...........__ ........ 5
Smart technology need decision models .............. ...............56....
Remote control-voice decision model .......__................. ............... 57. ....
Household automation decision model .............. ...............57....
Personal robotic assistance decision model .............. ...............58....
Participant smart technology overall decision model ................. ........_.. .........58
Elder smart technology decision tree model .............. ...............58....
Summary ........._.. ..... ._ ...............58.....

4 FINDINGS ........._.. ..... ._ ...............78.....


Introducti on ........._..... ......_ ._ ...............78....
Description of Participants .............. .......... ..... .......................7
Research Question 1: What Do Elders with Mobility Impairments Perceive as Their
Areas of Difficulty in Maintaining Independence? ................ ........._._. ...._... ....80
Activities of Daily Living. ........._.._... ......._. ...............80...
Instrumental Activities of Daily Living ................. .. .... ................ ........
Research Question 2: Which Smart Technology do Elders with Mobility Impairment
Perceive as Solutions in Maintaining Their Independence? ................ ... ................8
Research Question 3: How do Elders with Mobility Impairments Make Decisions in
Choosing Which Smart Technology is Needed? ............ ...............83.....
Elder Smart Technology Decision Tree Model ........._.._.. ....._.. ........__. .......8
Key Barrier Themes .............. .. .. .... ... .... .. .. .......8
Do I desire to start performing all or part of the activity again? ........._...._ .............84
Satisfied with current activity performance?. ..........._.._ ....... ................. .87
Is ST a practical solution? ............... ...............91....
Can I physically use the ST device? ................ ..........._._.....93...... ..
Is the ST easy to learn and use? ................ ...............94..
Will using the ST create more stress/problems? ............. ...............94.....
Is the ST reliable? ................ ...............99........ .....

Key Facilitator Themes .............. ...... ... ...............9
Decrease imposition on family/friends .............. ...............100....
Increase sense of autonomy .....__ ................. .........__ ........ 10
Assist with a difficult activity ........._......... .... ...............103. .....
Assist with an activity currently unable to perform ........._...... ......_._...........106
Replace existing technology to perform activity more safely ............... ..............107
Add a safety net .........._.... .. .......__ ...............108.....
Enhance ability to monitor health .............. ...............109....
Summary ......_ ................. .......__ .........11












5 CONCLUSIONS AND RECOMMENDATIONS ................ ...............................130


Introducti on .........__.. ..... ._ __ ...............130....

Maj or Findings. ........._.___..... .__. ...............130...
Barrier Themes ........._._... ... ....__ .. ........_._. .. ..... .........3
Do I desire to start performing all or part of the activity again? ........._._................13 1
S ati sfi ed with current activity p erformanc e? ................. .....__. ................1321
Is ST a practical solution? ............... ... ......... .... .... ... .......13
Can I physically use the ST device? Is the ST easy to learn and use? ................... 133
Will using the smart technology device create more stress/problems? ..................1 33
Is the ST reliable? ................ ...............133...............
Facilitator Themes .............. ... ......... .... ...............134......
Decrease imposition on family/friends .............. ...............134....
Increase sense of autonomy ................. ..... .. ...... .. ................ ........ 13
Assist with a difficult activity/Assist with an activity currently unable to
perform ................. ... .... ... .. .. ............ 3
Replace existing technology to perform activity more safely ........._..... ..............135
Add a safety net ........._...... .. ......._ ...............135...
Enhance ability to monitor health .............. ...............136....
Lim stations ............ ..... .._ ...............136...

Im plications .............. ...............137....
Future Research .............. ...............138....
Conclusions............... ..............13


APPENDIX


A INITIAL INTERVIEW GUIDE ................. ...............140......... .....


B CURRENT ACTIVITY PERFORMANCE GUIDE ................. ............... ......... ...149


C IN-DEPTH INTERVIEW GUIDE ................. ...............157......... .....


D SMART TECHNOLOGY DEVELOPMENT FRAMEWORK ................. ............... .....160


E SMART HOME TECHNOLOGY VISUAL INFORMATION BOARDS ................... .......161


F PARTICIPANT OB SERVATION GRID GUIDE ................. ...............170..............


LIST OF REFERENCES ................. ...............173................


BIOGRAPHICAL SKETCH ................. ...............18. 1..............










LIST OF TABLES


Table page

2-1. Smart home technology definitions ..........._...__........ ...............34...

2-2. Smart technology development around the world categorized by the five technology
component areas............... ...............35.

3-1. Advantages and disadvantages of ethnography ................. ...............60........... .

3 -2. Description of research roles ................ ...............61........... ..

3-3. List of Activities of Daily Living (ADL) assessed ................. ...............63.............

3-4. List of Instrumental Activities of Daily Living (IADL) assessed ................. ............... ...64

4-1. Demographic, health, and activity status information ................. ............................113

4-2. Itemization of smart technology cited as needed by participants ................. ................ ..126

4-3. Key need barrier themes .........._.... ...............128._.__. ....

4-4. Key facilitator themes. .........._.... ...............129.__._. .....











LIST OF FIGURES


Figure page

1-1. User research in product development cycle............... ...............18.

1-2. Research questions 1, 2, and 3 inputted into the ICF Model ................. .......................19

2-1. Example elements of smart technology that produce a smart structure .............. ................33

2-2. Six primary themes reported in literature incorporated into ICF model .............. ................43

3-1. Techniques in user participatory design ................ ...............60........... .

3-2. Interview data collected by topic and subtopic question areas............... ..................6

3-3. Early decision model regarding activity limitation .............. ...............65....

3-4. Participant 3's assistance with activity decision model ................. ................ ...._.. .66

3-5. Early decision model attempt at categorizing 26 ST devices within one decision model.....67

3-6. Participant 3's background information sheet ...._._._._ .... ... ..... ...............68.

3-7. Participant 3's smart technology remote control voice recognition need analysis
information sheet .............. ...............69....

3-8. Participant 3's smart technology remote control touchscreen need analysis information
sheet .............. ...............70....

3-9. Participant 3's smart technology household automation need analysis information sheet ...71

3-10. Participant 3's smart technology personal robotic assistance need analysis information
sheet .............. ...............72....

3-11. Participant 3's smart technology monitoring technologies need analysis information
sheet .............. ...............73....

3-12. Participant 3's smart technology prompting/reminding technologies need analysis
information sheet .............. ...............74....

3-13. Participant 3's smart technology prediction technologies need analysis information
sheet .............. ...............75....

3-14. Participant 3's smart technology overall views need analysis information sheet ..............76

3-15. Composite elder smart technology decision tree model ....._____ ........._ ..............77

4-1. Participants with deficits in activities of daily living ...........__.......__ ...............1 14











4-2. Report of ADL tasks with/without difficulty and whether need was met/unmet for the
sam ple ................. ...............115......... ......

4-3. Report of how ADL-difficulty needs are being met ................. ...............116............

4-4. Report of unmet ADL-difficulty needs ................. ...............117..............

4-5. Perceived unmet ADL assistance areas that participants cited could be replaced or
improved to resolve unmet need ........._...... ...............118...__.......

4-6. Participants with deficits in instrumental activities of daily living ................. .................1 19

4-7. Report of IADL tasks with/without difficulty and whether need is met/unmet for the
sam ple .............. ...............120....

4-8. Report of how IADL-difficulty needs are being met ................ ................ ......... 121

4-9. Report of unmet IADL-difficulty needs ................. ...............122..............

4-10. Perceived unmet IADL assistance areas that participants cited could be replaced or
improved to resolve unmet need ........._...... ...............123...__.......

4-11i. Percentage of sample that cited a maj or smart technology component area need ............124

4-12. Percentage of need cited by sample regarding smart technology applications ................. 125

4-13. Comparison of average smart technology device need cited per group ................... .........127

D-1. Smart technology development framework ................. ...............160........... ...

E-1. Smart home description display board. ......_.._._ ... ........ ...............162..

E-2. Remote control voice recognition display board .............. ...............163....

E-3. Remote control touchscreen display board ...........__......__ ....___ ...........6

E-4. Household automation/monitoring display board. ....._____ .... ... .__ ..........__......165

E-5. Personal robotic assistance display board ...._. ......_._._ .......__. ..........16

E-6. Monitoring technologies display board ...._. ......_._._ .......__. ............6

E-7. Prompting/reminding technologies display board .............. ...............168....

E-8. Prediction technologies display board .............. ...............169....









Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy

PERCEIVED SMART TECHNOLOGY NEEDS AMONG ELDERS WITH MOBILITY
IMPAIRMENTS: AN ETHNOGRAPHIC APPROACH

By

Rick Dean Davenport

December 2007

Chair: William C. Mann
Major: Rehabilitation Science

Comparatively little research has been conducted regarding the smart technology needs of

the elder population despite the proliferation of smart technology prototypes. The purpose of this

study was to explore the perceived smart technology needs of elders with mobility impairments

while constructing a preliminary decision tree model of how these decisions are made. An

ethnographic research approach, with a decision tree modeling component, was utilized to

explore the complex variables surrounding the elder ST need decision process. In-depth

individual interviews with 11 elders aged 65 and older with mobility impairments, and their in-

home observations, provided insight into how elders perceived smart technology. Audio-taped

interviews were transcribed verbatim and then analyzed for key phrases that represented

participant decision criteria. Decision criteria concepts were combined to construct an elder

smart technology decision tree model.

The model identifies that elder participants must first determine if they are satisfied or not

satisfied with their current activity performance level. If satisfied with their activity performance

level then the elders do not critically consider the ST device. However, dissatisfaction with

current activity level is no assurance that elder participants will desire ST to assist with their

daily activity needs, due to the numerous other potential barrier criteria identified in the model









(i.e., not practical, not easy to use/learn, not reliable, or whether it may add more problems). If

any of the other barriers are a concern then elders will not desire the ST device. The model also

identifies important facilitator criteria (i.e., decreasing imposition on family/friends, increasing

sense of autonomy, assisting with difficult tasks, replacing existing technology in order to

perform task safely, providing a safety net, and enhancing the monitoring of their health) that

could motivate elders to adopt ST assistance. This decision model adds to the elder ST needs

literature and potentially will help future designers create appropriately matched technological

devices that will assist in the care of aging baby boomers with mobility impairments.









CHAPTER 1
INTTRODUCTION

Introduction

This chapter includes three sections. The first section introduces smart technology's

potential to help elders and how the private smart technology industry is expected to have a

technology boom over the next 20 years. The second section examines the product development

cycle and how today's technology devices have not been designed well for elder needs. The third

section outlines the purpose of the study and the specific research questions addressed in the

study. The last section describes how suited the conceptual model is in exploring the complex

nature of an elder' s perception of his/her problems and the solutions.

Problem

The potential to help elders (> 60 years old) maintain independence has increased

extensively with recent advancements in smart technology (Eriksson & Timpka, 2002; Haigh,

2002; Said, 2005). Future smart technology (ST) will assist elders in their homes by providing

medication, hydration, and activity reminders; monitoring body temperature, heart rate, sleep

patterns; detecting falls; and assisting with meal preparation and transfers (Carnegie Mellon

University, 2004; Said, 2005). In the near future elders with mobility impairments (MI) may no

longer need a cane or a walker, and instead will don a lower extremity exoskeleton to assist with

ambulation (Kawamoto, Lee, Kanbe, & Sankai, 2003). In the distant future high-level

quadriplegic patients will benefit from advances in experimental implantable electrode arrays

that will allow their mind to control a robotic arm (Duke Med News, 2003, 2004). ST innovation

will provide one of the solutions to the growing needs of the aging population.

While early prototype ST is costly and unwieldy, the private sector ST industry of today is

expected to have a boom similar to advancements seen over the past 20 years with the personal










computer industry (Kanellos, 2004; Valigra, 2004). With a technology boom there is a proj ected

natural reduction in associated manufacturing costs (Kanellos, 2004; Said, 2005; Valigra, 2004).

However at present the mass produced technology products for business and communication

have primarily benefited younger cohorts (Eriksson & Timpka, 2002). As a result elders

commonly use devices that have not been designed for their needs (Eriksson & Timpka, 2002;

Lee & Liao, 2003). For example: cell phone interface designs and feature options are targeted at

younger populations (Davenport, Mann, & Helal, 2005; Lee & Liao, 2003; Mann et al., 2004);

and software and web page designers continue to use non-elder friendly small font sizes, along

with pull down menus that may be difficult for elders with an unsteady hand to navigate (Becker,

2004). Commonly, designers choose to address the physical interface problems of their products,

while failing to address the underlying design needs for the elder population. For instance while

designers of the web interface for the new Medicare Part D prescription drug program included

both an alternative larger font and screen reader versions (Centers for Medicare & Medicaid

Services, 2006), elders found the overall web interface to be confusing and frustrating, which

deterred many from enrolling in the new federal government prescription drug program (Alonso-

Zaldivar, 2005; Basler, 2006; Eastern Virginia Medical School, 2006). To avoid future

technology-person mismatches a better understanding of ST design needs of the elder population

is essential.

Product development is costly and it takes a long time to bring a product to market, with

no guarantee that the technology will not become obsolete during the development cycle

(Dekker, Nyce, & Hoffman, 2003). Therefore designers must decide on the amount of time and

resources that will be invested in research during the development cycle. Figure 1-1 illustrates









where user research (needs analysis and prototype evaluation) could be used to improve product

design and validate design choices (Anderson, 2001; Fleck, 2002).

As Figure 1-1 illustrates the product development cycle ideally begins with needs analysis

research, however developers typically end up investing a maj ority of resources during the

prototype evaluation phase. Path A in Figure 1-1 illustrates how usability testing can be used to

guide the refinement of a prototype's design. Usability testing (Path A) is ubiquitous in the ST

literature and typically involves quantitatively evaluating the interaction between the user and

prototype. Path B illustrates how needs analysis research could be used to provide guidance for

maj or revisions if a product has been released and receives exceedingly poor usability ratings.

Needs analysis research can help reveal any missed consumer needs and guide development of

future prototype concepts (Anderson, 2001; Fleck, 2002). A resourceful way to avoid maj or

problems late in the development process is to initially perform a comprehensive needs analysis

to gain clues on any unmet needs and how to address the needs (Anderson, 2001). However the

problem lies in the fact that there is a deficiency of needs analysis research on what prototypes

should be created in the ST literature, particularly pertaining to the needs of the elder population

(Baillie, 2003; Mihailidis, Cockburn, & Longley, 2005).

Purpose

The purpose of this study was to explore the perceived smart technology needs of elders

with mobility impairments while constructing a preliminary decision tree model of how these

decisions are made. The three research questions in this study were:

* Research Question 1: What do elders with MIs perceive as their areas of difficulty in
maintaining independence?

* Research Question 2: Which ST(s) do elders with MIs perceive as solutions (or
encumbrances) in helping maintain their independence?










*Research Question 3: How do elders with MIs make decisions in choosing which ST is
needed or not needed?

Conceptual Framework

A conceptual model recognized in rehabilitation science was utilized to provide a basis

for exploring the various health, psychosocial, and environmental factors surrounding the

perceived ST needs of elders with MIs. The World Health Organization International

Classification of Functioning, Disability and Health (ICF) model was used as the framework for

this study (Schneidert, Hurst, Miller, & Ustun, 2003). The ICF model was well suited to explore

the complex nature of an elder' s perception of problems and the solutions. The ICF model

classifies disability as a dynamic multidimensional phenomena (Schneidert et al., 2003; World

Health Organization, 2001). This dynamic nature of the ICF model assisted when exploring

elders with MIs perception of their areas of difficulty in maintaining their independence

(research question 1). Figure 1-2 illustrates where the research questions 1-3 fit into the ICF

model .

The ICF is able to document a barrier whether located at the body structure, activity

limitation, or participation restriction level (Schneidert et al., 2003; World Health Organization,

2001). If the solution to a barrier is perceived to be at the environmental level it can be

documented within the contextual factors component of the ICF model (research question 2). For

example if a participant cited difficulty climbing stairs, a robotic walking aid may be perceived

as a solution to this activity.

The dynamic nature of the ICF model assisted in exploring how elder participants made

decisions in choosing which ST device was needed or not needed (research question 3). The ICF

was able to illustrate how a smart technology device may be affected by the various component

areas (i.e., body structure or function, the impact of personal factors, and an individual's









immediate or surrounding environment) of the ICF model. For example when a participant is

deciding if a robotic walking aid device is needed, the ICF model illustrates that the participant' s

decision could be affected by either the body structure component area in the form of a previous

stroke, or the personal factors component area in the form of a perceived stigma associated with

wearing the robotic walking aid. The multidimensional nature of the ICF model was one of the

primary reasons it was chosen as the overall conceptual framework for this study.

Summary

Smart technology is being looked towards as a possible solution to the growing needs of

our aging population. At present there is a deficiency of needs analysis research on what ST

prototypes should be created, particularly pertaining to the needs of the elder population. Further

exploration is needed into how elders perceive their ST need. This study explored the perceived

smart technology needs of elders with mobility impairments and constructed a preliminary

decision tree model of how these decisions were made. The decision model will add to the elder

ST needs literature and potentially will help future designers create appropriately matched

technological devices that will assist in the care of aging baby boomers with mobility

impairments.


































Figure 1-1. User research in product development cycle. [Adapted from Anderson, G. (2001).
Making use of user research. Retrieved July 20, 2006, from
http://www. cooper. com/newsletters/200 1_09/makings_ouserof seresarch .htm.]













Healtlh coalition

(disorder or dlsease;


?encne


Research Question #3)
How do elders with M Is make dec isions
in choosing which ST is needed or not
needed?

What are the primacy factors in the
decision process?


Life style, life experience,
habits, age, gender, race,
coping skills, fitness, and
social status.


Research Question #11
What do elders with M ls
perceive as their areas of
difficulty in maintaining


I 1 Idnoepedni


Environmental
Fa cto rs


Assistive Technology

Smart Technology


Research Question #)
Which ST~s) do elders
wuith Mls percewe as
solutions (or
enc umbrances) in
helping maintain their
independence?


Smart
Medication
Reminder



S art


Figure 1-2. Research questions 1, 2, and 3 inputted into the ICF Model.









CHAPTER 2
REVIEW OF LITERATURE

Introduction

This review focuses on the issues related to smart technology. This chapter reports on the

various terms associated with smart technology (including assistive device and assistive

technology); emergence and definition of the term 'smart technology'; and multiple definitions

of 'smart home technology'. It also looks at the state of smart technology development around

the globe, including both commercial and university-based smart technology ventures. The

chapter concludes with a review of needs analysis research that focuses on prototype smart

technology development.

Assistive Technology

Assistive technology (AT) and assistive devices (AD) have multiple meanings in the

literature (Mann, Hurren, Tomita, & Charvat, 1995). This study will use the term AT as entailing

a "broad range of devices, services, strategies, and practices that are conceived and applied to

ameliorate the problems faced by individuals who have disabilities" (Cook & Hussey, 2002, p.

5). The specific definition used in the 1998 Assistive Technology Act Public Law 105-394 states

an AD is, "any item, piece of equipment, or product system, whether acquired commercially,

modified, or customized, that is used to increase, maintain, or improve functional capabilities of

individuals with disabilities" ("Assistive Technology Act," 1998). The Assistive Technology Act

broadly defines the term AD, and what might be an AD for one person may not be considered an

AD for another person. An oversized universal remote control or large button telephone may be

considered a standard product marketed to the general public (the oversized buttons would be

viewed as a convenient feature). However an elder individual with fine motor impairment would

consider the same oversized universal remote control or large button telephone an AD. ADs and









the application of the devices are unique to every circumstance (Cook & Hussey, 2002).

Therefore ADs are challenging to categorize (Cook & Hussey, 2002). This study will potentially

explore many forms of ADs, therefore the more global term AT will be utilized.

One way researchers have attempted to categorize AT is by grouping them as either 'high'

or 'low' tech. This clarification scheme reflects the rapid advancement of electronic technology

over the past two decades (Cook & Hussey, 1995). The number of AT that employ electronics

has increased while the cost has decreased (Cook & Hussey, 1995). Low technology devices are

typically simple to create and easy to acquire (Cook & Hussey, 1995). High technology devices

are often high-priced, more challenging to make, and more difficult to acquire (Cook & Hussey,

1995). Examples of low-tech AT are transfer benches, sock aids, modified eating utensils, and

communication boards. Examples of high-tech AT are powered wheelchairs, electronic

communicative devices, and environmental control units. A rapidly growing sector of AT is in

the field of smart technology (Eriksson & Timpka, 2002; Said, 2005).

Smart Technology

The term smart technology (ST) is said to have emerged during the early 1980s when

researchers working within the United States defense system were combining computer systems

with advanced sensors and materials (Goddard, Kemp, & Lane, 1997). These compact computer

systems could monitor their environment in real-time and independently counteract (Goddard et

al., 1997). While the technology has improved since the 1980s the definition of ST still remains

imprecise (Goddard et al., 1997; Worden, Bullough, & Haywood, 2003) and at times is used

strictly for marketing purposes (Worden et al., 2003). After considerable research of the

literature databases: (ISI Web of Knowledge), (National Library of Medicine and the National

Institutes of Health), (CINAHL Information Systems), (IEEE Publications Online), (Association

for Computing Machinery), (CiteSeer), (NetLibrary), (Books24x7), and online websites: online









technology dictionaries and smart technology related websites, only a few definitions of ST were

discovered. Caldwell (2001) globally defines ST, as a "design philosophy concerned with

integrating materials, sensing, processing, actuation and control into structures which should be

able to adaptively respond to their environment to optimize their operating conditions" (p. 965).

Worden (2003) stresses that in order to be classified as smart technology the devices should

"possess an awareness of their situation.... capable of reacting to it:" (p. 1). For the purposes of

this study Goddard's 1997 categorization of the term ST will be utilized. Goddard (1997)

classifies ST as any enabling technologies that intermingle to produce a 'smart structure'.

Goddard defines all structures, such as actuators, sensors, control hardware, control algorithm,

and structural members, that assist a structure in becoming aware and automatically optimizing

and reacting as smart technology (Figure 2-1) (Goddard et al., 1997).

Goddard emphasizes that there are not any commercially available 'smart structures' on

the market and for a structure to be classified as smart it must have the ability to improve "its

performance over years of adapting to changes in its environment by learning from past

operating experience" (1997, p. 131). While there are not any smart structures in product form,

there are plenty of ST that can intermingle to produce structures that are moving closer to

meeting the definition of a smart structure. For example ST exists in: automobiles that can sense

an obj ect in its path and alerts the driver by beeping or shaking the drivers seat (McCormick,

2005); movie theaters that can detect how many people are in the theater with carbon-dioxide

detectors and automatically adjust the climate controls, as well as automatically be notified if

bathroom supplies are low (Dyer, 2006); and elementary schools that can automatically take

attendance and monitor bathroom use with radio frequency identification (RFID) tags (Bradner,










2005; Gibbs, 2005). The remainder of this literature review will concentrate on the broad range

of ST that can be applied in the home to assist elders in their daily tasks.

Smart Home Technology

While definitions of ST may be insufficient, definitions of ST for the home are reported

more frequently in the literature. Table 2-1 documents various definitions of smart home

technology.

For the purpose of this study smart home technology was defined as any ST (including but

not limited to actuators, sensors, computer processors/software, and supporting structures) that

creates an integrated home capable of monitoring and supporting residents in real-time. This

study focused on ST that can assist elders with mobility impairments (MI) in their homes

whether the technology was limited to the infrastructure of the home (fall detection system) or

moves with the resident (powered smart walker/scooter). Therefore the terms smart technology

and smart home technology were used interchangeably.

State of Smart Technology Development

We can expect commercial ventures in connection with smart home technology to

extensively grow over the next few years and expand into mainstream population. This can

already be seen in the private smart home residences constructed in Roanoke, Virginia (Lawson,

2003; Zurier, 2003) and Stockholm, Sweden (Electrolux, 2005; Giesecke et al., 2005) where

residents can remotely control their home through the internet. Residents at the IT

Condominiums, in Stockholm Sweden can utilize a terminal with a touch screen, or a personal

computer for food management (including shopping and meal preparation); access a family

calendar system for scheduling activities of all family members; and access the safety and

security systems that detect and reports fires, water leakage, and intruder alarms (Electrolux,

2005; Giesecke et al., 2005). Commercial ventures by assisted living facilities have already










begun to incorporate ST into their care management, as seen in Miwaukie, Oregon (Elite Care,

2006). Residents and staff wear a small locator badge clipped onto their clothing to help record

response time of staff-to-resident request to ensure timely responses. Resident' s weight, sleep

patterns, movements and interactions with other residents are collected and family members can

monitor this data via secure web portal (Elite Care, 2006).

Commercial companies are joining together to develop and test smart home technologies

and have built demonstration smart homes in Duisburg, Germany (inHaus, 2006), Eindhoven,

The Netherlands (Philips, 2006), and Hunenberg, Switzerland (FutureLife, 2006). The largest of

the three commercial smart home technology collaborations is in Hunenberg, Switzerland where

over 60 companies have installed prototype and product smart technology in the FutureLife

Smart Home (FutureLife, 2006). A family of four have been residents of this home and have

been evaluating it for the last 5 years. The house includes: a smart refrigerator that is able to

download recipes and cooking programs from the internet; a solar powered lawnmower that

follows an underground induction loop that autonomously cuts the grass; an automatic door

opening system that recognizes a chip in the resident's wrist watch and opens and locks the door

automatically; sensors throughout the house where voice commands can prepare the room for

TV viewing by lowering the blinds, closing the curtains, dimming the lights, and lowering a

proj ector; and appliance sensors that can send messages to the residents when the washers spin

cycle or dryer is done (FutureLife, 2006).

While the commercial ventures in smart home technology have been increasing, the

maj ority of ST research has primarily been conducted by university-based institutions. At

Georgia Institute of Technology's Aware Home researchers are developing prototype smart

home technology systems to assist elders with impairments including: a Gesture Pendant with an









embedded wireless camera that can translate simple hand motions made to control house

functions; Cook' s Collage that utilizes cameras placed in specific locations to record steps

performed when preparing a meal or doing laundry and, when prompted, displays the last few

steps performed so the resident would be aware if the detergent was already been inserted or a

cup of flour was already added; and Digital Family Portrait that displays daily activity performed

by an elder resident in the form of various icons on a digital picture frame so family members at

another location can check in on their family members by viewing this portrait in their home

(Georgia Institute of Technology, 2006; Mynatt, Melenhorst, Fisk, & Rogers, 2004).

At University of Virginia Medical Automation Research Center' s Smart House

researchers are developing a sensor suite and data analysis system that can gather activity and

health status of elder residents. Wireless sensors on stove-top, bed pad, shower, and a floor

vibration sensor sends information to computer-based data manager where caregiver or family

can monitor resident' s behavior. Researchers have constructed a 3.5 lb. prototype fall detector

that when placed on the floor can distinguish between a person falling and a 5-15 lb. object that

has been dropped.

At University of Rochester' s Smart Medical Home researchers are developing systems that

can potentially detect resident' s symptoms before the resident is aware, thereby providing

support before a crisis arises (Medical Automation Research Center, 2006). By installing

accelerometers, gyroscopes, and RFID sensors that monitor speech patterns, breathing patterns,

computer mouse activity, body motion, and gait patterns, early detection of a health condition

could be successful (Medical Automation Research Center, 2006).

At MIT' s PlaceLab sensors are located throughout an apartment which can detect whether

an obj ect is moved, opened/closed, turned on/off, and also detect resident' s limb motion with









wearable accelerometers (Massachusetts Institute of Technology, 2006). A resident' s activities

and behaviors can be recorded with one of the 9 infrared cameras, 9 color cameras, and/or 18

microphones distributed throughout. Researchers are working on a prototype system that

promotes healthy lifestyles in the home. These prototype systems use social science and

behavioral science techniques to motivate change in a resident' s behavior (Massachusetts

Institute of Technology, 2006).

At University of Colorado' s Adaptive House researchers are developing a system that

will 'program itself,' therefore no speech input, hand gesturing, gaze tracking, touch pad

interfaces are used in the home (Mozer, 2005, 2006). Over 75 sensors monitor indoor/outdoor

temperature, ambient light, audio level, movement in home, and door/window position. The

house attempts to learn and anticipate the resident's needs and automatically sets the HVAC

(heating, ventilation, and air conditioning), water heater, and interior lighting levels (Mozer,

2005, 2006).

The ST field is expanding and progressing rapidly both in the private and university-based

sectors. Researchers are looking towards smart home technology as one of the solutions to the

proj ected strains on the healthcare system during the future population shift (Eriksson & Timpka,

2002; Said, 2005). An important role of university-based research will be to address the need for

further user research exploring the prototype ST needs of the elder population.

For this study ST development research has been divided into five component areas:

* Remote control technologies (voice activated: lights, blinds, and temperature)
*Automation technologies (automated: microwave, temperature, safety lighting)

* Monitoring technologies (vital signs, falls, security, and activity/sleep patterns)

* Prompting/Reminding technologies (physical exercise, medication management, and diet
choices)










*Prediction technologies (behavior learning and early detection of health conditions).

An extensive review of the state of smart technology development is summarized in Table 2-2.

Table 2-2 categorizes each example of ST development research, by the five technology

component areas listed above, in both the private sector and university settings around the world.

Prototype Smart Technology Development

In trying to provide a better technology-person match, developers typically conduct studies

(interviews, surveys, focus groups, field trials, lab testing, live-in trials, etc.) to evaluate

prototypes during the development process. Prototype trials have been conducted on: intelligent

thermostats (Freudenthal & Mook, 2003), smart front door reminder systems (Kim, Kim, Park,

Jin, & Choi, 2004), smart shirts (Shant, 2006), exoskeletons (Kawamoto, Lee, Kanbe, & Sankai,

2003), robotic home personal assistants (Carnegie Mellon University, 2004; Rotstein, 2004),

infrared home health monitoring systems (Banerjee, Steenkeste, Couturier, Debray, & Franco,

2003; Ohta, Nakamoto, Shinagawa, & Tanikawa, 2002), tele-surveillance sensors in care rooms

(Banerj ee et al., 2003), tele-health home monitoring and educating devices (Kobb, Hoffman,

Lodge, & Kline, 2003), a virtual health counselor (Kaplan, Farzanfar, & Friedman, 2003), and

robotic home companion pets (Libin & Libin, 2003; Omron, 2001; Wada, Shibata, Saito, &

Tanie, 2002, 2003). The maj ority of ST literature centers on prototype evaluations.

In 2004 consumers evaluated five prototype smart technology devices at Georgia Tech

(Mynatt et al., 2004). Forty-four elder participants, who were 'living independently' (no

demographics on disability status were reported) were given individual tours of Georgia Tech's

Broadband Institute Residential Laboratory-The Aware Home followed by a structured interview

(Mynatt et al., 2004). While the tour showcased 5 prototype smart technology devices only 3

were discussed in the manuscript: 1) Gesture pendant simple hand motions interpreted by a

pendant that can control blinds, doors, lights, and a thermostat, 2) Cook's Collage cameras









placed in specific locations to record steps performed when preparing a meal or doing laundry

and when needed could display the last few steps performed so the resident would be aware if

the detergent was already placed or a cup of flour was already added, and 3) Digital Family

Portrait digital picture portrait displays daily activity performed by an elder resident in the form

of various icons (up to 4 weeks of data can be displayed). A family member at another location

could check in on their family member by viewing the digital portrait located in their home.

While the authors obtained data on the elder participants' perception of Georgia Tech's

Aware Home prototype ST that have already been created, they did not specifically explore the

participants' need for any further ST devices to be created. In fact the authors discovered that

most of the elders felt the existing Gesture Pendant may be good for them in the future but not

needed now. The authors acknowledge the complexity of the elder rationale when deciding if the

existing prototypes at Georgia Tech were desirable. At times elders were willing to trade off

privacy concerns for a device that would allow for more independence in their home, but at the

same time they would easily rej ect a device due to concerns of over reliance on technology.

Future research resources may be conserved if a thorough needs assessment study determines

that elders are resistant to specific ST devices due to concerns of over reliance.

While the prototype evaluation phase can involve the consumer in the design process,

typically it is only after the initial concept and working prototype has been established. Usually

after the prototype has been created too many resources have been committed to scrap the overall

concept (if needed) and to construct a ST application in a new direction (Dekker, Nyce, &

Hoffman, 2003; Woods & Dekker, 2000). Therefore the prototype evaluation phase is typically

limited to investigating the ergonomics or usability aspect of a prototype and not able to fully









reevaluate the overall concept of the ST. Woods (2000) reinforces the dilemma of involving the

user at the later stages of prototype development when stating:

Late testing studies are not able to tell developers how to use those degrees of freedom to
create useful and desirable systems. The problem in design today is not can it be built but
rather what would be useful to build given the wide array of possibilities new technology
provides. (p. 275)

Baillie (2003) reports this has been a longstanding issue, stating:

The call from the early 1980s to include users in design has still not been heeded. What we
see in the household is exactly the problems we have seen and continue to see in the
workplace. For that reason the home is likely to become a crucial proving ground for all
those interested in developing a HCI (human computer interaction) that includes users as
full partners in the design process. (p. 42)

Inadequate user involvement prior to the conception of the prototype creates an

environment where technology is the principal guiding force in product development cycle,

which can lead to countless person technology mismatches.

Mihailidis (2005) interviewed 15 baby boomers (born between 1946-1965) and 15 elders

(aged 65 and older) to explore: their willingness to accept smart home technology, which types

of smart home technology they preferred, and if there was difference between groups. An overall

trend of higher acceptability/willingness scores were noted by the baby-boomer group. Their top

five device areas were: health monitoring devices(100%), environmental control units(100%),

personal emergency response system(85%/), fall detection(78%), and lifestyle monitoring(62%)

(Mihailidis et al., 2005). The top five device areas the elder group was willing to have in their

home were: personal emergency response system(90%/), health monitoring devices(80%),

environmental control units(78%), fall detection(64%), and lifestyle monitoring(54%). These

results suggest that baby boomers and elders most prefer to have environmental control units,

personal emergency response systems, and health monitoring devices, which could be designed

and built into smart homes. However Mihailidis points out further exploration is needed into the










rationale (perceived abilities, previous falls, loneliness/death) that was given for choosing one

device over another (Mihailidis et al., 2005). Exploring the elder's attitudes and perceptions

further would potentially help developers determine their ST needs and what device would

match that need.

Mihailidis also relates suggestions for developers of future smart home technology:

* keep cost low
* keep devices small, discreet, and comfortable
* keep maintenance low
* allow user control
* follow principles of universal design
* protect privacy from outside intruders
* minimize false alarms and ensure technical support available
* have a back-up system in the event of power failure (Mihailidis et al., 2005).

However these concrete suggestions primarily focus on cost and usability and do not add

to the needed literature on revealing which prototypes need to be created.

Demiris et al. (2004) used a focus group format when evaluating 15 elder participants'

perceptions and expectations toward smart home technologies. Three focus group sessions (six,

five, and four participants) each lasting 1-hour were conducted. The focus groups explored

residents' (in a continuing care retirement facility) perspectives on future smart home

applications (Demiris et al., 2004). Demiris (2004) reports potential elder smart home technology

needs as:

* Emergency help
* Assistance with hearing and visual impairment
* Prevention and detection of falls
* Temperature monitoring
* Automatic lighting
* Monitoring of physiological parameters (e.g., blood pressure, glucose levels)
* Stove and oven safety control
* Property security
* Intruder alarm
* Reminder system announcing upcoming appointments or events










* Timely and accurate information on adverse drug events and contraindications. (p. 91)

Demiris reported five areas of concern expressed by elder participants on smart home

technologies:

* Possible privacy violation resulting from the use of cameras
* Lack of human responders or possible replacement of human assistance by technology
* The user-friendliness of the devices, and
* The need for training tailored to older learners. (p. 91)

Participants also revealed privacy concerns regarding the use of cameras within their

homes to detect falls or other accidents (Demiris et al., 2004). However elders felt that if the data

being collected by the camera was in the form of a shadow or movement without identifying

characteristics then privacy would not become an issue (Demiris et al., 2004). All participants

had positive attitudes toward having smart technology enhance their lives (Demiris et al., 2004).

The author noted that this sample may be more accepting of technology in their everyday lives

due to 97% of participants currently used personal computers in their home and 66% regularly

used their computers for surfing the Internet and sending emails. The elder group revealed that

they might not be representative of their older friends; stating that some of their friends may not

welcome technology into their homes as easily. The group suggested installing non-obtrusive

devices that do not require users to operate or control them (such as automatic sensors).

Demiris was able to compile a list of smart technology areas elders perceive as important,

such as providing for emergency help, detection of falls, automatic lighting, security, and oven

control. However in agreement with previous research conclusions by Mynatt (2004) and

Mihailidis (2005) further exploration of how the elder participants came to choose this list of ST

is of most importance. The themes (surrounding the elder ST need decision process) that have

been reported in this (prototype ST development) literature section have been integrated into the










ICF model and are illustrated in Figure 2-2 (Demiris et al., 2004; Mihailidis et al., 2005; Mynatt

et al., 2004).

Summary

Scores of commercial companies are joining together to develop and test ST devices.

Commercial ventures in connection with ST are expected to extensively grow and expand into

mainstream population. Presently there are very few studies addressing the deficiency of needs

analysis research on what ST prototypes should be created, particularly pertaining to the needs of

the elder population. An important role of university-based research is to address the need for

further user research exploring the prototype ST needs of the elder population. The existing elder

needs analysis literature has made recommendations for further exploration into how elders

perceive their ST need. At present the terminology cited in the literature is very limited. Terms

such as 'favorable', 'open to the idea', 'convenient', 'willingness to accept or have in home' is

frequently used to describe elder ST need. However these terms do not fully capture the elder ST

need decision criteria. Constructing a preliminary decision tree model of how elders make ST

need decisions may assist future designers in creating appropriately matched technological

devices.





































Figure 2-1. Example elements of smart technology that produce a smart structure. [Adapted
from Goddard, N., Kemp, R., & Lane, R. (1997). An overview of smart technology.
Packaging Technology and Science, 10, 129-143 (Page 132, Figure 1).]










Table 2-1. Smart home technoloav definitions


Source
Medical
engineering
and physics
journal


Scottish
government
publication




Information
technology
Online
resource

Scottish
environmental
design
research
center paper

Artificial
intelligence
conference
workshop


Description/definition -smart home technology
The term Smart House' is commonly used to refer to a living or working
environment, carefully constructed to assist people in carrying out required
activities, using various technical assistive systems. This idea can be applied to
the needs of a wide range of people, but presents particular potential benefits to
elderly, or handicapped people. (Allen, 1996, p. 203)

In most homes, heating, lighting, security and entertainment systems all
operate independently. Smart technology brings these systems together through
a communication network providing new ways of managing and living in the
home. Such inter-linked command and control systems have been extensively
used in commercial buildings for years but have only recently started appearing
in the home. (Scottish Executive, 2005, p. 54)

"A home that is highly automated. It uses a common network infrastructure for
lights, appliances and other devices" (TechWeb, 2006).



Homes that contain devices that are able to operate complex tasks that are pre-
programmed either into the devices themselves (via a bus line) or through a
computerized operating system (X10). (Dewsbury, 2001, p. 4)



Systems that have sensors and actuators that monitor the occupants,
communicate with each other, and intelligently support the occupants in their
daily activities. For elders, tasks can range in complexity from reminders to
take medication to monitoring the general deterioration in functional capacity.
(Hainh, 2002, p. 40)









Table 2-2. Smart technology development around the world categorized by the Hyve technology component areas
Name/location Structure Technology Description of smart technology development
description component

Commercial ventures
Blueroof 3 free standing Remote Handheld remote control interface, personal computer (PC) interface,
Technologies, single-storied control: and remotely control home via intemet portal.
McKeesport, model smart Automation: Appliances, lighting, keyless entry, heating ventilation air conditioning
Pennsylvania homes completed. (HVAC), backup natural gas generator, and, security.
(Blueroof Buyers have 4 Monitoring: Security, water leaks, and personal emergency response system (PERS).
Technologies, 2006; styles of smart Internet capable cameras in home and at front door.
Camegie Mellon cottages to Prompting/ None reported on home website.
University, 2005). choose. remindin:
Prediction: None reported on home website.
e2-home 59 private Remote Touch screen, personal computer (PC), and remotely control home via
ITcondominiums, residence control: intemet portal.
Ringblomman, condominiums. Automation: Lighting, heat, and, security.
StockolmMonitoring: Security front door camera and smoke/fire.
Sweden(Electrolux,
2005; Giesecke et Prompting/ None reported on home website.
al., 2005). reminding:
Prediction: None reported on home website.
Oatfield Estates, Six assisted living Remote Touch screen utilized by resident to check daily weather, facility
Miwaukie, Oregon smart homes control: activities, email, and call for assistance.
(Elite Care, 2006). housing 68 elder Automation: Doors auto open (via verification by infrared/RFID pendant)
residents.
Monitoring: Staff utilizes touch screen to monitor weight/sleep pattern (recorded via
bed sensors). Tracks resident's activity in room and on grounds (via
bracelet). Family members remotely monitor resident activity patterns,
vital signs, and track response time of staff via intemetpotl
Prompting/ None reported on home website.
remindin:
Prediction: None reported on home website.













Name/location Structure Technology Description of smart technology development
description component

Commercial ventures
Blueroof 3 free standing Remote Handheld remote control interface, personal computer (PC) interface,
Technologies, single-storied control: and remotely control home via intemet portal.
McKeesport, model smart Automation: Appliances, lighting, keyless entry, heating ventilation air conditioning
Pennsylvania homes completed. (HVAC), backup natural gas generator, and, security
(Blueroof Buyers have 4 Monitoring: Security, water leaks, and personal emergency response system (PERS).
Technologies, 2006; styles of smart Internet capable cameras in home and at front door.
Camegie Mellon cottages to Prompting/ None reported on home website.
University, 2005). choose. remindin:
Prediction: None reported on home website.
e2-home 59 private Remote Touch screen, personal computer (PC), and remotely control home via
ITcondominiums, residence control: intemet portal.
Ringblomman, condominiums. Automation: Lighting, heat, and, security.
StockolmMonitoring: Security front door camera and smoke/fire.
Sweden(Electrolux,
2005; Giesecke et Prompting/ None reported on home website.
al., 2005). remnindin:
Prediction: None reported on home website.
Oatfield Estates, Six assisted living Remote Touch screen utilized by resident to check daily weather, facility
Miwaukie, Oregon smart homes control: activities, email, and call for assistance.
(Elite Care, 2006). housing 68 elder Automation: Doors auto open (via verification by infrared/RFID pendant)
residents.
Monitoring: Staff utilizes touch screen to monitor weight/sleep pattern (recorded via
bed sensors). Tracks resident's activity in room and on grounds (via
bracelet). Family members remotely monitor resident activity patterns,
vital signs, and track response time of staff via intemetpotl


Table 2-2. Continued












Name/location Structure Technology Description of smart technology development
description component

Prompting/ None reported on home website.
reminding
Prediction: None reported on home website.
Village at Tinker 20 free standing Remote Remotely control home via internet portal.
Creek in Roanoke, private residence control:
Virginia (Lawson, smart homes in a Automation: Lighting, heating ventilation air conditioning (HVAC), and security
2003; Village at 170-unit Monitoring: Appliance, gas meter, panic button, and indoor web cameras.
Tinker Creek, 2006; development. Prompting/ None reported on home website.
Zurier, 2003). remindin:
Prediction: None reported on home website.
Demonstration/ Model Homes Non-University-Based
FutureLife Smart Live-in/ Remote Voice interface, touch screen, smart phone, and smart car remotely
House, Hunenberg, development/ control: control the house.
Switzerland demonstration 3- Automation: Lighting, blinds, curtains, auto open/close windows, keyless auto front
(FutureLife, 2006). story smart home door, saves preferred shower water-temperature, smart refrigerator that
*Past 5-years is able to download recipes and cooking programs from the internet, and
have had a family a solar powered lawnmower that follows an underground induction
of four lop
permanently Monitoring: Washing machine that notifies resident when washer spin cycle is done.
residing in the Prompting/ None reported on home website.
smart home. reminding:
Prediction: None reported on home website.
HomeLab, Philips, Live-in/ Remote Voice interface, gesture recognition, interactive mirror (allows you to
Eindhoven, The development/ control: check the traffic/weather condition, examine your weight, try different
Netherlands (Philips, demonstration hairstyles, and both show your backside or magnify).
2006). smart home.
Automation: Lighting and blinds.


Table 2-2. Continued












Name/location Structure Technology Description of smart technology development
description component

Monitoring: Resident tracking via sensors in carpet, participants live in the house
between 1-14 days to test prototype smart home technology.
Researchers observe participants through two-way mirrors, cameras,
and with microphones.
Prompting/ A virtual fitness coach that monitors physiological data while
reminding: calculating intensity and provides encouragement to meet exercise
goals. A robot cat assistant in kitchen that monitors resident' s weight,
daily activity, personal preferences and gives exercise and diet
suggestions.
Prediction: None reported on home website.

Independent Development -of Remote Touch screen, web pad, and remotely control home via internet portal.
LifeStyle Assistant, smart home control:
Honeywell automation Automation: Door lock, lighting, thermostat, water flow, and prepare grocery list.
Laboratories, systems. Monitoring: Mobility, falls, toileting patterns, temperature, camera, infrared, blood
Minneapolis, pressure, heart rate, glucose level, medication use, eating patterns,
Minnesota pressure pads, microphone, monitor cognitive decline, fires, bums, and
(Honeywell, 2006). poisonin.
Prompting/ Medication use, health care appointments, plan nutritionally balanced
reminding: meals.
Prediction: An alert is sent when elder is behaving in an unusual way (not taking
medications, wandering, not moving)
The Intelligent Development/ Remote Touch screen, PC, smart car, and remotely control home via intemet
House Duisburg. demonstration control:potl
Innovation Center smart home Automation: None reported on home website.
(inHaus), Duisburg, includes a Monitoring: Appliances (including pantry/refrigerator tracking contents/expiration
Germany (2006). residential home, dates), fire, water leaks, and humidity.
with a workshop, Prompting/ None reported on home website.
and networked reminding:


Table 2-2. Continued












Name/location Structure Technology Description of smart technology development
description component

car/garden. Prediction: None reported on home website.
Demonstration/ model homes university-based
Adaptive House, Live-in(principle Remote Opposes any alternative interface (including voice, gesture, and touch
University of investigator' s control: screen).
Colorado, Boulder, residence) Automation: Lighting, ceiling fans, furnace, space heaters, water heater.
Colorado (Mozer, /Development/
Monitoring: Over 75 sensors monitor indoor/outdoor temperature, ambient light,
2005, 2006). demonstration 4..'
audio level, movement in home, and door/window position.
room smart home.
Prompting/ None reported on home website.
remindin:
Prediction: The house attempts to learn and anticipate the resident' s needs and
automatically sets the HVAC, water heater, and interior lighting levels.
Aware Home, Development/ Remote Gesture and touch screen.
Georgia Institute of demonstration control:
Technology, Atlanta, three-story, 5040- Automation: Lighting, blinds, keyless entry/automatic front door, and HVAC.
Georgia (Georgia square-foot smart Monitoring: Family members remotely monitor resident activity patterns, vital signs
Institute of home. via internet portal picture frame. Cameras placed in specific locations to
Technology, 2006; record steps performed when preparing a meal or doing laundy
2004). 1 Prompting/ When prompted, displays the last few steps of select tasks performed so
reminding: the resident would be aware (i.e., if the detergent was already placed or
a cup, of flour was already added).
Prediction: Monitoring hand gestures possible prediction of Parkinson' s disease.
GatorTech Smart Live-in/ Remote Voice, touch screen, PDA, and remotely control home via internet
House, University of development/ control: p ortal/smart phone.
Florida, Gainesville, demonstration Automation: Lighting, blinds, keyless entry/automatic front door, and auto-program
Florida (RERC on one-story, 2,400- microwave.


Table 2-2. Continued












Name/location Structure Technology Description of smart technology development
description component

Technology for square-foot, 3- Monitoring: Tracking resident' s movement and falls (via floor sensors), mailbox,
Successful Aging, bedroom smart microphone/camera at front door, body weight, temperature, water leak,
2006). home. toilet paper, water temperature, soap dispenser, and bed sensors monitor
sleep patterns.
Prompting/ Microwave prompts food preparation steps, and reminders in home
reminding: provided to take medications and upcoming appointments.
Prediction: None reported on home website.
MavHome, Development/ Remote Voice, touch screen and remotely control home via internet portal.
University of Texas demonstration control:
at Arlington, two-story, 5,500- Automation: Lighting, kitchen automatically retrieves recipes online, robot cuts grass
Arlington, square-foot smart and vacuums, and auto bath water temperature/filling
Texas(2006). home/banquet Monitoring: Weight, appliances (including refrigerator tracking contents and
hall/meeting- automatically ordering, food online).
classroom Prompting/ Dietary recommendations based on resident ideal weight.
complex. reminding
Prediction: Emphasis is on developing computer prediction algorithms to assist in
adjusting the home environment (i.e. temp) and predicting health needs
of residents (monitoring. short and long, term changes in health)
PlaceLab, MIT, Live- Remote None reported on home website.
Cambridge, in/development/ control:
Massachusetts demonstration Automation: None reported on home website.
(Massachusetts 1,000-square-foot
Monitoring: Sensors are located throughout the apartment which can detect whether
Institute of smart apartment.
an obj ect is moved, opened/closed, turned on/off, and also detect
Technoogy, 006).resident' s limb motion with wearable accelerometers. A resident' s
activities and behaviors can be recorded with one of the 9 infrared
cameras, 9 color cameras, and/or 18 microphones.


Table 2-2. Continued












Name/location Structure Technology Description of smart technology development
description component

Prompting/ Prototype system that promotes healthy lifestyles in the home. These
reminding: prototype systems use social science and behavioral science techniques
to motivate change in a resident' s behavior. Examples promoting
healthy eating, energy conservation, increase physical activity, and
sftpractices.
Prediction: None reported on home website.
Point of Care Development of Remote None reported on home website.
Laboratory, Oregon smart control:
Health & Science technologies. Automation: None reported on home website.
University, Portland, Monitoring: Bed pads/loading cells to assess quality of sleep (restless leg syndrome,
Oregon (2006). COPD), and development of algorithms to detect when medication
regimens are not adhered.
Prompting/ Developing interactive computer games as cognitive exercises.
reminding: Reminding of medication administration times.
Prediction: Developing technology systems that through monitoring elder
movements may detect early onset of cognitive impairments.
Smart House, Duke Live- Remote Voice.
University, Durham, in/development/ control:
North Carolina demonstration Automation: Lighting, temperature, music, television, and security
(2006). 4,500-square-foot Monitoring: Facial recognition security cameras.
smart home. Prompting/ None reported on home website.
remindin:
Prediction: None reported on home website.
Smart House, Development/ Remote Family members remotely monitor resident health status and sleep
University of demonstration control: conditions.
Virginia Medical smart home. Automation: None reported on home website.


Table 2-2. Continued












Name/location Structure Technology Description of smart technology development
description component

Automation Monitoring: Stove-top, bed mattress pad (breathing, pulse, room light level, and
Research Center, body temp/position). Gait pattern sensor and a fall detector (floor
Charlottesville, vibration sensor).
Virginia (2006). Prompting/ None reported on home website.
remindin:
Prediction: None reported on home website.
Smart Medical Development/ Remote None reported on home website.
Home, University of demonstration 5 Control:
Rochester, room smart home. Automation: None reported on home website.
Rochester, New Monitoring: Vital signs (blood pressure, pulse, and respiration), speech patterns,
York (2006). breathing patterns, computer mouse activity, body motion, and gait
pterns are monitored.
Prompting/ None reported on home website.
remindin:
Prediction: Developing a smart home system that potentially could detect various
health problems before the resident is aware.


Table 2-2. Continued
























































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habits, age, gender, race,
coping skills, itness, and scial
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independnce?


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indepen dence ?




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Research Quesion #31
Eb.I.1 do elder s lith MIs make
decisions in choosing w..hich ST is
< needed or not needed?

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User Friendlinesf of Dvice (DE

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Health Condition

(disord~er or disease)









CHAPTER 3
METHODOLOGY

Introduction

In this chapter the methodology for this study is presented in detail. The rationale for the

research approach, a review of the ethnographic decision tree modeling method, role of the

researcher, sampling criteria, participant recruitment, are presented. Data collection techniques

and analysis process are also described. Finally, an exemplar of the analysis process conducted

for participant three is described in detail to illustrate the process of analysis completed with

each study participant.

Research Approach

Few studies have explored elder perceptions of needs in smart technology (ST). Therefore

an ethnographic research approach was utilized to explore elders' perceptions of ST solutions.

This study was designed to address the following questions:

1. What do elders with mobility impairments (MIs) perceive as their areas of difficulty in

maintaining independence?

2. Which ST(s) do elders with MIs perceive as solutions (or encumbrances) in helping

maintain their independence?

3. How do elders with MIs make decisions in choosing which ST is needed or not needed?

Rationale for Research Approach

A practical means of exploring end-users' needs is to involve the elder in the design

process. User participation can be performed early or late in the product development cycle and

can be studied in a controlled lab setting and/or in a naturalistic environment. Figure 3-1

illustrates techniques involving user participation along the development cycle (Muller,

Wildman, & White, 1993). The horizontal axis of Figure 3-1 provides an approximate guide to









when a technique might be most useful during the development cycle (early or late). The vertical

axis illustrates when the designer participates more directly in the users' world and vice versa.

Suitable group sizes for each technique are indicated in the figure with superscript letters (Muller

et al., 1993). Customization technique, collaborative prototyping for design technique, and

participatory analysis of usability data technique are typically employed later in the product

development cycle. In contrast, co-development technique, envisioning future solutions

technique, and ethnography technique are approaches that would allow designers to get a better

understanding early in the development cycle (which helps guide early prototype creation). Co-

development technique, mock-up technique, and participatory ergonomics technique typically

have users participate in a lab setting. While envisioning future solutions technique, contextual

inquiry technique, and ethnography technique generally have the designers participate more in

the user' s world (which provides a richer dialogic context of their world). A rich dialogic context

is important because it helps categorize the end-user' s perspective of their situation in terms that

are meaningful to the participant (Blomberg, Burrell, & Guest, 2003). Understanding the terms

and categories utilized by the end-user can improve upon the validity of future quantitative

studies (i.e., survey design) where the terms and categories have to be known in advance

(Blomberg et al., 2003).

Ethnographic Decision Tree Modeling

Data analysis related to ethnographic product design should go beyond simple structured

reporting of the interviews and observations (Mariampolski, 2006). They should produce

interpretations of the data that potentially help developers in the design of products

(Mariampolski, 2006). Developers would find it useful to know the types of ST devices

perceived as needed by elders and how these need decisions are made. The goal of ethnographic

decision tree studies is to predict decisions that will be made by modeling and identifying the










specific decision criteria used by most individuals in a group (Gladwin, 1989). Ethnographic

decision tree modeling elicits "why people in a certain group do what they do" (Gladwin, 1989,

p.7). Knowing a groups' decision making process may enhance the success of the (ST)

intervention being implemented (Gladwin, 1989).

There are two phases in building ethnographic decision tree models. Phase one, the model

building phase, is an inductive process consisting of a series of ethnographic interviews and

participant observations. Through these ethnographic field techniques decision criteria are

elicited from each decision maker (i.e., elder consumer) and then combined to form a diagram

(i.e., decision tree) of their choices. A composite decision model of all the individual decision

trees is then constructed to represent a group model. Phase two, the model testing phase, utilizes

a formal questionnaire to test the predictive accuracy of the composite model (created during

phase one) on a separate group of decision makers from the same population. In this study, the

initial stages of phase one were carried out which resulted in a preliminary ethnographic decision

model of the elder ST decision process. This preliminary model could be utilized by future

researchers to more thoroughly explore the decision criteria surrounding the elder ST need

decision process. In summary an ethnographic research approach, with a decision tree modeling

component, was chosen to explore the complex variables surrounding the criteria elders utilize

when selecting ST prototypes early in the development cycle.

Ethnography and Technology Development

While ethnographic research comes from the discipline of cultural anthropology beginning

in the early 1900's (Creswell, 1998), it was not until the 1960's that companies utilized

ethnographers to understand their customers (Ante & Edwards, 2006), and early 1980's that

ethnographers were utilized to assist in examining human-computer interactions (Blomberg et

al., 2003). The impetus for utilizing an ethnographic approach was due to technology moving









from engineering and research labs into the mainstream workplace environments (Blomberg et

al., 2003). Designers realized that they could not solely rely on their own expertise as a guide for

user requirements, they immersed themselves in real work situations to learn as much as possible

from the user' s point of view (Blomberg et al., 2003; Preece et al., 1994). Today large

corporations are frequently utilizing ethnographers to help reveal consumer needs, for example:

Sirius Satellite Radio had consulting ethnographers shadow 45 participants for four weeks

studying how they interacted with entertainment technology prior to designing a new portable

satellite-radio player; General Electric Company consulted ethnographers who conducted

interviews over a period of four months to break into the plastic fiber industry; Intel Corporation

had consulting ethnographers help devise a $500 community computer that would operate on a

truck battery in 113 degree temperatures. Furthermore Intel is currently utilizing ethnographers

to perform a needs assessment to prepare for the wave of aging baby boomers (Ante & Edwards,

2006; Berner, 2006; Loudon, 2005).

Advantages and Disadvantages of Ethnography

An advantage of using an ethnographic methodology to initially explore elder' s perception

of ST is its underlying assumption that in order to understand a world that you know little about,

you must explore elders' everyday realities firsthand (Blomberg et al., 2003). The advantage of

the holistic empirical nature of the ethnographic method will assist in understanding the cultural

forces that shape the elder participants' everyday realities (attitudes, beliefs, and perceptions) in

regards to ST needs (Portney & Watkins, 2000). Table 3-1 describes various advantages and

disadvantages of utilizing an ethnographic approach.

An additional advantage of the ethnographic method in this study is that context rich data

may potentially provide an initial framework that describes the elders' perceptions of their ST

needs. Disadvantages of using the ethnographic method are the disruption caused by the









researcher' s presence in the home and poor generalizability of results. However the emphasis on

discovery and context rich data made ethnography best suited method for exploring any unmet

ST user needs (Martin, Murphy, Crowe, & Norris, 2006).

Role of Researcher

Prior to data collection the ethnographic researcher determined which researcher role

(ob server-participant, participant-ob server, insider-ob server, and interviewer) was appropriate

during the study (Table 3-2) (Blomberg et al., 2003; McMillan & Schumacher, 1997). The effect

on the participant, researcher and event varies with each role (Blomberg et al., 2003; McMillan

& Schumacher, 1997). As Table 3-2 illustrates both pure participant or observer roles were

inappropriate as neither were interactive (McMillan & Schumacher, 1997). Participant-observer

role (i.e. spouse-assistant) and insider-observer role (i.e. therapist, nurse) would both require

time and resources to assimilate into the home and would take from the ability to interact with

the elder participant. However both observer-participant and interviewer role were found to be

appropriate for this study. An observer-participant role provided rich context specific data on

how elder participants performed activities in their home environment. Interviewer role produced

an in-depth understanding of any unmet elder needs and perceptions of ST solutions.

Sample

Inclusion and Exclusion Criteria

Inclusion criteria for this study included age 1 60 years, self-report of mobility impairment,

and English-speaking. Exclusion criteria included participants who were unable to complete the

interview session (d/t marked communication or cognitive deficits), reside in a skilled nursing

facility, or nursing home. For this study mobility impairment was defined as a limitation in the

execution of: carrying/manipulating obj ects, changing body position, or transferring from one

place to another by walking or climbing stairs due to a physiologic abnormality or loss. The









definition of mobility impairment was composed from the World Health Organization ICF

(2001) definition in which mobility is defined as, "moving by changing body position or location

or by transferring from one place to another, by carrying, moving or manipulating obj ects, by

walking, running or climbing, and by using various forms of transportation" (p. 138) and

impairment is defined as, "a loss or abnormality in body structure or physiological function" (p.

213).

Recruitment

Subj ects were recruited from the Rehabilitation Engineering Research Center on

Technology for Successful Aging (RERC-Tech) research sample pool. Participants'

demographics, health, and functional status information were screened for inclusion and

exclusion criteria prior to being recruited via phone call. A total of 11 elders were recruited

through purposive sampling method.

Data Collection Techniques Used

Interviewing

Interviewing is the most important data gathering technique for the ethnographer

(Fetterman, 1998a) and is essential in understanding the participant' s perspective (Blomberg et

al., 2003). Ethnographic interviews were the primary data collection stratagem during the study

and were a secondary outgrowth from participant observation sessions (McMillan &

Schumacher, 1997). Interviewing was vital for this study due to the limited access this researcher

had to observe participants performing their ADLs/IADLs and the conceptual nature of the

study. This researcher conducted all in-depth interviews.

Structured and semi-structured interview approaches with open and closed-ended

questions were utilized to obtain background information, descriptions of daily activity levels,









and participant perceptions of ST component areas (Figure 3-2). Figure 3-2 illustrates data that

was collected by topic and subtopic areas.

The 'Initial Interview Guide' (Appendix A) was used to compile information such as basic

demographic, health activity, aging in place, and technology experience information. This

background information provided contextual information that assisted in describing the

participants' views on smart technology.

The 'Current Activity Performance Guide' (Appendix B) was utilized to document the

participant' s description of their daily task (e.g. bathing, grooming, dressing, sleeping, and health

management) execution. These activities are adapted from the Occupational Therapy Practice

Framework' s categorization of the Areas of Occupation (ADLs, IADLs, work, play, leisure and

social participation) (Youngstrom et al., 2002). This activity performance information assisted in

describing the participants' daily difficulty areas in maintaining independence (research question

#1). Table 3-3 and Table 3-4 summarize all ADL and IADL activities assessed during the study.

The 'In-depth Interview Guide' (Appendix C) was utilized to probe participants'

perceptions of various component areas of ST (research question #2). The ST component areas

are based on a Smart Technology Development Framework' (Appendix D) that was created for

this study to illustrate the central ST component areas in development around the world. Eight

visual display boards (Appendix E) were utilized to introduce smart technology and help

participants visualize the differences between automating, monitoring, prompting/reminding,

predicting, and remote controlling technologies in smart home design.

Participant Observation

Typically ethnographers utilize multiple methods and sources to collect and validate data

(McMillan & Schumacher, 1997; Portney & Watkins, 2000). A fundamental assumption of

anthropology is what people say they do may not always represent what they do in reality










(Blomberg et al., 2003). Therefore to verify and enhance the interpretation of the interview data

participant observation technique were utilized. Participant observation helped capture behavior

that participants were unaware of due to the habitual nature of tasks and relevant details that

were missed due to dynamic nature of the home (Blomberg et al., 2003). A participant

observation grid was utilized due to the limited observation time and the complex nature of the

home environment (Appendix F). Utilizing a participant observation grid allowed the researcher

to remain focused on descriptive details salient to the phenomena under study, which later led to

more subtle information surrounding the phenomena (McMillan & Schumacher, 1997).

Use of Camera

Cameras enabled the ethnographer to document field observations, which acted as

mnemonic devices during analysis phase (Fetterman, 1998a). Photographs captured during the

beginning of the study were retroactively examined for themes (Fetterman, 1998a). Still camera

photography was utilized to capture elder problem areas and success areas in their environment.

Photographs of environmental modifications (i.e., ramps, grab bars, railing), homemade assistive

devices (i.e., jar/soda can holder, yogurt cup holder), and problem areas (narrow door frames,

uneven floor tiles, steep stairs) were recorded.

Field Notes

Ethnographic observations and interviews can be exhaustive (Fetterman, 1998b); therefore

field notes were needed to capture the content rich data before subsequent events overshadowed

the experience (Fetterman, 1998b). Field notes were indispensable in this study as they formed

the building blocks necessary for the in-depth analysis process (Fetterman, 1998b). There are

many styles of recording field notes in ethnography (Spradley, 1979). This study utilized three

formats (condensed account, expanded account, and fieldwork j journal) to record field notes

(Spradley, 1979). A condensed account is comprised of field notes taken during the interview









and observation process (Spradley, 1979). Condensed field notes included short phrases,

abbreviations, unconnected sentences, and mnemonics that later assisted the researcher in the

reconstruction of events (Fetterman, 1998b; Spradley, 1979). After the field observation and

interview session ended, the expansion account of recording field notes was initiated to expand

upon the condensed field notes (Spradley, 1979). Expansion field notes included filling in all

needed details surrounding the events not recorded on the location (Spradley, 1979). The final

method of field note recording involved the researcher keeping an introspective fieldwuork

journal, which accounted for any biases or feelings that may have influenced the research

process (Spradley, 1979). Fieldwork j ournal descriptions included recording problems,

breakthroughs, confusion, mistakes, and ideas (Spradley, 1979).

Data Collection Protocol

Study sessions began with an initial interview phase to gather background information,

including specific information on participants' current activity status. This was followed by an

in-depth interview phase to explore participants' perceptions of smart technology. During the in-

depth interview phase, visual display boards were utilized to introduce smart technology and

help participants visualize the different technologies in smart home design. A brief participant

observation phase followed to document the participant' s use of space and integration of

technology into their home. During the participant observation stage, still camera photography

was utilized to help capture any problem or success areas in the home environment.

Outline and time that was allotted for each phase of data collection is listed below:

Phase 1 -Initial interview (45-90min.)

Initial Interview Guide A structured interview approach with closed-ended questions
were utilized to gather basic demographic, health activity, aging in place, and technology
experience information (Appendix A).










* Current Activity Performance form (Appendix B) was utilized to document the status of
participant' s description of their daily task (e.g. bathing, grooming, dressing, sleeping, and
health management) execution.

* Phase 2 In-depth interview (45-90min.)

* hI-depth hIterview Guide Semi-structured open-ended questions (Appendix C) along with
eight visual display boards (Appendix E) were utilized to thoroughly explore participant' s
perceptions of various component areas of ST.

* Phase 3 Participant observation (20-30min.)

* Participa~nt Observation Grid (Appendix F) helped document observations while having
the participant give a tour of their home and point out their success and problem areas.
Utilizing the participant observation grid allowed the researcher to remain focused on
descriptive details, which later led to more subtle information.

Interview and participant observation phases were audio recorded and transcribed

verbatim. Field notes were written during interview sessions (condensed field note account),

following interview (expanded field note account), and throughout the study (fieldwork j ournal

account). Still camera photography was utilized during the participant observation phase (phase

3) to capture elder problem and success areas in their environment.

Data Analysis

Qualitative data analysis begins the moment a research problem is selected and builds on

insights throughout the study (Fetterman, 1998a). Demographics, health, activity status, previous

experience with technology, and views on aging in place were analyzed to help determine any

trends in the study sample. Categorical variable (frequencies) and non-categorical variable

(means, standard deviations, and range) background data were evaluated. All In-depth interviews

were transcribed verbatim.

Bias

To help avoid researcher bias, during the analysis process multiple meetings with a

qualitative advisor were conducted to analyze the researcher' s interpretation of the findings. An










open coding process (as opposed to a preexisting list of codes) was utilized to capture all

emerging decision criteria during the analysis process. Preliminary findings were also presented

to a qualitative data analysis group, where the researcher' s interpretations of the data were

examined.

Data Saturation

In qualitative research the sample size varies due to the flexible nature of sampling. Data

collection continues until data saturation (when no new themes emerge from the data) is

achieved (Ploeg, 1999). Typically in ethnographic research themes begin to emerge within the

first few interviews (Anderson, 2001; Muller et al., 1993) and data saturation almost completely

occurs within the first 12 interviews (Guest, Bunce, & Johnson, 2006). For this study the

maj ority of new themes emerged within the first four in-depth interviews. A couple of new

themes were revealed during interview #7; however no new themes emerged in the last four

interviews.

Ethnographic Decision Tree Modeling

As the goal of this study was to explore how participants made their decisions regarding

ST, an ethnographic decision tree modeling approach was utilized (Gladwin, 1989). Interview

transcripts, field notes, and field j journal entries were analyzed based on this inductive approach

geared toward eliciting contextual data about decision processes (Gladwin, 1989). Initial phases

of data analysis involved many iterations of sorting, comparing, and identifying key phrases that

both represented participant decision criteria, and reflected any contrasts in decision behavior

(Gladwin, 1989). Decision criteria themes were then combined in the form of a decision tree to

build decision models (Gladwin, 1989). Transcripts were read multiple times and expansively

converted into decision models illustrating each participant' s conceptual perceptions of their

activity and ST needs. The final phase of analysis involved combining all participant conceptual









decision models into a broad composite conceptual model illustrating the issues surrounding the

elder groups' ST need decision process.

Data analysis process involved creating numerous drafts to reflect the participant' s

decision process. For example early versions of participant-1's activity limitation decision

models were basic and only illustrated contrasts between the types of assistance (person,

equipment, no assistance) utilized (Figure 3-3). Later versions of this activity limitation decision

model were more comprehensive and differentiated between types of assistance (AT, family, AT

and family, no assistance) and status of the activities (satisfied with activity, problem with task

completion and would like a solution, problem with task completion but not concerned)(Figure3-

4). Early versions of the ST need decision models were often too complex. For example during

initial phases many attempts were made to illustrate contrasts between all 44 ST devices in a

single decision tree. Figure 3-5 documents an attempt to illustrate contrasts made by participant-

1 between 26 ST devices.

Example Analysis Process for Participant Three

Background information

An exemplar of the analysis process completed with each study participant is reviewed in

the following section. Each transcript was read multiple times and information regarding health

condition, living arrangements, description of AT utilized, experiences with technology, and

views on aging in place were synthesized and consolidated into a single coversheet (Figure 3-6).

This participant background information sheet provided quick access to contextual information

which assisted during the analysis process. For example a quick glance at participant-3's

background information sheet illustrates that he is a 74 year old, Caucasian male, with a history

of multiple strokes, who wears an orthotic brace on his left leg, owns a cell phone (and uses it










daily), lives with his daughter in a rented condo, and utilizes a powered wheelchair for

ambulation.

Activity need decision model

As discussed in the previous section, later versions of activity-need decision models were

able to differentiate between types of assistance (AT, family, AT and family, no assistance) as

well as perceived status of activity performance levels (satisfied with activity, problem with task

completion and would like a solution, problem with task completion but not concerned)(Figure

3-4). Utilizing a decision modeling approach, a key barrier theme of being satisfied with an

activity performance was revealed. For example participant-3 cited being satisfied with his

current activity performance level with regards to his assistive technology assisting him in his

showering and walking activities. This is illustrated in his decision process: activity limitation,

assistance utilized, assistive device utilized, satisfied with current performance level of activity

(with assistive device) (Figure 3-4). A key facilitator theme of wanting to decrease imposition on

family was revealed by participant-3 as well, who cited not being satisfied with his dressing

activity. This is illustrated in his decision process: activity limitation, assistance utilized,

family/person assistance utilized, problems with task completion (with family assistance), and

would like solution to problems of completing activity. Where participant-3 cites,

Oh I am not comfortable, because it [donning slacks] is awful difficult, and sometimes she
[daughter] is doing something else and gets all ticked off....I don't like to have to depend
on my family because they got their own lives and everything. (Transcribed Interview,
pages 21, participant 3).

Smart technology need decision models

As discussed in the previous section, early versions of the ST need-decision process were

found to be too complex when attempting to illustrate contrasts between all 44 ST devices in a

single participant's decision model (Figure 3-5). Therefore separate decision models were









constructed for each of the ST component areas (remote control-voice, remote control-

touchscreen, household automation, personal robotic assistance, monitoring technologies,

reminding technologies, and prediction technologies) for each participant (Figures 3-7 to 3-14).

Several of the smart technology decision models constructed for participant-3 are discussed in

the next section.

Remote control-voice decision model

Utilizing a decision modeling approach, a key barrier theme of being concerned about the

reliability of ST was revealed by participant-3. Participant-3 cited being concerned about the

reliability of a remote voice controlled device. This is illustrated in his decision process of:

remote-voice control (VC), no need, additional problems arise with the incorporation of

technology (i.e., reliability a concern), VC-TV set (Figure 3-7). Where participant-3 cites,

They [voice recognition] act up an awful lot. And I don't think you really need it, hell if
you can't mash the button on the remote control what's the use, I mean, it would be nice to
have it [voice recognition] but I don't think it's very important. (Transcribed Interview,
pages 39, participant 3).

Household automation decision model

Utilizing a decision modeling approach, key ST facilitator themes were also revealed

during the analysis. For example a key facilitator theme (diagrammed as a red cloud icon in the

decision model) of desiring additional assistance with a difficult task was revealed (Figure 3-9).

Participant-3 cited desiring further assistance in performing the difficult activity of

opening/closing his front door. This is illustrated in his decision process: household automation,

need, slight need, automatic front door (Figure 3-9). Where participant-3 cites,

Well that [automated front door] would be nice, I could push the button and tell them to
come in the front door and that would be nice. (Transcribed Interview, pages 42,
participant 3).









Personal robotic assistance decision model

The decision modeling approach was able to reveal complex decision criteria. For example

participant-3 cited needing assistance with transferring in/out of his bathtub; however he was

concerned about the size of the technology and the heat generated by the technology. This is

illustrated in his decision process: personal robotic assistance, need, strong need, transfer aid,

concerned about, size of technology, and heat generated by the technology (Figure 3-10).

Participant smart technology overall decision model

An overall participant ST decision model, which represented all ST component areas, was

built for each participant (Figure 3-14). This overall ST decision model illustrated all primary

barrier themes (cost, fear of dependency, additional problems, no gain, stigma, donning

difficulty, reliability concerns), facilitator themes (decrease imposition, replace unsafe activity,

assist with activity that is difficult to perform, enhance ability to monitor health), as well as all

ST devices (automatic front door, early detection of changes in activity level, voice control

dialing of phone numbers, dressing aid, carrying aid, transfer aid) cited as needed by participant-

three.

Elder smart technology decision tree model

The final phase of analysis involved combining all participant ST decision models into one

broad composite conceptual model that represents the groups' decision process (Figure 3-15).

Barrier and facilitator decision criteria cited in participants' ST decision models were utilized to

build the final composite model. This final composite model illustrates the criteria surrounding

ST need decision process and is discussed thoroughly in chapter 4.

Summary

Potential participants were pre-screened for inclusion criteria (65 or older, self report of

mobility impairment) and exclusion criteria (reside in skilled nursing facility, or nursing home)










prior to being recruited via phone call. The in-depth interview/in-home observation session took

2.5 4 hours to be completed. Firstly participants were asked demographic and functional status

questions. This was followed by exploring participants' perceptions of various smart technology

component areas. During this stage, visual display boards were utilized to introduce smart

technology and help participants visualize the different technologies in smart home design. The

final stage involved the participant giving a tour of their home where still camera photography

was utilized to capture any problem or success areas in their home environment. The interviews

were transcribed verbatim and analyzed for key phrases that both represented participant

decision criteria, and reflected any contrasts in decision behavior. Decision criteria themes were

then combined in the form of a decision tree to build decision models.











Custormization


Position of Activity in the Development Cycle


Low-tech Prototyping S
Participatory Ergonomics "M


Co-development as


Mack-ups *


Video Prototyping f
Storyboard Prototyping S,.ne
Cooperative Prototyping rS


Card Games "


(Semi) Structured Confeenmces M.


Cooperative Evaluation T
Collaborative Prototyping for Design T.

Partcipalory AnalysIs of Usabiliry Data T.

Appropriate group size for each technique:
T=tiny (2-4) S=small (6-8)
M-mRod~erate (up to 40) 8=big (up to 200)


Translators "


Collaborative Prototyping v.s
Envisioning Future Solu~tions s$U
Contextual Inquiry LAN
Ethnographic Methods T.s.


Figure 3-1. Techniques in user participatory design. [Adapted from Muller, M., Wildman, D., &
White, E. (1993). Taxonomy of PD practices: A brief practitioner's guide.
Communications of the ACM, 36(4), 24-28 (Page 27, Figure 1).]


Table 3-1. Advantages and disadvantages of ethnography. [Adapted from Denscombe, M.
(2003). Thze good research guide: For small-scale social research projects (2nd ed.).
Philadelphia: Open University Press. (Page 92-94).1


Advantages:
Direct observation- Have direct observation
via fieldwork, rather than using only
second-hand data.
Empirical- Grounded in empirical research
by direct contact with pertinent people and
places.
Links with theory- Can be used as a process
for developing and testing theory.

Detailed data- Rich data can deal with
complex and subtle realties.
Holistic- Focuses on processes and
associations that lie below the surface
events .
Actors' perception- deals with the way
participants perceive events as seen
through their eyes.


Disadvantages:
Stand-alone descriptions- Potential to
generate depictions of isolated stories that
are not linked together.
Story-telling- can become the exclusive
purpose, leaving research product which is
theoretical, unempirical and non-critical.
Reliability- Potential limitation of poor
reliability and diminutive prospect of
generalizing.
Ethics- Greater potential of problems linked
with infringement upon privacy.
Access- Acute complications in gaining
access to settings that would avoid
unsettling the naturalness of the setting.
Insider knowledge- can potentially
overlook habitual phenomena.










Table 3-2. Description of research roles. [Adapted from McMillan, J., & Schumacher, S.
(1997). Research in education: A conceptual introduction (4th ed.). New York:
Addison-Wesley Educational Publishers Inc. (Page 437, Table-12-1).]


Role
Observer


Observer-
participant

Participant

Participant-
observer

Insider-
observer

Interviewer


Description
Researcher is physically absent (observer
looking through a one-way mirror).

Observing events and interacting with
participants from a subtle position. Does
not experience the activity first hand.
Researcher lives through an experience and
recollects personal insight.
Actively involved in the events being
observed. Researcher creates role (i.e.
caregiver-assistant) for purpose of study.
Researcher has an existing formal position
(i.e. superintendent, teacher, and
counselor) in organization.
Establishes role (i.e., graduate student)
with each person interviewed.


Use
Inappropriate for ethnographic
study; may be used for other
forms of qualitative research.
A typical role in ethnographic
study .

Inappropriate for ethnographic
research.
A typical role in ethnographic
study .

Used in special circumstances.


Primarily used in ethnographic
interview studies.













INTERVIEW DATAI
(Phase 1 + 2)


PICTURE OF CURRENT ACTIVITY
STATUS

CURRENT IACTIVTY PERFRIIIMIANC~E GUIDE

REGARDING:
1 Does or Does not Perform Activity
2. Current Assistance Level Required
a). Type of current assistance
3 Preferred Solution
a). Whether open to the idea of
using ST If available

ADLs (i.e. bathing, grooming,
functional mobility, dressing)

IADLs (1.e. meal preparation,
communication device use, home
management)

Social Participation (i.e. remembering
birthdays and community events)

Leisure Activities (1.e. TV viewing)


INITIAL INTERVIEWS GUIDE


Demographic Information

De scri pti on of Exi stin g
Health Conditions

Description of Mlobility
Assistive Devicels) Utilized

Past Experiences (i.e. with
technology, falling)

Living Arrangement (1.e.
alone, gated community)


Views on Aging in Place


EXPLORATION INTO PERCEPTIONS OF
VARIOUS COMPONENT AREAS OF ST


IN-DEPTH INTERVIEW GUIDE

Remote Control
(volce/touchscreen)

Household Automation

Personal Robotic Assistance

Monitoring Technologies


Prompting Technologies


SPrediction Technologies


BACKGROUND INFORMATION


Figure 3-2. Interview data collected by topic and subtopic question areas.









Table 3-3. List of Activities of Daily Living (ADL) assessed
ADL (taking care of one's own body)
Bathing and Showering
Physically bathing/showering
Turning on/off shower/sink faucets
Adjusting water temperature of shower/sink
Bowel and Bladder Management (intentional control
bowel/bladder)
Dressing
Lower body dressing (including shoes)
Upper body dressing
Eating
Functional Mobility
Functional ambulation
Getting in/out of bed
Getting in/out of shower
Getting in/out of tub
Carrying items around the house
Personal Hygiene and Grooming
Brushing teeth/combing hair
Toilet Hygiene
Transferring to/from and maintaining toilet position









Table 3-4. List of Instrumental Activities of Daily Living (IADL) assessed
IADL (oriented toward interacting with the environment)
Communication Device Use: Home Establishment and Management (home, yard, garden):
Cell phone/telephone Adjusting the thermostat in home
Computer Checking the mail
Community Mobility: Preventing food from expiring before use
Driving and using public transportation -taxi, bus Keeping track of food in kitchen
Financial Management Doing laundry
Health Management/Maintenance : Vacuuming
Monitoring vital signs (blood pressure, temp., resp. rate) Remembering appliance maintenance
Monitoring sleep patterns Mowing the yard
Tracking the frequency of trips to the bathroom at night Turning on/off lights in home
Physical fitness activity/routines Seeing who is at the front door
S'Mental fitness activity/routines Opening/closing all doors/windows/blinds in home
Maintaining well balanced nutritional meal choices Unlocking/locking all the doors/windows in home
Decreasing health risk behaviors Setting the home security alarm
Medication management/routines Seeing which stove top burner is on/off
Remembering physician appointments Safety Procedures and Emergency Responses:
Meal Preparation and Cleanup: Remembering to check in with designated family/friend
Planning/preparing meals Remembering to turn off all appliances
Using a microwave to reheat items Shopping:
Using a microwave to cook a prepackaged frozen meal Preparing grocery shopping list
Cleaning up food and utensils Purchasing items at a store


































Figure 3-3. Early decision model regarding activity limitation.

















Model Interview #3
Assistance with Activity Info


AtIY
ActivityL~mtabon

Ass stance
Utlred





Satisfiedso Assls DVeev

Performanc Devce [it Famil Asitnc)Asitv Dvc adDec n
Lebel ofAcndt ASstnc aml
(witi~~~ssistlveAs Fa ltsitac) sssane




Spongeolem Showe Chair Gra Acdt Com lein tobthaotI~ etd tAtvt cyt8p crip ntns" Duh r Assstance) -'e ahIf
a s)-rgtnoewlolnt wan Activityc TThtseleterol anafod roothtcnhl
anyonesl tom com In, Iffomac Iee ge n meoopng 10 ete e, eas tI al
wo e e utrrigtat he Dagtrprom -prli Ant f Openng idw-100 Drsig50 D uhersit scr tehlon slyh veon go
edge TOPPE PEFRIIG: Tasfrngosf omoe drvshel soe W tngCeks-(7% Dagtr efom ) Teon it rssn)-O a otO sin lilg nIh etDSad nth
BahngI T b(S o e Itb) (ra ar) I old t an auhe pror s prciat inm ro hsalac o t o fotbebcas Isonig(itDS net ptte od n I h
som boyi thr m sin et aghe ko hwm ch ad ts ohadtatIcat slcs I wfldifiut ndcn ralyhldm uImE




relaxedme Iedn get up and m (5 0% Daughte) cl er Nt~o m caethed lat itadeething Pefr It0) cngt n niwudtcs
ne saretyngtobuckleIsofMdcain aagmnt(5 meatn nymoneyo b~hawulder
STOPE PERFOMN gota hol ontog all thi an It c great Becaus sometime she justa tla Poles
Settngn then Secrit Alar vey cayI ll last weeky Vacuuming (10 Daugter Che in Blood Sugar-(P bx) hik dSontr w an to Grb e botr d, she
(Ual om gettth l ar gtnm ss el(0 Daugter Canylngr Io pltem aond h aciga rga n
Spongekypa inue timer 10a theein wic backard andu my hea hitt hous (Duhe assists) "Itecpbn agte~ ssace
Bars) -~ r gthe do r andldn bam ngvty in theror [robo thatrc can Items]ha woul Decm
bathroom Tain Blood Prssr bet vey nice It would stakes at Im oio on
Answrin th ooblf tiPPOERO m e- (100%relors D atllaug ter Dau epnn Wlcod (h1e%0 Ioady ofh of her Yo seee In cetFaiy It-
(slowto ge DB o bed nd ea out)reall cry nyhng,50 Da thi s [Let]
Into~~~~oesn~ awic) "I ustel coe am ealy anthol cap ve
Irastrng niifcom Cldrean ng r Pl tes/UnlgChcs ~% agtensl -enrs 'Teoe wthugI tres t gio n car t ngwth
Trabdynsf her e A esd (10 Daughter) It butw Io just drop Its5 adm tI atcnte h eu m
WaI (In-03 Carying Aidcart a o ah con) ee noKti~ ysmtmsseI on
-tm Nowtheyputthem pund yo ~st eveoe
90% ~ ~ ~ siths In thee back,~e andknth~ if00 Iagh Donus anoc Acivt Repac anetin Unsa fe TPE EFOMN o et oItgeu ~ase a oadhep i
frtont buGamr getto (r ach Peor (Int-03) Cuanl benIfsongi

overe therendm 100 the switch, wayese n Pefrme with Existingh n
Ieng the back ty and Iaumn burned mygtr onwnt ebohrds

Figure 3-4. Participant 3's assistance swit civt ecso m dl








































Men itorin g Te chnolo g ies


Medication Management

BloodPressure Management


Figure 3-5. Early decision model attempt at categorizing 26 ST devices within one decision
model .







67


M iorow~~ave Oven

Lights

Auto mated F ront Doo r

P ers onal R ob otic
Assistance















Model I ntervi ew #3
Background Info


Denmqraphicinfornation
Diabetic since 1970's (Has Health Descr bed as "Plss Poor" aea~r20
Divorced (x3), Completed some college receded Dialysis 3xweek
coursewo~rk, Annual Incorre ($10-20k) supports 2 1 I for past 12 months) IICABG 991 Stroke l 989, 1994, and 2004 IProsaeCancerO~ 200



SLivng Ar~rangennt -Periodic Generalized Body -Bilateral Cataracts

Lwes wth Adult Daughter (daughter has had following dialysis read Prescription Bottle directions)
epilepsy and cogndi~e Irrpairments since
childhood) Has rentedecondo from ex-wife for past I~an~


-L-Shoulder limited to 70 degrees elevation

L ve-ln tdul du htr p deed s iy check I -L-elbow lmded to 80 degrees extenslan

Reports Security system has been turned off for
last 3-4years. Stated that they stopped using It
because it would go off when he was not able to
get hiswic Into the home In time If he stood up-LHnmakdow vee,
he would fall against the keyboard "We rarely lock III-R-Hand Flexlon poor coordination, and laelon
It [front door] I couldn't tell you the lasitimelII IlmitedBO%ROMImtdoBO
Locked or unlocked n "


[0ulsid Asistance Daaugs er calls loafmih rsueSr n CI iLrql Ierosrreer hh oeda lcs fokeep foot In
the floor and can'tget up
R-Leg marked
Desripio ofATUtiize waknssfrom knlee Due to history of multiple strokes participant has
dcwn poor coordination, Ilmited ROM, and Ilmited
strength in LUE and LLE Two handed tasks are
Shower Chair, Long Handled Sponge, Grab Bars, difficult due to Ilmited coordination of LUE
Large Button Phone, Pill Bmc, and Rarrp at Limited rruscle strength In Bilateral Lower
Ertranceextremitles, 4-5 steps mrraximum, has fallen 688
Poweed weelhair Prmariy 9% ofimetimes over the past 12 months due to legs gwing
Cane- Sldo, Waker Sedomout, participant utilizes pcwer wkc 90% of time



Viewson Aqing in Place
Past Experience with Technoloquv

|"Strongly Agreed' mth the staternent'I'd real lketo Ilvein rry current residence for as long as
Owns a cellphone and uses Dosnthv ESpossble'
( dail4.
Will accept anything (Including technology, personalifamily attendants) to remain In home,
Has copute, ues t a ew ime a wek.HasComfort level remains steady as long as stay In home
Highspeed Internet access; "Ure to be every day I
would use my computer but R's got to where my Does plan to continue to lve In current residence for the next 10 years Would not continueto lve
back hurts after an hour but I can't stay long, you In horre If It was not safe
know when you get on the computer you're usually
there for three or four hours" Three things that you feel may causeyou to have to rrove out of your home- #1 -Fall and break
rry hip, #2- Vision Loss
Technology helps me connect with other people
Somehatliks t tr ne tehnoogyGenerally where would you seek assistanceto remain lving at home
1- Family (U~ve-n dtr) "Well with the way their [family/friends] Ilves are, they are tootled up, they
Been on a tour of a smart home and has couldn't help me "I can'thire nobody, I aln't got any money And my friends well rry friends are
participated In a focus group on smrrart horre BS 18 and the other one is 77 years old I think" ""I couldn't mrrke it by rryself, no way, I rrean I would
technology Ilke to try, I couldn't do 4 '


Figure 3-6. Participant 3's background information sheet.



















Remote -Voice Control (VC)


Additional Problems Arise with
the Incorporation of Technology
(Int-03) (i.e, reliability a


"[Technology can] probably save a lot
of energy, because ittakes going i
there and taking a bath, coming back
and laying dowin, and getting dressed,
is a complete day's activity for me, I
can hardly go."(Ilnt-03)


"They [voice recognition]
act up an awful lot. And I
don't think you really need
it, hell if you can'tmash
the button on the remote
control what's the use, I
mean, it would be nice to
have it [voice recognition]
but I don't think it's very
important." (Int-03)


Figure 3-7. Participant 3's smart technology remote control voice recognition need analysis
information sheet.









Interview #3
Remote -Touchscreen Control


TS Washer & Dryer


"I can't imagine needing it [remote control -
Tou chscreen], if you are going to do something at
th e wash ing machine you are going to be standing
there and looking at it, I can't see where that would
make any difference to me at all, honest to God,
finding the damned control would be the biggest
problem." (Int-03)


Rerrote Control -
Touchscreen (TS)


TS -Thermostat,
TV set, Security
system ,
Microwave oven,
and lights.


Figure 3-8. Participant 3's smart technology remote control touchscreen need analysis
information sheet.












I interview #3
Household Automation


Satisfied with current performance of
activity (int-03)


"That'd (Household Automation] be nice,
but things take a little bit of time right
now and I can do it, so there's no need
for it. I am in a lot better shape, than a
lot of people that go out to that clinic.
And a lot better attitude, a lot of them
are so damn depressed, I try to keep a
positive attitude." (Int-03)


"Well that [automated front door]
would be nice, I could push the
button and tell them to come in
the front door and that would be
nice." (Int-03)






Assist with activity
that is difficult to be
performed


Household Automation


Thermostat, TV set,
Security system,
Blinds, Washer and
dryer, Microwave, and
Lights.


Figure 3-9. Participant 3's smart technology household automation need analysis information
sheet.


Automatic Front Door













Interview #3
8-2-2007 version
Personal Robotic Assistance


Figure 3-10. Participant 3's smart technology personal robotic assistance need analysis
information sheet.











Interview #3
Monitoring Technologies


Monitoring Technologies


Medication Management,
Sleep Pattern Monitoring,
Tracking Visits to the
Bathroom, Blood Pressure
Management, Walking
Patterns Monitoring, Cooking
Pattern Monitoring,


"You know how much it'd cost?
Who is going to put it in?" (Int-03)


"I really don't know, it might be
worth the $30 [month], but if I got
me and my daughter living
together whnat the hell do I need it
for." (Int-03)


"They don't seem really interested
out there at dialysis. They want to
know what you weigh whsen you
come in, and you have to weigh
before you leave. monitoringg my
weight] that's not abig thing." (Int-


Figure 3-11. Participant 3's smart technology monitoring technologies need analysis information
sheet.











I interview #3
Prompting/Reminding Technologies


Satisfied with current performance of
activity (Int-03)


"It's a waste of time....I'm just not that interested in this [technology]. We do the pills and know exactly what we're doing with
it, food recommendations I like all of that, apples and oranges I eat all that anyways we buy and eat fruit a lot, physical
exercise I can't hardly do any....Appointments, events, and doctors appointments we keep up with all those pretty good,
sometimes we miss one but I stay friendly with the girls and you would be surprised what you can get when you are nice to
them....Y(eah, I just don't see any of the others [technology devices] that much, I wouldn't really go alter them because
they're not that important to me. I mean because I can do it now myself. Or my daughter can do it." (Int-03)


Medication Prompting, Mental Exercise,
Important Event Reminder, food
recommendations, Health Condition
Management, and Physical Exercise.


Prompting/Reminding
Technologies


i


Figure 3-12. Participant 3's smart technology prompting/reminding technologies need analysis
information sheet.




































Satisfied with current
performance of activity (Int-03)




"I go to the doctor so damn much, saving a visit wouldn't
even make a difference. I go every 2 weeks to get my
blood checked, for the Coumadin, and I go the doctor's
appointments, and they are in the same place, the same
place they do my heart thing, they check that, hell I don't
know. About 3 or 4 visits a month I think....It's just like this
other one [pacemaker checked] I can do over the
telephone, I'd rather go down there, because I'm going to
be there anyways. So I asked the girl and she'll take me
right in their and do it there. And I don't even need to make
an appointment, sometimes."(tInt-03)


"I know mrine [activity level] is down, down,
down, because like I said I can hardly,
getting to my car wears me out....Well if it
(activity monitoring) would help, and make
me understand more different things....]
have to more understand the whole thing.
That tracking might be a luxury." (Int-03)


Enhance Ability of
assessing activity status
and potentially make
recommendations (Int-03)


Early Detection of Tremors



"Well I have that [tremors],
it's not bad, you saw me
trying to stick that needle in
the bottle participantt drew his
own insulin]. I don't need a
house to tell me that."(Ilnt-03)


Figure 3-13. Participant 3's smart technology prediction technologies need analysis information
sheet.


'Well I'II tell you I remember a
whole hell of a lot better than a
lot of people my age. I don't
know that'snever been a real
thought for me."(Ilnt-03)

















Participant #3 Overall Views on ST


Specific Need to Change Current Activity Performance


Do an acdivity currently unable to perforrn
(Int-03)
[Dialing numbers on a phone]
[Dressing Aid]
[Trans er Ald]
[Carry ng Ald]
[DOaling numbers on a phone]


FmlyUA stance FriendA isac Agency Assistane AssieDeieUiie No A5ssisane Utlized



Figure 3-14. Participant 3's smart technology overall views need analysis information sheet.











Elder Participant ST Need Decision Process


Barrier
Themes


Facilitator
Themes


Figure 3-15. Composite elder smart technology decision tree model.









CHAPTER 4
FINTDINGS

Introduction

The purpose of this study was to explore the perceived smart technology needs of elders

with mobility impairments while constructing a preliminary decision tree model of how these

decisions are made. To accomplish this task, the following research questions were addressed:

1) What do elders with mobility impairments perceive as their areas of difficulty in maintaining

independence? 2) Which smart technology do elders with mobility impairments perceive as

solutions (or encumbrances) in helping maintain their independence? 3) How do elders with

mobility impairment make decisions in choosing which smart technology is needed or not

needed? As characteristic with qualitative research description as well as discussion of the

Endings from the data will be integrated throughout this chapter.

This chapter includes four sections. The first section presents the demographic information

of the sample. The next three sections correspond to the three research questions identified for

this study. The next section examines participants' current activity performance status, thus

determining the difficult areas participants had in maintaining independence. The third section

focuses on categorizing the ST selected by study participants. The fourth section examines how

study participants made their decisions regarding ST need. In this section themes are identified

and quotes are used to provide greater understanding of each theme. Specifically an ethnographic

decision tree modeling approach was utilized in this section to create a preliminary elder smart

technology decision tree model.

Description of Participants

Participants ranged in age from 69 to 88 years, with a mean of 76(6.2). Sixty-three percent

were female, and all were Caucasian. Fifty-five percent completed some college, and 27%









achieved at least an undergraduate degree. Demographic, health, and activity characteristics of

the sample are summarized in Table 4-1. Thirty-six percent of participants lived alone, while

45% lived with a spouse, and 18% lived with an adult-child. Eighteen-percent of the sample had

incomes under $15,000 per year, while 18% had incomes above $50,000 per year. Sixty-three

percent of participants described their health as 'Good'. Fifty-five percent of participants could

walk greater than 100-yards, and 27% had not fallen in the last year. Sixty-three percent of

participants had less than five chronic conditions, and 18% utilized less than six assistive

devices.

While sample findings are not generalizable due to the qualitative nature of the study, a

comparison of the study sample parameters to the national elder population parameters is

described below. The study sample ratio of male (36%) to female (63%) closely resembled the

national parameter of male (41%) to female (59%)(He, Sengupta, Velkoff, & DeBarros, 2005).

The study sample ratio of elders who lived alone (36%) to elders who lived with someone (63%)

also closely resembled the national parameter of 28% to 66% respectively (Gist & Hetzel, 2004).

In terms of education the study sample had a higher level of education with 18% receiving HS

diplomas, 55% attending college, and 27% achieving a bachelor' s degree as compared to

national parameter of 32%, 18%, and 15% respectively(Gist & Hetzel, 2004). In terms of

functional status the study sample had a much higher frequency of reported ADL difficulties

with 18% of participants having difficulty with 1-2 ADLs, 55% of participants having difficulty

with 3-4 ADLs, and 27% of participants having difficulty with 5-7 ADLs as compared to

national parameter of 6%, 4%, and 3% respectively(He et al., 2005). However the study sample

had a slightly lower prevalence of back problems (27%) as compared to the national parameter

of 38%(Pfizer Global Pharmaceuticals, 2007). Lastly the study sample had a much higher









percentage of participants with a history of a stroke (36%) as compared to the national parameter

of only 9%(Federal Interagency Forum on Aging-Related Statistics, 2004).

Research Question 1: What Do Elders with Mobility Impairments Perceive as Their Areas
of Difficulty in Maintaining Independence?

The aim of the analysis in this section was to examine participants' current activity

performance status, thereby determining the areas in which participants have dimfculty

maintaining independence. Documenting the status of the participants' daily activity needs is

pivotal to the overall goal of this study, which is to explore how elders perceive the degree to

which smart technology can meet these daily activity needs.

Activities of Daily Living

Within the seven maj or categories of activities of daily living (1 -bathing/showering, 2-

bowel and bladder management, 3-dressing, 4-eating, 5-functional mobility, 6-personal hygiene

and grooming, and 7-toilet hygiene) assessed, the most frequently cited dimfculties were

functional mobility (100%), and bathing/showering (82%). The least frequently cited dimfculties

were bowel and bladder management (9%) and none of the participants had dimfculty eating

(Figure 4-1).

Out of the 154 ADL tasks assessed (14 ADL tasks assessed for each participant, refer to

itemized list in Figure 3-3) participants cited having dimfculty 47% of the time. These dimfculties

were met (via acquisition of AT, or family assistance) for 39% of the ADL tasks, however needs

were reported unmet for 8% of the tasks (Figure 4-2).

Assistive technology (82%) and AT-family assistance (8%) were the most frequently cited

method for resolving their ADL dimfculties (Figure 4-3). The most commonly cited unmet-tasks

were dressing (33%), getting in/out bathtub (17%), carrying items (17%), and climbing stairs









(17%) (Figure 4-4). Assistive technology (58%) and family assistance (25%) were the most

frequently cited assistance methods that were not fully meeting their (unmet) need (Figure 4-5).

Instrumental Activities of Daily Living

Within the eight maj or categories of instrumental activities of daily living assessed (1-

communication device use, 2-community mobility, 3-financial management, 4-health

management and maintenance, 5-home establishment and management, 6-meal preparation and

cleanup, 7-safety procedures and emergency responses, and 8-shopping), the most frequently

cited difficulties were home establishment and management (i.e., vacuuming, yard care) (100%),

meal preparation and cleanup (63%), and community mobility (63%). The least frequently cited

difficulties were shopping (9%), and financial management (18%) (Figure 4-6).

Out of the 3 85 IADL tasks assessed (3 5 tasks assessed for each participant- refer to

itemized list in Figure 3-4) participants cited having difficulty 19% of the time. These difficulties

were met (via acquisition of AT, hiring assistance) for 16% of the IADL tasks, however needs

were reported unmet for only 3% of the tasks (Figure 4-7). Family assistance (48%) and hiring

assistance (20%) were the most frequently cited method for resolving IADL difficulties (Figure

4-8). The most commonly cited unmet-tasks were typing on a computer (23%), writing a

message when on phone (15%), preparing meals (15%), and cleaning utensils (15%) (Figure 4-

9). No assistance used (46%), AT (23%), and family assistance (23%) were the most frequently

cited assistance method that were not fully meeting their (unmet) need (Figure 4-10).

Research Question 2: Which Smart Technology do Elders with Mobility Impairment
Perceive as Solutions in Maintaining Their Independence?

The aim of the analysis in this section focused on categorizing ST selected by participants.

Maj ority of participants (82%) cited at least one smart technology device as needed. Out of the

seven maj or component areas of smart technology (1-remote control-voice, 2-remote control-









touchscreen, 3-household automation, 4-personal robotic assistance, 5-monitoring technologies,

6-reminding technologies, and 7-prediction technologies) assessed, the most frequently cited (as

needed) component areas were personal robotic assistance (73%), and prediction technologies

(64%)(Figure 4-11). The least frequently cited (as needed) component areas were household

automation (18%), and remote control-touchscreen (0%).

Out of the 484 technology-deci sions (44 smart technology devices assessed for each

participant) participants regarded smart technology as needed only 1 1% of the time, (Figure 4-

12). Eighty-nine percent of the time participants cited technology as not needed to maintain

independence. Participants frequently cited ST as convenient or a novelty device. Of the 44

smart technology devices assessed (Table 4-2), only 16 devices (36%) were perceived as needed.

Of the perceived needed devices the maj ority (89%) were cited as only slightly needed. The three

ST devices that were cited as being moderately needed were the dressing-aid, blood pressure

management-aid, and the carrying aid. The two ST devices that were cited as being strongly

needed were the automatic front door, and the transfer-aid. Two of the ST main category groups

had all of their ST devices selected at least one time. All the types of personal robotic assistance

devices (walking aid, bathing aid, transfer aid, dressing aid, and carrying aid) were selected, as

well as all of the types of prediction technologies (early detection: changes in activity level,

memory loss, changes in walking pattern, and changes in eating/drinking pattern) were selected

by at least one participant. When the participants were asked if their were any additional smart

technology devices needed to assist in their daily activities, seven additional devices (voice-

message aid, voice-typing aid, voice-dialing phone number aid on cellphone, food prep aid,

utensil cleaning aid, monitor-appliance aid, and auto-checklist to remind when appropriate time

for routine checkups) were cited (Table 4-2).









To further explore perceived smart technology need, participants were grouped by health

condition, housing status, number of ADL deficits, and ambulation ability (Figure 4-13).

Averaging the number of smart technology devices cited by members of in each group, revealed

that participants with stroke cited more ST need than participants with back problems. The stroke

participants selected more devices to assist with two-handed tasks (i.e., voice message aid,

typing on a computer, and food preparation aid). Participants with additional deficits (ADL or

ambulation) cited more ST need than participants with fewer deficits.

Research Question 3: How do Elders with Mobility Impairments Make Decisions in
Choosing Which Smart Technology is Needed?

The aim of the analysis in this section was to explore how participants made their decisions

regarding ST need; while constructing a preliminary decision tree model of how these decisions

are made. The resultant elder smart technology decision tree model is discussed in this section.

Themes are identified and excerpts from the interviews are used to provide greater understanding

of the participants' perceptions of their ST need.

Elder Smart Technology Decision Tree Model

The elder smart technology decision tree model is presented in Figure 3-15. For these

elders with mobility impairments, the model identifies that they began the process (of

determining whether ST was needed) by ascertaining (if they were no longer performing all or

part of the activity) if all or part of the activity should be restarted. If the participants were

content with no longer performing all or part of the activity then the participants did not critically

consider the ST device. If the participants desired to restart all or part of the activity then they

would consider ST as a possible solution. If the participants were already performing the activity

they would begin by ascertaining if they were satisfied with their current performance level. If

the participants determined that they were satisfied with their current activity performance level









then they would not critically consider the ST device. If the participants determined that they

were not satisfied with their current activity performance level they would then consider ST as a

possible solution to assist with their activity performance. Dissatisfaction with current activity

level was no assurance that the participants would necessarily desire ST to assist with their daily

activity needs, due to the numerous other barrier criteria identified in the model. If any of the

other barriers were a concern then the elders would not desire the ST device. Additional potential

barrier decision themes that emerged when the participants were ascertaining if ST could assist

with their activity performance were if the ST device was: practical, usable, easy to learn,

reliable, or if it created more stress or problems. The model also identifies important facilitator

criteria that could motivate elders to adopt ST assistance. These key decision criteria (i.e.,

barriers, facilitators) identified in the model are discussed in more detail in the subsequent

sections.

Key Barrier Themes

Seven predominant barriers central to the participant ST need decision process emerged

from the data (Table 4-3). The analysis revealed many complex sub-themes surrounding several

of the predominant barrier themes that center on the participants' evaluation of the ST device

itself. As illustrated in Figure 3-15 the first two predominant barrier themes initiate the ST

decision process while the remaining five predominant barrier themes are not hierarchical. Each

of the predominant barrier themes as well as their integrated sub-themes is presented below.

Do I desire to start performing all or part of the activity again?

In the following sections excerpts from the interviews are used to provide greater

understanding of the participants' decision criteria. A primary barrier theme that emerged from

the analysis of the data was that these elders with mobility impairments did not aspire to perform

all (or part of all) 49 activities that were assessed. After their ability levels declined, activities









that were once performed in the past were no longer entirely performed. Participants were

content with not performing all or part of certain activities. A common activity that was no

longer performed was bathing in a bathtub (82%). Of those participants who no longer bathed in

a tub, 78% did not miss the activity. An obj ective of ST is to provide compensation techniques to

return an individual to functional status; however findings indicate that participants were content

with not performing all or part of certain activities any longer. The point of being content with no

longer performing all or part of certain activities is illustrated in the following quotes:

Participant-5: No, I miss it [bathing in a bathtub], ah, sometimes.
Interviewer: Now, if there was a relatively inexpensive technology that helps you get up
and down from the tub, would you be interested in a device such as that?
Participant-5: I don't miss it that much. (Transcribed Interview, pages 28, Participant 5).

Interviewer: Do you get down [in your tub] and take a bath; do you get into the bathtub?
Participant-11:. I haven't; I haven't gotten in a bathtub in years.
Interviewer: Is that something you miss, or is it--
Participant-11:. No.
Interviewer: You're okay without that.
Participant-11:. Uh-huh. (Transcribed Interview, pages 47-48, Participant 11).

A subcomponent of the barrier theme of being content stopping all or part of an activity

was that participants felt it was easier to adjust their actions or the activity itself rather than to

incorporate external assistance as a solution to the difficult task. Participants felt it was easier to

modify their behavior first over incorporating external devices. Rather than incorporating an

assistive device (i.e., dressing stick, sock aid, button hook, robotic dressing aid) into their activity

performance or asking for assistance (i.e., spouse, adult child) they would rather self-compensate

or modify certain activities. This point is illustrated below,

Well, you revise the way you're doing things, or you wear shoes that don't need to be tied
(laughs) or whatever--uh--so that, I guess my feeling about this was--my overall feeling
about the smart house was that it' s easier to adjust a person rather than this over-the-top
technology. (Transcribed Interview, pages 86, participant 8).










Another subcomponent of the barrier theme of being content with stopping all or part of an

activity was that participants were found to be preplanning to stop or limit certain tasks. Rather

than planning how they will maintain full functioning with tasks, the data analysis revealed

participants were preplanning how they would be limiting future activities. Participants cited

plans to stop certain parts of an activity (i.e., not having garments with buttons or zippers, not

wearing socks or trousers) over planning how to fully perform an activity. Therefore a ST device

that would allow them to wear garments with buttons and zippers would consequentially not be

needed. This point is illustrated in the following quotes,

Interviewer: Let's say it gets to the point where, you physically can't reach over anymore
to put on your socks?
Participant-4: I just wouldn't wear socks.
Interviewer: What about for your trousers, you would resort to using a reacher?
Participant-4: No, I'd wear skirts and tops. Of which I have a closet full, I just like wearing
pants .
Interviewer: So you would be able to modify your outfit so you wouldn't have to bother
with,
Participants-4: I would do that, before I went with those [assistive devices] other things.
Interviewer: So with skirts you would just have to step into them?
Participant-4: Well, you can pull it over your head, or you step into it, you see its not
stepping in to, now the underpants you always got to do those, just have to do that, or
Interviewer: So if it came to the underpants, you have to use some type of dressing stick?
Participant-4: I suppose a person would, I have, but I don't feel like that's like socks,
[participant laughs] I would just adjust my clothing, I wouldn't put on shoes and socks, I
would put a robe on, I mean, I would just make compensations as I've always have.
(Transcribed Interview, pages 20-21, participant 4).

This barrier may have several other subcomponents tied into the decision of stopping an

activity, such as the length of time since stopping an activity or the pre-defieit gratification level

of the activity. This barrier of being content with limiting all or part of an activity reveals a

primary barrier central to the participant ST need decision process, if the elder consumer is

content with not performing all or part of an activity then ST will not be needed to compensate









for the loss in activity performance. This barrier would limit the window of opportunity for ST to

be needed by elders.

Satisfied with current activity performance?

The second primary barrier theme that emerged from the analysis was the most frequently

cited barrier. Participants repeatedly cited being satisfied with their current activity performance

level. 'No need' for smart technology emerged routinely during the study. This finding was

reflected in data from research questions 1 and 2, where minimal overall reported unmet ADL

(8%) and IADL (3%) need was found.

Satisfaction with doing activities in their own way was commonly alluded to by

participants. Participants had adapted their method of activity performance and did not express a

need to make a change in their behavior. Even if the task could be simplified and performed

more easily with ST. Participants did not desire technology to help complete tasks more easily.

Participants who would benefit from a robotic carrying aid frequently verbalized being satisfied

with their method of activity completion and not desiring ST to assist. This point is illustrated by

participant-2 who had balance difficulties, utilized a 4-wheeled walker for long distances, and

had difficulty carrying items with both hands (contractured right-hand) below,

Interviewer: What if he [robotic carrying aid] was able to grasp and carry items for you?
What if he was able to grasp your basket that you use to carry items?
Participant-2: I can carry the basket in my right hand; my left hand has to hold the cane.
And I couldn't find a lot of use for him [robotic carrying aid]. Just to transfer a few books
in and out of a room he would be totally worthless. I take my groceries out of the wagon,
and put them on the counter....I think he would be too much trouble than he is worth.
(Transcribed Interview, page 39, Participant 2).

Participants also commonly alluded to being satisfied with tasks taking more time than

usual. If it took an extended amount of time to complete an activity (i.e., answering the door,

turning on/off lights, walking across a room) participants were ok with it. Participants did not

desire technology to help complete tasks faster. This point is illustrated by the quotes below,









Participant-5 who takes considerable time with her single-point cane (utilizes a 4-point cane at

night) to ambulate across a room,

Interviewer: Just getting around your home does take considerable time?
Participant-5: Yeah,
Interviewer: But giving you technology, it wouldn't be needed?
Participant-5: Yeah,
Interviewer: To save you time?
Participant-5: yeah, yeah,
Interviewer: Or do you feel that,
Participant: Time, I have plenty of it,
Interviewer: So you have plenty of time, you don't feel that, if you can only do things
faster, you would be able to do more things each day?
Participant-5: no,
Interviewer: So you are okay with the balance of time and how long each activity you do
takes?
Participant: Yeah.

Participant-3 had a history of multiple strokes, limited left-hand functioning, could perform

transfers only, and received dialysis three-times a week, stated,

That'd [household automation] be nice, but things take a little bit of time right now and I
can do it, so there's no need for it. I am in a lot better shape, than a lot of people that go
out to that [dialysis] clinic. And a lot better attitude, a lot of them are so damn depressed; I
try to keep a positive attitude. (Transcribed Interview, page 43, participant 3).

While household automation technology would have allowed participant-3 to more speedily turn

on/off his lights and open/close his blinds he verbalized that he felt he could sufficiently perform

the tasks (in his powered wheelchair). He cited 'things take a little bit of time right now and he

can do it, so there's no need for it', expressing that he is content with how long it takes him to

complete these activities.

Participants commonly alluded to being satisfied with their endurance level in performing

tasks. If they could only walk household distances or only walk up a few steps at a time

participants were generally satisfied with it. Participants did not have a strong desire for

technology to improve their endurance level. For instance the majority of sample (82%) required

AT to ambulate, however only 18% of participants cited a 'slight need' for the ST walking aid.









Even though participant-9 would benefit the most due to low endurance and difficulty walking

household distances, he did not feel a strong need for desiring the robotic walking aid. Although

the walking aid would allow participant-9 to potentially conserve his energy, and ambulate

longer distances, he only felt the walking aid would be 'convenient' but not necessary. This point

is illustrated in the below quotes,

Participant-9 able to ambulate household distances only.

Interviewer: Let's say it [walking aid] did work, just like your lift chair worked. Let's say
this thing worked and all the bugs were worked out of it and this thing would free up your
hands--you wouldn't have to hold onto a walker any more--and they can say, "Well, you
can use this and you wouldn't have to hold onto anything." What are your thoughts on
that?
Participant-9: It would be--be lovely.
Interviewer: Would it be a necessity, or would it be just convenient?
Participant-9: Convenient. (Transcribed Interview, pages 79, participant 9).

Participant-2 who has a history of a stroke, balance difficulties, utilizes a cane in home and

a 4-wheeled walker for long distances, and has difficulty carrying items with both hands

(contractured right-hand) cited that he considered the walking aid only appropriate for those who

had a 'spinal cord injury'. Participant-2 who had trouble walking up steep ramps, up/down stairs

without railing, and had problems carrying items while having to hold onto cane 'wouldn't

bother with [walking aid]'. Even when the walking aid was presented as easy as a pair of slacks

to don/doff the participant did not feel any need for the ST device. This point is illustrated in the

below quotes,

Interviewer: And now getting back to the robotic exoskeleton device, what are your
thoughts on this? [pointing to the exoskeleton on the diagram]
Participant-2: I, um, that's what I'm talking about I, I didn't see anybody, would this
device be able to help someone walk down steps?
Interviewer: Yes.
Participant-2: I guess if a guy really had a lot of problems with his legs, it might be a
good thing. I don't know, I would have to see a, the definite
Interviewer: you would like to see it?










Participant-2: no, I wouldn't want to see it, I would have to see the definite, it would have
to be a person that would want to use this really bad. Who didn't walk very well, I don't
walk very well, but rather than going to the trouble of putting this thing on, I would just
use the stairs.
Interviewer: so if this thing were to help you walk further, would be worth while to put it
on? It would not only help you walk up and down stairs but it would help you walk
further. It would be similar to putting on a pair of pants so once you got ready you would
just put these on like a pair of pants and you just go about your day.
Participant-2: I, um, today in my condition I wouldn't bother with it.
Interviewer: is that because it would be too much trouble?
Participant-2: too much trouble to put on.
Interviewer: would you be concerned about becoming dependent on this device?
Participant-2: that's not a concern. It is just too much trouble to put on. Now in all
fairness if somebody was in a condition like Mr. Superman, who had spinal cord injury, I
suppose it might be a good thing. (Transcribed Interview, pages 37, participant 2).

This barrier of being satisfied with their current activity performance level may have a

subcomponent of length of time since onset of disability. Participants who have already adapted

and established a daily routine for a long period of time may have become content with their

activity performance level. Changing to a new assistance routine may be viewed as more arduous

after having already modified or limited an activity. The analysis revealed that all participants

were at least one or more years from initial onset of their chief condition. Therefore the

participants may have become accustomed to their established daily routine for a long period of

time. If ST was offered within the first few weeks of a loss of ability then potentially ST need

would be greater, as the elder consumer may not have grown accustomed to their modified

routine.

This barrier of being satisfied with their current activity performance level reveals a

primary barrier central to the participant ST need decision process. If the elder consumers are

satisfied, then ST will not be needed to only replace their existing activity performance method

that they feel is being performed sufficiently. This barrier would limit the window of opportunity

for ST to be needed by elders. Future researchers could further explore the issues surrounding









this barrier theme, which may have many more subcomponent tied into it (i.e., accepting of

performance level, resisting change, established control issues).

Is ST a practical solution?

The third predominant barrier theme that emerged from the analysis centered on the issue

of whether ST devices were a practical solution. All participants in this study indicated at one

point concern that ST devices were not practical for their needs. When describing ST participants

expressed that it was 'too costly', 'excessive', or had 'no gain'. Participants did not view ST as a

practical solution to their daily activity needs.

Any gain to having ST device (sub theme):

Forty-five percent of participants expressed that certain ST devices were not practical for

their needs because they did not see any gains from the device. For example, participant-7 cited

that she (or her family or friends) would know if she was losing her memory, or if her walking

patterns changed. Therefore she did not need a ST device to tell her what she already knew. The

point that ST is perceived as not being practical for their needs because no gain was seen with

the device is illustrated in the following quote,

I don't need this [prediction technologies], I mean--I don't need all those things 'cause I--I
know--and people around me will notice--uh--that I'm losing my memory and my--I'm
not walking, I know that. (Transcribed Interview, page 84, participant 7).

Cost prohibitive (sub theme):

Ninety-one percent of participants expressed that certain ST devices were not practical

because the technology would be too costly for their needs. Participants expressed that they only

spent money on the necessities and that the minimal gain from technology was not worth the

cost. For example even when the cost of retrofitting and home installation of a fall monitoring

system was taken out of the equation, participant-3 did not feel a need to spend $30 a month for a









fall monitoring system. He felt that $30 a month would be too costly only to monitor him for

falls when his daughter was out of the home. This point is illustrated by the below quote,

Participant-3: You know how much it'd [fall monitoring system] costs?
Interviewer: Let's say $30 a month,
Participant-3: Who's going to pay to put it in?
Interviewer: Let' s say it comes with the house, let's say this is Hyve years from now, and
houses are being built with these technology devices preinstalled and can be available for
activation.
Participant-3: I know how it works, but I Eigured I couldn't afford it, and have it installed.
Interviewer: Let's say its there in your home just has to be activated.
Participant-3: I really don't know, it might be worth the $30, but if I got me and my
daughter living together what the hell do I need it for. (Transcribed Interview, pages 49-50,
participant-3).

Participant-7 initially expressed a desire to use a cell phone however changed her mind when she

stated that she does not like to spend money on anything except necessities. She did not feel the

added safety benefit of having a cell phone in her car was worth the expense. This point is

illustrated below,

Yeah; well (sighs), if I had one [cell phone], and somebody showed me how to use it, I
probably would use it, but uh, I don't--all that expense--the reason I can live on nothing,
which you know I do, uh is because I don't spend any money on anything except absolute
necessities--and all that stuff takes--costs money--I'm a-a product of the Depression,
that' s what I am (laughs)--never gotten over it! (Transcribed Interview, page 27,
participant 7).

Excessive technology (sub theme):

Sixty-four percent of participants expressed that certain ST devices were not practical

because they were too excessive for their needs. Participants frequently cited voice controlled,

home automation, monitoring, reminding technologies as excessive. A few participants

expressed that the only population that voice controlled and home automation technologies

would be good for were paraplegics or quadriplegic. This point is illustrated in the below

quotes,

I don't need anything except for the remote control that I have for my TV. There isn't
anything else that I would need to have done [to my home]. There is nothing there, I don't









need a voice control thermostat or lights or blinds....I don't see, in my case anyway, any
value in that [voice recognition]....I can't foresee that at all in my future unless I became a
quadriplegic, that's who this would benefit, maybe a paraplegic. (Transcribed Interview,
pages 33-34, participant 4).

Some of the new technologies that I have seen, as in the smart house, are so far-fetched, I
wouldn't waste my time on'em....The uh--opening and closing window shades, I think, is
far-fetched. (Transcribed Interview, page 38, participant 9).

Participants' often cited that a simpler and less excessive solution could be developed that would

be more practical for their needs. For example participants' often expressed a simpler solution

would be to have a human assist over acquiring 'excessive' technology. Stating that when their

needs became extensive they would need a human (personal caregiver) and it would be easier to

have a human do the task (as opposed to the ST). This point is illustrated in the following quote,

Well, I guess this was my thought somewhat, too, when I called the smart house "pie-in-
the-sky," that I think somebody needs so much help would probably be better off in a place
where--a group home, or something of the sort, where people are able to--to have various
kinds of assistance, rather than having it from their house. I think some of those house
things would be uh--more of a luxury or a convenience but not something for a real
impairment. (laughs) (Transcribed Interview, page 76, participant 8).

This barrier of perceiving ST as not being a practical solution for their needs is central to

the participant ST need decision process. If the elder consumer does not perceive ST devices as

practical solutions to their needs then ST will not be needed to assist with their daily activities.

Can I physically use the ST device?

The fourth predominant barrier theme that emerged from the analysis was the least

frequently cited (predominant) barrier. Twenty-seven percent of participants reported concerns

of potentially not being able to adequately utilize the ST devices. For instance participants with

limited use of an upper extremity expressed concerns of not being able to use touch screen

devices as it requires the use of both hands. Concerns of not having adequate hand dexterity to

don an exoskeleton walking aid were conveyed as well. Participants with visual impairment

verbalized frequent problems utilizing ATM machines; therefore participants with visual










impairment would have difficulty utilizing the ST touchscreen devices. This barrier, being

concerned that they would not be able to physically use the ST device, is central to the

participant ST need decision process. If the elder consumer perceives that they can not physically

use the device then ST will not be desired.

Is the ST easy to learn and use?

The fifth predominant barrier theme that emerged from the analysis centers on the ease in

which the participants perceive ST as being utilized. Sixty-four percent of participants indicated

concerns with both, how they were going to initially learn how to use the ST devices, and if their

daily interactions with ST would be too complicated. Participants expressed previous

experiences with not wanting to buy a new washer and dryer because they did not want to leamn

how to work the newer appliance. Therefore the idea of having to leamn how to interact with a

whole new (smart) home was overwhelming. This barrier is illustrated in the following quotes,

Interviewer: And why would you say you wouldn't want to live in the smart house?
Participant 9: It'd take too long to leamn how to use it. (Transcribed Interview, pages 36-37,
participant 9).

Well, I don't like it when I get a new washing machine or dryer 'cause I don't want to have
to leamn the machine again. Uh--I don't have a lot of patience. I have less patience now
that I've found out I've got Parkinson's (laughs) than I ever did.... I think I'd kill myself
before I have to live like that [in a smart house]. (laughs) I think it would be one
frustration after another, for me. (Transcribed Interview, pages 36-37, participant 11).

This barrier of being concerned with the ease in which the ST devices would be to learn

how to use and how complicated the daily interaction would be is central to the participant ST

need decision process. If the elder consumer perceives that the process of learning how to use the

ST device or their daily interaction level as complicated then ST will not be desired.

Will using the ST create more stress/problems?

The sixth predominant barrier theme presented as the most complex theme with six sub-

themes revealed during the analysis. This primary barrier theme centered on the concern that









utilizing the ST device would cause additional problems and stress. Fifty-five percent of

participants expressed concerns that additional problems may accompany the utilization of ST.

Any perceived value gained from utilizing the ST device would potentially be negated by the

associated perceived new problem. Participants expressed that technology could potentially:

cause physical dependency, bring unwanted stigma, replace needed human contact, and 'annoy'

and 'stress' the participants with an overload of information. These potential new problems are

discussed below.

Misinterpretation of information (sub theme):

Eighteen percent of participants expressed that there may be more stress and problems

created by the utilization of ST devices because the information output from the ST device may

be misinterpreted. Participants expressed that they may become more anxious, and potentially

would assume the 'worst-case scenario' when given so much information regarding their health.

This point is reflected in the below quote,

It [prediction technologies] sounds like a real stress inducer to me [participant laughs], this
sounds like a potentially really troublesome, because of, it says okay, it gives you a
symptom but it does not really interpret and the recipient' s immediate response is the
worst-case scenario, I have tremors oh my god I have Parkinson's now. (Transcribed
Interview, page 31, participant 1).

Information overload (sub theme):

Twenty-seven percent of participants expressed that there would be more stress and

problems created by the utilization of ST devices because they may become irritated by

technology telling or reminding them to do things. Participants expressed that having an

inanimate obj ect constantly telling them something would become annoying. This point is

illustrated by the below quote,

I know all these things [prediction technologies] when it happens, uh--I don't know the
advantage--if you got sick enough that you didn't know these things, I don't the advantage
of some inanimate obj ect telling you. I--I--I don't respond favorably to this....I don't









know that I would appreciate an inanimate obj ect telling me, "Hey, you're not walking so
good today" (laughs). (Transcribed Interview, page 79, participant 10).

Fear of dependency (sub theme):

Twenty-seven percent of participants expressed that there would be more problems created

by the utilization of ST devices because they have a fear of becoming dependent on the

technology. One participant reported a fear of dependency, not on technology, but rather fear of

dependency on having a personal assistant come in to help him bathe. His fear was that the less

he physically does himself the weaker he will get and the more dependent he will become on the

personal assistant. However the maj ority of participants who voiced fears of becoming

dependent cited technology rather than human assistance as a concern. Participants expressed

concerns such as having to use a wheelchair because they did not do enough for themselves. Or

as, one participant stated, she would have to 'strap her lift chair on her back and take it with her'

everywhere if she became dependent on her lift chair. The following quotes illustrate fear of

becoming dependent on technology,

Yeah; somebody thinks--somebody figures that out and thinks it up-they're smart, but
some of the things aren't needed....I don't know--I think that we have too much help--I
see my granddaughters, for instance, and they're both a little over-they're both
overwei ht 'cause they don't do enou h--they don't do enouh you know? And, I think
we need to keep doing things for ourselves--I just--that' s why this--all this stuff kind of
turns me off, to tell you the truth....I mean, a wheelchair--you could do some things for
yourself, and I'm not sure you don't end up in a wheelchair 'cause you don't do things for
yourself, you know, I mean--(laughs). (Transcribed Interview, page 68, participant 7).

Because I know that I'm not walking to get my exercise right now; and I know that pretty
soon, I won't be able to do anything [due to progression of Parkinson' s Disease]. If l use
that damn lift chair to get out of the chair all the time, I' d have to strap it on my back and
take it with me." And I'm not going to restrict myself like that. But I feel like my--my
legs need the struggle that I go through to get out of that chair the way I get out of it. But I
don't--I have never yet let it lift me up; I let it recline me. (Transcribed Interview, page
39, participant 11).

One caveat is that the analysis also revealed that a maj ority of participants (73%) were

adamant about not being concerned about becoming dependent on technology. They verbalized









that they would basically be aware of becoming dependent on technology, however did not have

a fear of it. Clarifying further if they were to start relying on technology (i.e., wheelchair) then

they would automatically know that they should be sure to do exercises to keep up their strength.

Potential stigma (sub theme):

The analysis revealed one participant that expressed a perceived stigma to technology. This

participant was one of the few who would have benefited the most from the exoskeleton.

Participant-3 utilized a powered wheelchair, could only perform transfers, fell 6-8 times in the

last 12-months (due to his knees giving out), however he cited a strong stigma to needing the ST

device. Specifically participant-3 felt the exoskeleton device was weird and he was concerned

that people may think he was totally paralyzed when he was wearing it. This point is illustrated

by the following quote,

You're going to ride in a car and go uptown and let everybody see you like that.... It
[robotic walking aid] looks yucky, I don't know, it looks like you're completely paralyzed
or something, and that things got you going. That's what I would say.... I don't like the
looks of it, I feel weird putting that damn thing on. (Transcribed Interview, page 44,
participant 3).

Privacy concerns (sub theme):

Eighteen-percent of participants expressed that there would be more stress and problems

created because they would potentially have privacy concerns if they installed the ST device.

Participants cited that they would not like having cameras monitoring their every move. This

point is illustrated below,

I wouldn't pay for that kind of [monitoring] agency. I could see myself paying for a
person to be a companion, but that--that companion also would not have her eyes on me
every instant of the time, uh--she would be there, but--it would also be a--uh normal
relationship--now, I would--I would not go for the camera system under--well, I don't
want to say "under any circumstances. (Transcribed Interview, page 72, participant 8).

One caveat was that when technology was presented in the form of monitoring with

cameras and sensors, privacy became a concern, however when technology was presented in the









form of robotics and dressing aids the opposite effect occurred. Privacy was perceived as being

enhanced by technology as participants did not want to have a human helping them with

sensitive activities (i.e., dressing tasks). Participants stated that having a person help you dress

may be too personal and a robot dressing aid would preserve some privacy.

Loss of human contact (sub theme):

Twenty-seven percent of participants expressed that there would be more problems created

by the utilization of ST devices because a few of the devices would limit human contact.

Participants expressed a need for human contact because it provided a 'human element' of caring

that a technological device was without. While participants expressed concerns of additional

problems (i.e., trust) when having a hired care person in their home, these concerns where

trumped by the potential of losing human contact. This point is illustrated below,

I don't think I would like it [robotic assistance]. I would rather have human help or at
pre--present, I don't need it. I can get up and down myself, but if I needed help, I think I
would rather have human help than this....When you have someone come in your home
and work, you don't immediately trust'em to help you get in and out of the bathtub. But,
after they have become your friend and helped you in other areas, then I think you would,
uh--you have to learn to trust' em--it doesn't come automatically, like--a robot--you
don't care whether it trusts you or not (laughs)--it just does its j ob. The human--with a--
with a human being, the human element comes into it.... and the fact that my husband
helped me get dressed when I was sick--that--that warms your heart. (Transcribed
Interview, page 68, participant 10).

This barrier centering on the concern that utilizing ST would cause additional problems

and stress is central to the participant ST need decision process. If the elder consumer perceives

that the utilization of ST would cause more stress and problems then any perceived value gained

from utilizing the ST device would be negated. Therefore ST will not be desired. As this primary

barrier theme was the most complex, further exploration of the issues surrounding the type of

stress associated with type of problem would be beneficial. The study analysis process did not

clearly differentiate between stress and problems that would be created.









Is the ST reliable?

The seventh predominant barrier theme that emerged from the analysis centered on the

issue of perceived reliability of ST devices. Seventy-three percent of participants indicated

concern that ST devices were not reliable. Participants with previous experience interacting with

voice-recognition software expressed concerns that the technology was still not advanced enough

for reliable use. Participants frequently expressed concerns that ST would frequently break.

When evaluating ST need the participants frequently compared ST reliability with that of having

a human caregiver. For example participants would cite that you do not have to worry about a

human not understanding what you say. The concerns with ST reliability are illustrated by the

following quotes,

The reason--well, if, you know--if you have a good person that is reliable (laughs)--
technology is not. (Transcribed Interview, page 77, participant 8).

Right, because you wouldn't have those dirty, cords, I started to say that you wouldn't have
to worry about them [voice controlled blinds] breaking, but the piece of machine is going
to break first, (participant laughs). (Transcribed Interview, page 38, participant 4).

This barrier centering on the issue of perceived reliability of ST devices is central to the

participant ST need decision process. If the elder consumer perceives the device as unreliable

then the ST device will not be desired.

Key Facilitator Themes

Seven predominant facilitators central to the participant ST need decision process emerged

from the data (Table 4-4). Facilitator themes were categorized by the type of assistance provided

to the participant. For example 'assist with an activity currently unable to perform' was classified

as providing physical assistance, 'enhance ability to monitor health' was classified as providing

cognitive assistance, and 'increase sense of autonomy' was classified as providing psychosocial

assistance. Elders with mobility impairments expressed more physical assistance facilitators (i.e.,









assisting with tasks that are difficult or are unable to be performed) than cognitive assistance

facilitators (i.e., assisting with monitoring personal health status) or psychosocial assistance

facilitators (i.e., decreasing imposition, increasing sense of autonomy) facilitators. Facilitator

themes generally provided multiple types of assistance (physical, cognitive, or psychosocial) and

as illustrated in Figure 3-15 they are not hierarchical in the elder ST need decision process. Each

of these facilitator themes is discussed in detail below.

Decrease imposition on family/friends (psychosocial)

A primary facilitator theme that emerged from the analysis of the data centered on the

issue of decreasing imposition on family/friends. Fifty-five percent of participants expressed a

desire for ST to assist in lessening the burden of live-in family members (i.e., spouse, adult-

child). Citing that at times family members would be burdened by having to stop doing what

they were doing in order to assist the participant with a (dressing) task. Participants expressed

that it would be 'more convenient' for ST to assist with their activity needs than imposing on

their families. This point is illustrated by the following quotes,

Dressing I don't really have a problem I just call my daughter, and she comes and helps
me. She does a tremendous amount of stuff for me....it [robotic dressing aid] may be nice,
does it button things? I mean that's one of the hardest things I can't do is button things.
Because I use to have one of them button hooks, but you know how long that thing
takes?.... I just leave my shirts buttoned, and pull them over my head like a T-shirt.... I can
do it, but it's a tough j ob. If it would help, hell yeah....well so far I do not need it [robotic
dressing aid], but it would sure be nice if I had it. I mean I don't know what kind of attitude
to give you, but that's the way I feel about it....Oh I am not comfortable, because it
[donning slacks] is awful difficult, and sometimes she [daughter] is doing something else
and gets all ticked off. You know how that is so....I don't like to have to depend on my
family because they got their own lives and everything. (Transcribed Interview, page 45-
46, participant 3).

The [dressing aid] robot' s not as good-looking as she [spouse] is, but probably would be
more--probably be more convenient. Just--just so she wouldn't be--one of the things she
wouldn't have to do. (Transcribed Interview, page 51, participant 9).









Yeah I would get the robot, over my husband....I don't want to interrupt him [spouse],
because it's always more convenient to call a robot over a person. (Transcribed Interview,
page 51, participant 5).

Findings also indicate that the facilitator theme of desiring to decrease burden of family

extends beyond live-in spouses and adult-children. Participants in the study who did not

currently live with any adult children indicated they felt that their children have lives of their

own and they did not want to burden them. A few participants indicated that they would rather

hire someone to assist with their needs rather than burdening a family member. This point is

illustrated in the following quote,

Yes; I would like to have somebody because I don't know if I would need something, you
know. But, otherwise, they [neighbors in building] have told me that, "You do have a
son." Well, thank goodness, I do, but I don't like the idea that I have to depend on my
kids, and I don't want them to feel that they are obligated to have to run every time that I
need something, you know, I don't like that dependent feeling. It makes me uneasy, to say
the least.... I wouldn't mind having to pay somebody to, I don't know, whatever it is---
But, uh--Or the maintenance people, whatever, but the maintenance people are--he's
actually doing double the amount of work that he would be, that person should be having
to do, you know what I mean? They should really have two people for maintenance, but
they just have this one, and he's really over-worked. And, so, I really would hesitate to
call him, knowing that he's doing more than his share. (Transcribed Interview, page 16,
participant 6).

Uh-huh. I think that' s [remaining in own home] key to my happiness and--and what I
want for my daughter and her husband also. I don't want them to have to give up their
lives to worry about me. I have a long-term care policy, but it' s--(laughs) they're never
long enough term, you know? (Transcribed Interview, page 16, participant 6).

A subcomponent of the facilitator theme desiring to decrease imposition on family

members, that was revealed was those participants who have previous experience with care

giving may be wary of burdening their family members. For example participant-10O expressed

concerns of potentially losing her 'very good relationship' with her children by burdening them

with her activity needs. Participant-10 cited the experience of losing the great relationship she

had with her 'angel mother', when she had to start caring for her mother who became very









distrustful while the participant was her caregiver. An example of this is illustrated by a quote

from participant-10 below,

That' s the main thing. We have a very good relationship with both of our [children]--they
like us; we're friends; they enj oy being with us; we go out to eat for every birthday and
every anniversary and every opportunity we get; we just were out last Saturday night' s
why I keep pointing at this (gestures)-uh-after my experience with my mother, I--Ijust
don't think it would work; and I would not risk our relationship for that, uh--if I couldn't
afford to hire somebody, one of our--we have some insurance policies that, when the CD
rates went down, we bought....but one of the policies has a thing that if I get where I can't
live alone and I need help, that I can borrow money from that to go into a nursing home. I
would go into a nursing home before I would stay with my children. Now, the only way I
could afford it would be either sell the house or somehow qualify for Medicaid. Uh--I
think you can keep your house and qualify for Medicaid, and I could probably qualify for
Medicaid money wise, uh--if they let me keep the house. If I had to sell the house, of
course, I'd have that money. So, that would not be my first choice.... like I said, when we
came here (laughs) from a very happy life of traveling in an RV to take care of my "angel
mother," who had always been the world's greatest--my--my friends all called her
"Mom"-she was just--she was just "Mom"-but the--the disease made her very uh-
contrary--very suspicious. (Transcribed Interview, page 23, participant 10).

This facilitator theme centering on the issue of decreasing imposition on family/friends is

central to the participant ST need decision process. If the elder consumer perceives the ST device

as potentially relieving a family member's burden then ST device may be desired.

Increase sense of autonomy (psychosocial)

The second primary facilitator theme that emerged from the analysis of the data centered

on the issue of increasing the participants sense of autonomy. Eighteen percent of participants

expressed a desire for ST to assist in providing more autonomy. For example a few participants

chose technology over hiring a caregiver due to perceiving that technology would provide a

greater sense of autonomy. Also participants expressed that they would feel more in control of a

robot than a hired caregiver. This point is illustrated by the following quotes,

Interviewer: You can either have this robot stay with you and help you dress and do your
morning routine, or have an agency care assistant come in and help you?
Participant-6: I probably would prefer the robot.
Interviewer: And that would be because? Privacy?









Participant-6: Um (long pause), possibly. I probably would feel that I was still
independent.
Interviewer: Because you would be having the robot do something for you? Rather than
relying on?
Participant-6: On a human being, yes.
Interviewer: Now, with the human being, you would have control of the human being; you
know, you would pay them and stuff--but, that wouldn't necessarily be as much control as
having the robot and telling the robot what to do?
Participant-6: Right.
Interviewer: Because you can tell the robot to put on your sock a lot easier than telling a
person to put on your sock.
Participant-6: Well.
Interviewer: Depending on the relationship you had with that caregiver?
Participant-6: Yeah. (Transcribed Interview, pages 73-74, participant 6).

This facilitator theme centering on the issue of increasing sense of autonomy is central to

the participant ST need decision process. If the elder consumer perceives the ST device as

potentially increasing their sense of autonomy then the ST device may be desired.

Assist with a difpcult activity (physical/cognitive assistance)

The third primary facilitator theme that emerged from the analysis of the data was the most

frequently cited facilitator. This theme centered on the issue of assisting with activities that were

currently dimfcult to perform. Eighty-two percent of participants expressed a desire for ST to

assist in providing assistance (i.e., physical, cognitive) with activities that they were having

dimfculty performing. Participants frequently cited a desire for ST to assist with physical

activities such as dressing or preparing meals, and with cognitive activities such as medication

management or remembering to perform daily exercises.

A few participants who had dimfculty with two-handed tasks frequently expressed a need

for ST to assist with food preparation activities. For example, participant-1 cited he no longer

utilized his stove or oven but rather only utilized his microwave to prepare his meals. He stated

that prepackaged meals were all that he could make and that a ST device that would assist with

preparing food would be readily accepted. Also, participants who had dimfculty getting in and









out of their front door expressed a need for physical assistance in the form of an automatic door.

The need for ST to provide physical assistance with difficult tasks is illustrated in the quotes

below,

Nah most of this [reminding technology] is stuff I'm so conscious of anyways that I really
don't need any of this. Now on the other hand for the food recommendations, if it could
just fix the food that would be great [participant laughs]. I know what I should be eating
but I, I would like more salads but fixing them is not the easiest. (Transcribed Interview,
page 30, participant 1).

Yes I would like that [automatic front door] because I could buzz in and out with my
scooter, I would be interested in that. Oh boy....The door would be nice because I would
be able to zoom in and out with my scooter, because now I have to get up and prop the
door. (Transcribed Interview, page 33, participant 1).

A few participants who had difficulty with their medication routine frequently expressed a

need for ST to assist with reminding them when it was time to take their medications. For

example participant-6 normally had a routine (i.e., keeping her medication bottle inverted) in

place to remember if she took her medications. However on the days that she would do certain

activities (i.e., paying bills) on her kitchen table she would move her pill bottles and

subsequently forget to take her evening medications. Participants who had difficulty

remembering to always perform exercises expressed a desire to have technology assist in

reminding them to perform daily exercises. For example participant-9 who sometimes had his

wife remind him to exercise, wanted more assistance as he felt that he was too often forgetting to

exercise. The need for ST to provide cognitive assistance with difficult tasks is illustrated in the

quotes below,

Well, not actually necessary, but it probably is getting to that point because I occasionally
have forgotten to take this [gestures to medication bottle]....Yes, I think that would be
almost a necessity because I do occasionally forget to take the medications at night, you
know. In the morning, I just automatically do that the first thing, see; I do that even before
I get dressed, so--to make sure that I'm taking them, you know; but, occasionally, I forget
to take this one here (gesturing) that I take only once a week, and, every now and then, I'll
forget about that, even though I usually put it like this (gesturing) so that I don't forget it;
and yet, in the evening, I'll take this here and I'll put it away like this here (gesturing) in









order to have a space over here to do something else, uh, pay the bills or something, you
know,--And, then I forget to put this back here so that I would remember, and then I'll
forget-- (Transcribed Interview, page 67, participant 6).

[Reminding technologies physical exercise] Well, I hate to say this because it opens the
door for her [spouse]-but I need help being reminded to do more physical [exercises].
(Transcribed Interview, page 85, participant 9).

A subcomponent of the facilitator theme assisting with activities that are currently difficult

to perform, that was revealed was that participants had certain expectations of how long an

activity should take. While some participants were comfortable (as cited in earlier examples)

with activities taking a long duration of time, other participants cited a need to lessen the time

required to complete certain activities. Difficult activities that take longer than a participant

expects potentially may be an area for ST assistance. For example participant-7 expressed a

desire for ST to assist with donning her support stocking due to the fact that it takes her a long

time to put them on. Tasks that are difficult but are quickly performed may not necessarily need

ST to assist, however if a task is difficult and takes too long (per participant' s expectations) then

ST potentially may be desired. This point is illustrated in the below quote by participant-7,

Interviewer: So, if there were a device that could help you put on your support stockings or
hose, you'd be open to that idea?
Participant-7: Yeah, right.
Interviewer: Would it be necessary, convenient, or not needed, as far as that technology is
concerned?
Participant-7: Well, I'd say, necessary--I guess, except that, since I don't use it now, it' s
obviously not necessary 'cause I get along without now (laughs)--but, it could be
necessary, yeah--if it was available.
Interviewer: So, you're not able to put on the stockings yourself at this point--?
Participant-7: Yeah, I put'em on; but it' s time-consuming and not easy--
Interviewer: So the reason that shifted to necessary is because it' s something that you're
able to do, but you're not able to do it at the speed
Participant-7: Yeah
Interviewer: Or at the comfort level that you want, so that' s why it became necessary--?
Participant-7: Yeah, yeah--exactly--

This facilitator theme centering on the issue of assisting with an activity that is difficult to

perform is central to the participant ST need decision process. If the elder consumer perceives









the ST as assisting with activities that are physically or cognitively difficult to perform then ST

device may be desired.

Assist with an activity currently unable to perform (physical assistance)

The fourth primary facilitator theme that emerged from the analysis of the data centered on

the issue of assisting with activities that were currently unable to be performed. Fifty-Hyve

percent of participants expressed a desire for ST to assist in providing physical assistance with

activities that they were no longer able to perform. The Eindings indicated that participants were

the most open to solutions to tasks that they were no longer able to perform (as long as they

desired to restart the activity). This facilitator theme was the most easily identifiable theme as

these activities were not being met by their present resources (AT, family, hired assistance).

Participants were quicker to accept the idea of ST assisting them with these tasks. For example

participant-3 who no longer could carry items due to his poor coordination and decreased range

of motion in his left hand desired ST to assist with carrying items for him. This point is

illustrated by the following quotes,

That [robotic carrying aid] would be good too, you see I can't really carry anything, this
arm really can't hold crap....Even though I try to carry things with it but I just drop it. It
would be very nice, it would take a load off or her. Like I said she washes all the clothes
and dries all the clothes. (Transcribed Interview, page 23, participant 3).

Yeah-that'd [climbing stair aid] be kind of nice, if it--if it--if it really helped and I--it
didn't, you know, my back didn't kill me when I used it--that would be nice to be able to
walk --no--I' d like that. (Transcribed Interview, page 72, participant 7).

This facilitator theme centering on the issue of assisting with an activity that is unable to

be performed is central to the participant ST need decision process. If elder consumers perceive

that ST devices can assist with activities that they are physically unable to perform then the ST

device may be desired.









Replace existing technology to perform activity more safely (physical or cognitive)

The fifth primary facilitator theme that emerged from the analysis of the data centered on

the issue of replacing existing technology in order to perform an activity more safely. Forty-five

percent of participants expressed a desire for ST to assist in providing assistance (i.e., physical,

cognitive) with activities that they felt needed to be performed more safely. Participants

frequently cited a desire for ST to assist with physical activities such as carrying items or turning

on/off bedroom lights, and with cognitive activities such as appliance monitoring.

A few participants who had difficulty with two-handed tasks frequently expressed a need

for ST to assist with carrying activities. For example, participant-1 cited that he felt as though he

was 'walking on the edge of disaster' because he would either have to ambulate without his cane

or utilize his affected extremity to carry an item while walking. Either method was not ideal as it

took him considerable attempts to transfer from a seated position to a standing position and once

ambulating his balance and coordination were both poor. This point is illustrated by the

following quotes,

Physical assistance:

Well I tell you something that would be useful, would be a big carrier, a wired controlled
carrier, for instance a dolly in which I can put things on it and then control it with a like a
remote-controlled car and having carry things back to my bedroom. A radio controlled
cart....Yeah it would definitely be a very practical utilitarian device; you can carry your
laundry basket on it or trash basket or whatever. You know when I'm walking I'm trying
to carry something I have my cane in the left hand and have to carry something in my right
hand, so I'm usually walking on the edge of disaster. (Transcribed Interview, page 24,
participant 1).

Yeah--I would--I would probably go for that [voice control lighting], particularly at night
would be convenient, you know, if I'm sitting out here reading, and turn this light off,
then--I don't want to walk to the bedroom in the dark, so I either have to have a flashlight
or have a light already on in there--and, uh, so--that would--that would be a convenient
thing to have, uh--you know, we--we function very well this way--uh--my husband
doesn't--uh--lights don't annoy him, and a flashing light will immediately awaken me, so
we've-we've learned to (laughs)--how to adjust for this, so if I'm in bed, he will use a
little flashlight so he doesn't turn on the light and awaken me, and that kind of thing--so,









if we--if there were some other kinds of ways to uh cope with lighting, that would uh be a
useful thing--(Transcribed Interview, page 42, participant 8).

Cognitive assistance:

A few participants who had difficulty remembering to turn off their stovetop expressed a

need for ST to assist in notifying them or automatically shutting off the stovetop appliance. For

example participant-8 who had a gas stovetop in her previous home expressed that it was

difficult to notice if she (or her husband) left the electric stove top on. This point is illustrated by

participant-8's quote below,

Uh huh--I would like that [stovetop monitoring]... .Yeah--somebody--you know,
somebody's been having something on low heat, and you'll walk away--uh--my spouse
has that problem more than I do (laughs), but-uh-we've-we've each done it
sometimes--and there--there again, it' s--it' s principally 'cause we were always used to
gas [burners], and then, you know, you--it' s off--you know it' s off or on (laughs)--and--
and with this little [electric] grill, you--you don't necessarily--uh--that also could be
better controlled by uh--a smarter stove (laughs)-- (Transcribed Interview, page 47,
participant 8).

This facilitator theme centering on the issue of replacing existing technology in order to

perform an activity more safely is central to the participant ST need decision process. If the elder

consumer perceives the ST as assisting with activities that are being performed unsafely then the

ST device may be desired.

Add a safety net (physical/psychosocial)

The sixth primary facilitator theme that emerged from the analysis of the data centered on

the issue of providing a safety net. Eighteen percent of participants expressed a desire for ST to

assist in monitoring for falls. This facilitator was not frequently cited by participants as the

maj ority of participants lived with someone (i.e., spouse, adult-child) and they felt that the live-in

person acted as their safety net. However a few participants expressed a desire for ST to assist

with monitoring them for falls. For example Participant-1 felt ST would be ideal for monitoring

him for falls while his adult-son was gone weeks at a time. Also participant-6 lived alone and









cited a need for a fall monitoring system due to her fear of falling while in her apartment. This

point is illustrated by the following quotes,

Yeah it would be useful especially when my son is on the road, and he gets concerned
when I try to do things too fast he is concerned about me falling. I have fallen a few times,
but it has been a quite a while since I've fallen. (Transcribed Interview, page 28, participant


Participant-6: I have felt that way up 'til now, yes. But, lately I've been wondering if I
shouldn't--as long as I have a little bit more money than I did have in the past, that maybe
I should get that---
Interviewer: Pendant---the emergency response system?
Participant-6: Yes. So, out of all of these, nothing's really necessary, whereas the only one
that's necessary is the fall [monitoring system]--
Participant-6: Yeah--
Interviewer: and, at this present time, it may be necessary--?
Participant-6: Right. (Transcribed Interview, page 65, participant 6).

This facilitator theme centering on the issue of providing a safety net is central to the

participant ST need decision process. If the elder consumer perceives the ST device as

effectively providing a safety net (i.e., monitoring for falls) then the ST device may be desired.

Enhance ability to monitor health (cognitive)

The seventh primary facilitator theme that emerged from the analysis of the data centered

on the issue of enhancing cognitive ability to monitor health status. Seventy-three percent of

participants expressed a desire for ST to assist them with monitoring their health condition.

Participants frequently cited a desire to more obj ectively measure their health status. For

example participant-1 felt that his subj ective impressions may be inaccurate and he may not

become aware that his abilities were declining. Also participant-2 expressed a strong desire for

an obj ective system that would remind him when he needed to get a checkup. This point is

illustrated by the following quotes,

Well, tremors if I, if I starting to get the shakes every once in a while, I would go see the
doctor, I have a problem, but I never had before, if I get out of bed, and I get up really fast,
there are times that I get a little dizzy, so I called the provider, and I said this happens to
me, and she said believe it or not it happens to me too, and I am only a third as old as you










are, that's perfectly normal, I said well okay, then I won't concern myself with it, but, that's
the important thing, you got to find, there should be a checklist, that you, you, like you get
a driver's manual, when you buy a new car you open the glove compartment there is
always a driver's manual and it. And they say this is the thing you look for, the tire
pressure, you know, there should be a manual, and I think that would be more helpful than
anything. (Transcribed Interview, page 45, participant 2).

For me, oh boy. I suppose, yes, because sometimes our subjective perceptions aren't as
obj ective assessment of what we think we are doing, yeah yeah yeah I agree, this
[prediction technologies] could be enlightening because sometimes what we think we are
doing is not really what we are doing....I suppose that would be useful, if I started to get
lazy, and then I would see the graph and say oh my goodness.... I'm just saying it would
seem to be more beneficial, because I think that activity could change without being aware
of it. You could start getting lazier and lazier, and think that things are just fine.
(Transcribed Interview, page 32, participant 1).

Summary

The results suggest that the general perception of the sample was that the maj ority of their

ADL and IADL needs were being met. Participants perceived very little unmet ADL and IADL

needs. In addition the results suggest that the general perception of the sample was that ST was

perceived as not needed in order to maintain their independence. Participants frequently

perceived ST as a novelty or a convenience device but not needed for their independence.

The results suggest that when ST was perceived as needed, robotic assistance technologies

may easily match many of the ADL and IADL unmet needs cited by study participants. Robotic

assistance technology (i.e., dressing aid, carrying aid, food prep aid) was found to be the most

frequently desired ST component area. In addition the results also suggest that prediction

technologies may be perceived by study participants as adding something to their abilities.

Specifically prediction technology may be perceived as going beyond compensation for a loss in

activity performance. Prediction technologies may have been perceived by participants as

providing an additional ability (beyond compensation) to monitor their health.

The results also suggest that there are multiple key barriers and facilitators involved when

elders with MIs make decisions in choosing which ST is needed or not needed. A predominant









barrier to ST need that was identified in the findings was that study participants were found to be

satisfied with their current activity performance. Study participants were content with performing

their activities in their own adapted styles. The results suggest that if the study participant was

satisfied with their activity performance status, then ST will not be needed to only replace their

existing activity performance method that they feel is being performed sufficiently.

Another predominant barrier to ST need that was identified in the findings was that study

participants had concerns that utilizing ST would create more stress and problems. For example

participants expressed that they may become more anxious, and potentially would assume the

'worst-case scenario' when given so much information regarding their health. The results

suggest that if the study participant perceives that the utilization of ST would cause more stress

and problems then any perceived value gained from utilizing the ST device would be negated.

Therefore ST will not be desired.

A predominant facilitator to ST need decision process that was identified in the findings

was that study participants desired to decrease imposition on family and friends. Participants

frequently cited that at times family members would be burdened by having to stop doing what

they were doing in order to assist the participant with a task. Participants desired to lessen the

burden of their live-in family members. The results suggest that if the study participant perceives

the ST device as potentially relieving a family member's burden then ST device may be desired.

Another predominant facilitator to ST need decision process that was identified was that

study participants desired ST to replace existing technology in order to perform their activities

more safely. For example participants reported a need for ST to assist in carrying items, turning

on/off lights, and monitoring appliances. The results suggest that if the study participant










perceives the ST as assisting with activities that are being performed unsafely then the ST device

may be desired.

Finally the resulting preliminary decision tree model suggests that the elder smart

technology need decision process is complex. The model illustrates that there are numerous

decision criteria surrounding the elder ST need decision process. The results suggest a decision

process that is not linear, but more of a multidirectional process.





















2-3
4-6
7+
No. of ADL Difficulties
1-2
3-4
5-7
No. of IADL Difficulties
1-2
3-4
5-8
No. of Falls-last 12 months
none
1-3
4-6
7-9
Typical Walking Distance
>100 yards (>300 ft)

House & Yard Only
Household Only
Transfers Only


Table 4-1. Demographic, health, and activity status information
N= 1 1
Frequency (%)
Age Mean = 75.8 Overall Health
(SD= 6.2) Described as
65-69 3 (27%) Excellent
70-74 2 (18%) Good
75-79 3 (27%) Fair
80-84 2 (18%) Poor
85+ 1 (9%) No. of Chronic


N= 1
Frequency (%)


Condition


7 (63%)
3 (27%)
1 (9%)>

1 (9%)>
2 (18%)
7 (63%)
1 (9%)>

2 (18%)
6 (55%)
3 (27%)

3 (27%)
4 (36%)
4 (36%)

3 (27%)
6 (55%)
1 (9%)>
1 (9%)>

6 (55%)

3 (27%)
1 (9%)>
1 (9%)>


:Conditions


Sex
Male
Female
Race
Caucasian
Education
High School
College No Degree
College Degree
Living Arrangements
Live Alone
Live with Spouse
Live with Adult-Child
Annual Income
Less than $15,000
$15,000-$29,999
$30,000-$49,999
$50,000 or more
No. Assistive Devices
Utilized
1-5
6-10
11-15
16+


4 (36%)
7 (63%)

11 (100%)

2 (18%)
6 (55%)
3 (27%)

4 (36%)
5 (45%)
2 (18%)

2 (18%)
3 (27%)
4 (36%)
2 (18%)


2 (18%)
6 (55%)
2 (18%)
1 (9%)>













100-


90





70-







20

6-





30
M-


Functional Personal Hygiene Toi et Hygiene
Mobility and Grooming


0


Bathingll and Bowel and
Showering Bladder
Management


Eating


Dressing


Activities of Daily Living

Figure 4-1. Participants with deficits in activities of daily living.










ADL Difficulty -Need
Unmet (12 instances)
8%


No Difficulty cited with
ADL (82 instances)
53%


ADL Difficulty Need Met
(60 instances)
39%


Figure 4-2. Report of ADL tasks with/without difficulty and whether need was met/unmet for
the sample. A total of 154 instances ADL tasks were assessed (that is 14 ADL tasks x
11 participants = 154 instances).










Need met without
Assistance (3 instances
5%


Need met by -Family
(3 instances)
5%



Need met by -AT and
Family (5 instances)
8%













Need met by -A'
(50 instances)
8 3%

Figure 4-3. Report of how ADL-difficulty needs are being met. This is out of a total of 60
instances were ADL tasks were reported as difficult whilst needs were met for the
sample.










Toilet Hygiene (1 instance)
8%


Bathing (1 instance)
8%






Climbing Stairs
(2 instances)
17%







Carrying Items
(2 instances) --
1 7%


Dressing (4 instances)
33%


' In/out Tub (2 instances)


Figure 4-4. Report of unmet ADL-difficulty needs. This is out of a total of 12 instances were
ADL tasks were reported as difficult whilst needs were unmet for the sample.










AT and Family
(2 instances)
17%


AT
(7 instances)
58%


Family
(3 instances)
25%


Figure 4-5. Perceived unmet ADL assistance areas that participants cited could be replaced or
improved to resolve unmet need. This is out of a total of 12 instances were ADL tasks
were reported as difficult whilst needs were unmet for the sample.





-511


)


oin Iii1
10 -t -_ -



IntrnntlAciite o au ivn


Figur 4-6.Partiipant withdefiitsinstnrmental activities of daily living .






















119










IADL Difficulty -Need
Unmet (13 instances)
3%


IADL Difficulty -Need
Met (60 instances)
16%


No Difficulty with IADL
(312 instances)
81%


Figure 4-7. Report of IADL tasks with/without difficulty and whether need is met/unmet for the
sample. A total of 385 instances IADL tasks were assessed (that is 35 IADL tasks x
11 participants = 385 instances).











Need met without Assistance
(1 instance)
2%


Need met by -Family and Hlring
Assistance
(2 instances)
3%

Need met by -AT and Family
(6 instances)
10%






Need met by -AT (10 instances)
17%










Need met by -Hiring Assistance
(12 instances)
20%


Need met by -Family
(29 instances)
48%


Figure 4-8. Report of how IADL-difficulty needs are being met. This is out of a total of 60
instances were IADL tasks were reported as difficult whilst needs were met for the
sample.










Managing HP
Mecasrerment (1 instance)


Dialing N's on Cellphone
(1 instance)




Rernembehr~ing to turn off
stovetop (1 instance)




Reachinmg Top Shelf
(1 instance)


Typing on Computer
(3 instances)












Writing Message when on
-Phone (2 instances)
15%


Preparing Meals
(2 instances)
15%


Figure 4-9. Report of unmet IADL-difficulty needs. This is out of a total of 13 instances were
IADL tasks were reported as difficult whilst needs were unmet for the sample.










AT and Family
(1 instance)
8%


Family (3 instances)
23%


No Assistance
(6 instances)


AT (3 instances)
23%


Figure 4-10. Perceived unmet IADL assistance areas that participants cited could be replaced or
improved to resolve unmet need. This is out of a total of 13 instances were IADL
tasks were reported as difficult whilst needs were unmet for the sample.


























900








30




Remote Control Remote Control H~ousehold Personal Robotic 11(onilrlring Rinlnding Prediction
(voice) !Ilouiheeircern) Automation Assistance Technologies 'Technologies Technologies
Smart technology Component Areas

Figure 4-11i. Percentage of sample that cited a maj or smart technology component area need.











ST Moderate need
(3 instances)
ST Slight need loo
(49 instances)
100. .


ST Strong need
(2 instances)
0.400


SST No need
-(430 instances)
88.500


Figure 4-12. Percentage of need cited by sample regarding smart technology applications. A
total of 484 instances of smart technology devices were assessed (that is 44 ST
devices x 11 participants = 484 instances).










Table 4-2. Itemization of smart technology cited as needed by participants
Smart Technology Assessed Selected Selected
Remote Control-Voice (10) Personal Robotic Assistance (7)
Voice- Thermostat 0 Walking Aid 2
Voice- TV set 0 Bathing Aid 2
Voice- Security System 0 Transfer Aid 2
Voice- Blinds 0 Dressing Aid 7
Voice- Washer + Dryer 0 Carrying Aid 3
Voice- Microwave Oven 0 *Food Prep Aid 3
Voice- Lights 2 *Utensil Cleaning Aid1
*Voice- Message Aid 2 Monitoring Technologies(9)
*Voice- Typing Aid 3 Monitor- Medication Management 0
*Voice- Dialing #'s on Cellphone 2 Monitor- Blood Pressure 0
Remote Control-Touch (6) Monitor- Weight1
Touch- Thermostat 0 Monitor- Visits to the Bathroom 0
Touch- TV set 0 Monitor- Fall Detection 2
Touch- Security System 0 Monitor- Cooking Pattemns 0
Touch- Washer and Dryer 0 Monitor- Walking Pattemns 0
Touch- Microwave Oven 0 Monitor- Sleep Pattemns 0
Touch- Lights 0 *Monitor- Appliances left on 2
Household Automation (8) Reminding Technologies (6)1
Auto- Thermostat 0 Health condition management 0
Auto- TV set 0 Mental Exercise 0
Auto- Security System 0 Important event reminder 0
Auto- Blinds 0 Medication Reminding 3
Auto- Washer + Dryer 0 Food Recommendation 0
Auto- Microwave Oven 0 Physical exercise 1


*Auto- checklist remind when
appropriate time for routine checkups


Auto- Lights
Auto- Front Door
Prediction Technologies (4)
Early detection changes in activity level
Early detection of memory loss
Early detection changes in walking
patterns
Early detection of changes in eating/
drinking patterns
Note: *Smart technology suggestions made


7
4

4

4
by participants that were not included in initial form.












10






7 7

~1 6




c 4 4











Back Problems vs. Stroke Live Alone vs. Live with~ 2-3 ADL Deficits vs. 4-5 ADL W~alk >100yards vs. Walk
Someone Deficits House/Yard Only


Figure 4-13. Comparison of average smart technology device need cited per group.









Table 4-3. Key need barrier themes
Number of
participants
Theme (potential barrier) h ie
theme (%)
Do I desire to start performing all or part of the
activity again? 11 (100%)
Satisfied with current activity performance? 11 (100%)
Is ST a practical solution? 11 (100%)
Any gain to having ST device 5 (45%)
Cost Prohibitive 10 (91%)
Excessive technology 7 (64%)
Can I physically use the ST device? 3 (27%)
Is the ST easy to learn and use? 7 (64%)
Will using the ST create more stress/problems? 6 (55%)
Misinterpretation of info 2 (18%)
Information overload 3 (27%)
Fear of dependency 3 (27%)
Potential stigma 1 (9%)>
Privacy concerns 2 (18%)
Loss of human contact 3 (27%)
Is the ST reliable? 8 (73%)









Table 4-4. Key facilitator themes

Theme (potential facilitators)


Number of
participants
who cited
theme (%)
6 (55%)
2 (18%)
9 (82%)
6 (55%)
5 (45%)
2 (18%)
8 (73%)


Decrease imposition on family/friends
Increase sense of autonomy
Assist with a difficult activity
Assist with an activity currently unable to perform
Replace existing technology to perform activity more safely
Add a safety net
Enhance ability to monitor health









CHAPTER 5
CONCLUSIONS AND RECOMMENDATIONS

Introduction

Comparatively little research has been conducted regarding the smart technology needs of

the elder population despite the proliferation of smart technology prototypes (Baillie, 2003;

Mihailidis, Cockburn, & Longley, 2005). A maj ority of studies involve evaluating smart

technology already in the prototype stages. There were few qualitative studies that specifically

addressed this gap in the literature on elder ST needs analysis, which would help in determining

what prototypes to create and test (Baillie, 2003; Mihailidis et al., 2005). Qualitative studies are

needed to provide insights to assist developers in the design of products (Mariampolski, 2006).

The purpose of this study was to explore the perceived ST needs of elders with mobility

impairments while constructing a preliminary decision tree model of how these decisions are

made. The resultant decision tree model was developed from data collected from in-depth

interviews and participant observations (Figure 3-15). This model conceptually outlines the

criteria surrounding how elders with mobility impairments make decisions in choosing which ST

device are needed. This decision model adds to the elder ST needs literature and potentially will

help future designers create appropriately matched technological devices that will assist in the

care of aging baby boomers with mobility impairments.

Major Findings

The results of this study expanded and clarified many of the previous ST themes reported

in the literature (Figure 2-2). Previous ST themes (i.e., fear of dependency, privacy concerns) are

illustrated in the decision tree model along with newly identified barriers and facilitators in the

ST need decision process. Only one ST theme (perceived abilities) reported in the literature is

not illustrated in the decision tree model. Although interviews with participants lasted from 2.5-4









hours, the design of the study (which assessed 44 ST devices) did not allow for complete

exploration of each ST concept that emerged. For example a few participants would express that

they did not need a fall monitoring system or a personal emergency response system (PERS) and

that they knew how to properly fall or that if they fell they felt that they would not be knocked

unconscious. This researcher did not further explore this perceived ability. Future researchers

could further explore the issues surrounding this barrier theme, which may have many

subcomponents tied into it (i.e., pride, denial, calculated risk, independence).

The results of the study suggest that elder participants continually assess the cost-benefit

ratio prior to determining if a ST device is needed or not needed. Elder participants would weigh

the cost aspect against the benefit aspect to determine if the ST device was desired. Barrier

themes (i.e., reliability, loss of human contact) that were cited by the participant were the cost

aspect and the facilitator themes (i.e., increase sense of autonomy, enhance ability to monitor

health) were the benefit aspect. For example participants would assess the cost-benefit ratio of

whether the need to decrease the imposition of a family member (benefit) was greater than the

potential of becoming dependent on the ST device (cost). Future researchers could further

explore the threshold needed in order for each ST device to be perceived as needed.

Barrier Themes

Do I desire to start performing all or part of the activity again?

This study has several important findings that have implications for designers needing to

create appropriately matched elder friendly technological devices. Elder participants were

content with stopping all or part of an activity. Therefore to create more appropriately matched

technological devices designers should conduct studies to confirm all or part of the specific

activity being addressed is in fact perceived as being missed. Elder consumers may be content









with limiting or no longer performing certain tasks, therefore products that address these activity

limitations may not be readily adopted.

Satisfied with current activity performance?

Elder participants were primarily satisfied with their current activity performance. Elder

participants were content with limiting and/or taking longer to complete activities. To create

more appropriately matched technological devices designers should be wary of developing ST

devices based solely on whether the device can do a task faster, more efficiently, and/or for a

longer duration. Elder participants were found to be content with performing activities in their

own adapted style. As identified in the model if a participant is satisfied with his/her current

activity performance level then he/she may decide that ST is not needed.

Is ST a practical solution?

A distinct feature of the study was to assess all 44 ST devices regardless of impairment

level. Participants were asked about each of the ST devices, specifically if the device could assist

in their daily activities. For example even if participants did not have difficulty operating their

TV remote control, they were still asked if a voice recognition remote control would be desired,

and similarly if a medication reminding system would be desired without having any difficulty

managing medications. This would explain some types of barrier themes that were revealed in

the findings, such as perception of 'no gain' from the ST device. For instance, if a participant did

not have an impairment that the specific ST device addressed then they may not easily see any

gain to adopting the ST device.

To create more appropriately matched technological devices designers should be wary of

developing ST devices that may be perceived by elder consumers as too costly for their needs.

Elder participants were often concerned with the costs associated with utilizing ST. Elder

participants cited being content with making minor adaptations in their behavior rather than









desiring ST to assist with a difficult task. Elder participants expressed that they only spent money

on necessities; therefore if a participant viewed a device as only slightly needed and the cost was

perceived as high, then he/she may decide that the ST device is too costly for his/her needs.

Can I physically use the ST device? Is the ST easy to learn and use?

To create more appropriately matched technological devices designers should be wary of

developing ST devices that utilize a touchscreen as the primary interface. When given the option

elder participants preferred voice recognition technology over touchscreen technology.

Touchscreen interfaces were perceived as cumbersome to learn and use. To create more

appropriately matched technological devices designers should be aware of how far removed from

existing technology a ST device may be perceived by the elder consumer. Elder participants

expressed concerns of having to learn a completely new system. Possibly incorporating ST

components into an existing technology design may be more readily adopted.

Will using the smart technology device create more stress/problems?

Elder participants had concerns of problems and stresses associated with utilizing ST. To

create more appropriately matched technological devices designers should be aware of the level

of information generated by the device. Elder participants perceived technology as potentially

overwhelming them with constant reminders or personal health information. To create more

appropriately matched technological devices designers should be cognizant of the amount of

human contact being replaced by the ST. The need for ST was often trumped by the desire of the

elder participants to have human interaction.

Is the ST reliable?

Elder participants were found to be concerned with the reliability of the technology. ST

was often perceived as not being advanced enough to be reliable. To create more appropriately

matched technological devices designers should be alert to the fact that elder consumers often










compare ST reliability with the reliability performance of humans. As identified in the model if a

participant is concerned about the reliability of the device then they may decide that ST is not

needed.

Facilitator Themes

The model identifies numerous facilitator criteria (i.e., decrease imposition, increase

autonomy) surrounding the elder ST need decision process (Figure 3-15). These facilitator

criteria are important additions to the elder ST needs literature as they outline potential

motivators to adopting ST assistance. Previous literature simply utilized terminology such as

'favorable', 'open to the idea', 'convenient', 'willingness to accept or have in home' when

describing elder ST decision criteria (Demiris et al., 2004; Johnson, Davenport, & Mann, 2007;

Mihailidis et al., 2005). This decision criteria knowledge will help designers create appropriately

matched technological devices that potentially decreases imposition on family/friends, increases

sense of autonomy, assists with difficult activities, assists with unsafe activities, and enhances

the monitoring of health.

Decrease imposition on family/friends

To create more appropriately matched technological devices designers could incorporate

features in the ST device that focus on decreasing the level of assistance participants receive

from family. Specifically elder participants frequently expressed a desire for ST to assist in

decreasing imposition on family caring for them. Incorporating ST features that are able to

decrease imposition on family members may increase the desirability of the ST device.

Increase sense of autonomy

Elder participants desired ST that assisted with increasing their sense of autonomy. Elder

participants felt more in control of a robot than with a hired caregiver, therefore ST devices that

replaced certain caregiver tasks may increase the participants' sense of autonomy. To create









more appropriately matched technological devices designers could focus on ST devices (such as

a robotic dressing aid, transfer aid, or bathing aid) that would decrease the participants' reliance

on others, thus increasing their sense of autonomy. As identified in the model if a participant

perceives the ST device as potentially increasing his/her sense of autonomy then ST device may

be desired.

Assist with a difpcult activity/Assist with an activity currently unable to perform

Generally the findings indicate that ST is perceived as a poor substitute for elder

participants' own skills, especially when they are satisfied with their current activity

performance status. However when elder participants cited an unmet need (i.e., unsatisfied with

activity performance) then ST was increasingly seen more as a potential solution. To create more

appropriately matched technological devices designers could focus on ST devices that would

address any frequently cited unmet activity need (i.e., dressing tasks, carrying items, or preparing

meal s).

Replace existing technology to perform activity more safely

To create more appropriately matched technological devices designers could focus on ST

devices that would allow activities to be performed more safely. It was found that elder

participants desired ST to replace existing technology (i.e., ambulatory device, stove safety

device) in order to perform activities more safely. Developers could focus on designing ST

devices (i.e., robotic carrying aid, smart stove) that would help meet these unmet activity needs.

Add a safety net

To create more appropriately matched technological devices designers could focus on ST

devices that provide elder participants with safety nets. Specifically elder participants felt a need

for a fall monitoring system to act as a backup incase they were to fall and be unable to call for

assistance. Incorporating a safety net feature may increase the desirability of the ST device.









Enhance ability to monitor health

It was found that elder participants frequently desired ST to assist with their ability to

monitor their health. This frequently expressed need may have been due to fact that this category

of ST device goes beyond compensation of a task. As elder participants were generally found

satisfied with their current activity performance level, they did not express a need for assistance

with tasks that they were already comfortable with. This specific prediction technology went

beyond compensation and may have been perceived as adding something to the participant's

abilities, specifically providing an additional ability to monitor their health. Therefore to create

more appropriately matched technological devices designers may focus on ST devices that would

be perceived as enhancing their abilities. Future researchers could further explore the issues

surrounding this facilitator theme, which may have many subcomponents tied into it (i.e.,

satisfaction level with their healthcare management, number of chronic conditions).

Limitations

Several limitations exist in this study. The first limitation in this study is generalizability of

the findings. The findings can not be generalized to the elder mobility impaired population due to

the purposive sampling method, small sample size, and lack of ethnic diversity (all Caucasian

participants) in this study. The findings can not be generalized to the population due to the fact

that all participants had 12 months to adapt to their impairment (all were at least 1 year status

post onset of decline). A cohort of elders with a more recent decline in mobility impairment may

provide a more unique reception to ST providing assistance.

Generalizability of findings to all ST devices may be limited due to the fact that the

maj ority of ST devices (i.e., remote control voice/touchscreen, household automation, personal

robotic assistance) assessed in this study provided compensatory interventions. Participants were

satisfied with their current activity performance level, therefore evaluating primarily ST that only










provided compensation assistance for tasks that they were already comfortable with may have

been incomplete.

An additional limitation may involve researcher bias. Having a background in occupational

therapy where the obj ective is to return clients to full functional status may have influenced the

progression of questions during the interviews. For example many of the questions centered on

exploring how to enable the participants to achieve full functioning. This may have limited the

number of questions that explored how participants were satisfied with limiting their activity

performance level.

Another limitation of the study is its conceptual nature. At times participants would

express a desire to physically see or utilize the ST device in order to be able to make a more

informed decision regarding whether they would use the device. Without being able to fully test

the ST devices, participants may have been able to only provide perfunctory answers. If the

participants were confronted with the actual ST device their perceptions may vary from those

reported during their interviews.

An additional limitation of this study is the study design. Although interviews lasted from

2.5-4 hours, the large quantity of activities (49) and ST (44) assessed, limited the researchers

ability to completely explore each concept that emerged. Future researchers could further explore

the issues surrounding each barrier/facilitator theme that was revealed by this study.

Implications

As advances are made with underlying ST we can expect commercial smart home ventures

to significantly move into the mainstream population. As a rule commercial products are not

created solely for the benefit of their users, they are created by companies whose target is to

make money (Kuniavsky, 2003). Therefore designers may design smart technology that benefits

primarily the technology-enthusiast or younger cohorts, as has been shown in the past with









communication and business technologies (Eriksson & Timpka, 2002). Therefore an important

role of university-based research is to ensure that ST also be developed with the elder consumer

in mind and provide the most support for older people with disabilities. The results of this study

have added to the literature that describes the elder consumer needs regarding ST. This

knowledge will help designers create appropriately matched technological devices that will assist

in the care of aging baby boomers with mobility impairments.

Future Research

The qualitative nature of this study served to create an initial overall conceptual

ethnographic decision tree model. This composite elder ST decision tree model illustrates the

decision criteria involved in determining elder ST need. This study carried out the initial stages

of the first of two phases in ethnographic decision tree modeling, resulting in a preliminary

ethnographic decision model of the elder ST decision process. Utilizing the composite decision

tree model created from this study, future studies can further explore each of the individual 44

ST devices that were assessed. Decision trees can be built for each of the 44 ST devices. During

phase two of the ethnographic decision tree modeling process these individual decision trees can

be formally tested for their predictive accuracy on a separate group of elder consumers from the

same population. Knowing the elder consumers' ST decision making process could provide

future direction for developers and policymakers.

The overall conceptual ethnographic decision tree model can also provide a basis for future

qualitative studies to further explore the issues surrounding each barrier/facilitator theme that

was revealed. These end-user concepts and decision criteria identified could also provide the

needed conceptual framework for future quantitative studies. Understanding concepts and

categories utilized by the end-user can improve upon the validity of future quantitative studies

(i.e., survey design) where the terms and categories have to be known in advance (Blomberg,









Burrell, & Guest, 2003). Therefore a quantitative survey design study could be fruitful and

would assist with generalizing the findings.

Specifically, a study focusing on a younger cohort (<50 years of age) would be beneficial

in establishing if a younger population would be eager to regain as much function and efficiency

as possible. Possibly this younger cohort would exhibit a stronger ST need, as they would be

willing to accept any ST in order to accomplish more throughout the day.

Finally a study focusing specifically on elders who have recently been admitted to an

assisted living facility or nursing home (or their caregivers) could be beneficial. These cohorts

may be able to provide further insights into what ST would be needed to slow decline and delay

the onset of transitioning to an ALF or nursing home.

Conclusions

The construction of a preliminary decision tree model adds to the literature on elder ST

needs analysis. The awareness of multiple barriers and facilitators to the ST need decision

process potentially will help future designers create appropriately matched technological devices.

As illustrated in the findings of this study the elder ST need decision process is complex and

multifaceted. Unmet activity needs are potentially effective ST gateways as these needs are not

being met. Satisfaction with current activity performance level is potentially a maj or barrier for

ST to be adopted. The findings of this research suggest that compensatory ST interventions may

not be readily accepted by elders with MIs. Potentially ST devices that could be presented as

preventing further decline, retraining physical abilities, or restoring cognitive functioning, may

be found to be more readily accepted.



















DEMOGRAPHIC INFORMATION:


6. Living Arrangement:
1. Live alone
2. Live with someone (Please Circle)
-Spouse
-Adult Child
-Parent
-Other Family Member
-Friend
-Room mate
3. Occasionally have family/friend stay overnight in home to help with care
4. Other


APPENDIX A
INITIAL INTERVIEW GUIDE


Confidential Study Participant Number:


Start Time


Completion Time:


Interview Date:


1. Age: [ >90yo will be utilized in future to de-identify data ]


2. Gender:
1. Male

3. Race:
1. Black
2. White
3. Hispanic


2. Female


Asian
Native American
Other


4. Level of Completed Education:
1. Less than 12th Grade 5. Bachelor's degree
2. High School Graduate 6. Master's degree
3. Some college, no degree 7. Doctorate/Medical degree
4. Vocational, tech, or business school degree


5. Marital Status:
1. Married
2. Widowed
3. Divorced


Single
Other









7. Description of Home:
1. A single-family detached home
2. A multi-unit building (apartment, either low-rise or high-rise)
3. A mobile home
4. A semi-detached home (townhouse or duplex)
5. Other

8. How much income do you (and your husband/wife) have a year?

Yearly
A 0-$10,000
B $10, 000- $20,000
C $20,000- $30,000
D $30,000- $40,000
E $40,000- $50,000
F $50,000- $60,000
G $60,000- $70,000
H $70,000- $80,000
I$80,000- $90,000
J $90, 000- $100, 000
K >$100,000

9. How many people altogether live on this income (that is, it provides at least
half of their income)?












your overall health condition?
Poor
Other


2. Description of Health Condition:
Type of Condition Has Condition

(Description)
Speech or Communication
Difficulties

Poor Hearing

Memory Difficulties


Low Vision
RIGHT EYE

Low Vision
LEFT EYE

Function of RIGHT Full/Partial Paralysis
Hand Not Fully Open/Close
Pain
Arthritis
Function of RIGHT Full/Partial Paralysis
Upper Arm Not Raise
over Shoulder
Pain
Arthritis
Function of LEFT Full/Partial Paralysis
Hand Not Fully Open/Close
Pain
Arthritis
Function of LEFT Full/Partial Paralysis
Upper Arm Not Raise
over Shoulder
Pain
Arthritis
Function of RIGHT Leg Full/Partial Paralysis
Pain
Arthritis
Function of LEFT Leg Full/Partial Paralysis
Pain
Arthritis


HEALTH AND ACTIVITY INFORMATION:


1. What best describes
1. Excellent 4.
2. Good 5.
3. Fair










Type of Condition Has Condition

(Description)
***Other (Heart dz,
diabetes, COPD, HTN,
dizziness, etc.):

Other:


3. Description of Fine Mlotor Assistive Device Used:
1. None 5. Button Hook
2. Built up Handle on Utensils 6. Plate Food Guard
3. Universal Cuff Utensils 7. Writing Aid
4. Other

4. Description of Mlobility Assistive Device Used:
(Please indicate primary mobility AD utilized indoor/outdoor)
1. None 5. Wheelchair
2. Cane 6. Scooter
3. Walker 7. Powered Wheelchair
4. Other

5. Description of Typical Walking Distance (can be with use of canelwalker):
1. No difficulty 4. Household Distances Only
2. Slow Gait Only 5. Transfers Only
3. House and Yard Only

6. Description of Falling History -Over the Past Year:
1. None 4. Three-Five
2. One 5. >Five
3. Two 6. Other

7. Do you find yourself limiting your activities because of a fear of falling?
1. Yes 3. Other
2. No

8. Description of Visual Assistive Device Used:
1. None
2. Glasses

3. Mlagnifier


4. Bioptic Telescope System (auto near and far focusing)











5. Closed Circuit Television Systems CCTV (video camera used to

capture image of reading material and magnify it on a monitor)


6. Screen Reader Software (software system that converts text to speech)


7. Blind Cane



9. Description of Visual Impairment:
(With Better Eye -can be with Glasses)
1. No Impairment
2. Unable to Read Prescription Bottle Directions
3. Unable to Read Newspaper Text
4. Unable to Drive Due to Loss of Vision
5. Unable to Read Facial Expressions
6. Frequently Bump into Objects in an Unfamiliar Environment

10. Description of Security around Home:
1. Gated Community
2. Home Security System
3. Personal Emergency Response System
4. Dog
5. Other

11. Description of Resident Safety Check System:
1. None
2. Live-in spouselfam ily/room mate bu ilt in m multiple dai ly check system
3. Personal Emergency Response System
4. Daily phone call/visit from family/friendlagency to check in
5. Weekly phone call/visit from family/friendlagency to check in
6. Monthly phone call/visit from family/friendlagency to check in
7. Other

12. Description of Availability Assistance from Outside Home:
1. None
2. Local family/friends available to assist when needed
3. Out of town family/friends available to assist when needed
4. Assisted Living Facility
5. Continuing Care Retirement Community









13. How would you define the word 'independence'?
1. Do everything by self without use of assistive devices (cane, walker, button
hook)
2. Do everything by self can use assistive devices (cane, walker, button hook)
3. Do everything by self Can use high-tech assistive devices (automatic front
door, floor safety monitoring)
3. Can accept assistance from spouse or family member
4. Can accept assistance from neighbor
5. Can accept having an agency personal attendant
6. Will accept anything to remain in home. Comfort level remains steady as long
as stay in home.









AGING IN PLACE INFORMATION:
1. Do you own or rent your place of residence?
1. Own
2. Rent
3. Other

2. How long have you lived in your current residence?
1. Less than 5 years 4. 21-30 years
2. 6-10 years 5. 31-40 years
3. 11-20 years 6. Over 41 years

3. Do you plan to continue to live in your current residence for the next 10
years?
1. Yes
2. No

a. Plan to move into smaller home (easier to maintain)
b. Plan to move in with family/friend
c. Plan to move into ALF or CCRC
3. Don't Know

4. What best describes your reaction to the following statement?
I'd really like to live in my current residence for as long as possible
1. Strongly Agree 4. Strongly Disagree
2. Somewhat Agree 5. Don't Know
3. Somewhat Disagree

5. You are living alone and you discover you require some assistance to
continue living in your home, where would you seek assistance to remain
living at home?
(Ran k)
Family Assist
Friends Assist
Hire Personal Care Assistance
Purchase Technology to Assist (PERS, robotic vacuum)
Don't Know

6. If it was not safe (d/t falling, constantly forgetting medication) to live alone
in your home do you think you would continue to choose to live there?
1. Yes
2. No
7. Name three things that you feel may cause you to have to move out of your
home (whether to an ALF, NH, family or friends)?
1. Fall 4. SOB
2. Vision loss 5. Other
3. Arthritis










TECHNOLOGY ATTITUDES/EXPERIENCE INFORMATION:


1. Which statement would you agree with more strongly (e.g., high definition
TV, robotic vacuum, automatic front door)?
1. I like to try out new technology
2. I do not like to try new technology

2. Which statement would you agree with more strongly?
1. Technology helps me connect with other people
2. Technology makes me feel detached from other people
3. I feel neutral about technology

3. Do you have a computer at home?
1. Yes
2. No

4. Do you have a web-camera at home?
1. Yes
2. No

5. How would you describe your familiarity with computers?
1. Very familiar 3. Somewhat unfamiliar
2. Somewhat familiar 4. Not familiar

6. How would you describe your frequency of computer use?
1. Daily 4. Rarely Use
2. Few times a week 5. Never Use
3. Few times a month

7. Do you have high-speed internet access?
1. Yes
2. No

8. How would you describe your familiarity with the internet?
1. Very familiar 3. Somewhat unfamiliar
2. Somewhat familiar 4. Not familiar

9. How would you describe your comfort level with the internet?
1. Comfortable 3. Somewhat uncomfortable
2. Somewhat Comfortable 4. Uncomfortable

10. Do you have a cell phone?
1. Yes
2. No









11. How would you describe your familiarity with cell phones?
1. Very familiar 3. Somewhat unfamiliar
2. Somewhat familiar 4. Not familiar

12. How would you describe your frequency of cell phone use?
1. Daily 4. For Emergencies Only
2. Few times a week 5. Never Use
3. Few times a month

13. Do you have a Personal Emergency Response System (PERS) at Home?
1. Yes
2. No

14. How often do you wear your PERS system?
1. All the time 4. VWhen feeling sick
2. During the daytime 5. Leave PERS (pendant, bracelet) by bed
3. During the nighttime 6. Never use

15. What is your experience with smart technology?
1. No experience
2. Have seen it on TV or in Newspaper
3. Been on a tour of the local smart house in Gainesville
4. Have participated in Focus Groups on smart house technology in Gainesville









APPENDIX B
CURRENT ACTIVITY PERFORMANCE GUIDE



















































(A) Example: Cooking Popcorn P C/ X

(A) Physically Bathing/ Showering self

(A) Turning on Shower/Sink Faucets

(A) Adjusting Water Temperature of
Shower/Sink

(A) Grooming (brushing teeth, combing hair, etc)

(A) Bowel and Bladder Management (intentional
control bowellbladder)


Confidential Study Participant Number:


Interview Date:


Start Time


Completion Time:


Q)
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Legend:
C=current status

P= preferred solution


l=informal care (family, spouse)
F=formal care (paid caregiver)


*Last column will be completed during in-depth interview
(phase 2) where thorough exploration of elder's
perceptions of ST occurs.


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(A) Getting in/out of Bed

(A) Getting in/out of Shower

(A) Getting in/out of Tub

(A) Transferring onloff Toilet

(A) Carrying Items around the House

(A) LB -Dressing (including shoes)

(A) UB -Dressing









(RC) Opening/closing Blinds in Home

(RC) Unlocking/Locking Front Door

(RC) Opening/closing Front Door

(RC) Answering the Doorbell in Time


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C= current status

P= preferred solution


l=informal care (family, spouse)
F=formal care (paid caregiver)


*Last column will be completed during in-depth interview
(phase 2) where thorough exploration of elder's
perceptions of ST occurs.


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(P) Planning/Preparing Meals

(A) Using a Microwave to Reheat Items

(A) Using a Microwave to Cook a
Prepckaged Frozen Meal
(A) Cleaning up Food and Utensils

(MI) Remembering to Turn Off Stove
ToplOven


Cell phone

Telephone

Computer


(MI) Preparing Grocery Shopping List
Purchasing Items at a Store


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P= preferred solution

l=informal care (family, spouse)
F=formal care (paid caregiver)

*Last column will be completed during in-depth interview
(phase 2) where thorough exploration of elder's
perceptions of ST occurs.


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(MI) Checking the mail
(MI) Preventing Food from Expiring
Before Use
(MI) Keeping Track of Food in Kitchen
(A) Doing Laundry
(A) Vacuuming
(P) Remembering Appliance
Maintenance
(A) Mowing the Yard


(RG)


AdjustIng tne I nermostat In Home






























(RC) Closing all doors/windows in home
(RC) Locking all the doors/windows in home
(RC) Setting the Home Security Alarm
(P) Remembering to check in with designated
family/friend (daily/weekly/monthly
(MI) Remembering to turn off all appliances
(MI) Knowing which stove top burner is onloff


(RC)


Seeing who is at the front door








































(RC) Unanging the Unannel
(RC) Changing the Volume


SCurrent Activity Performance Evaluation

Legend:
C= current status
P= preferred solution

ag l=informal care (family, spouse)
F=formal care (paid caregiver)

of*Last column will be completed during in-depth interview
S (phase 2) where thorough exploration of elder's
2 S perceptions of ST occurs.

(MI) Monitoring Vital Signs (Blood
Pressure, Temp, Respiration Rate)
(MI) Monitoring Sleep Patterns
(MI) Tracking the Frequency of Trips to
the Bathroom at Night
(P) Physical Fitness Activity/Routines
(P) Mental Fitness Activity/Routines
(P) Maintaining Well Balanced
Nutritional Meal Choices
(P) Decreasing Health Risk Behaviors
(P) Medication Management/Routines
(P) Remembering MD Appointments










Current Activity Performance Evaluation


Legend:
C= current status
P= preferred solution


l=informal care (family, spouse)
F=formal care (paid caregiver)


*Last column will be completed during in-depth interview
(phase 2) where thorough exploration of elder's
perceptions of ST occurs.


Remembering Birthdays
Remembering Important
Community Events









APPENDIX C
IN-DEPTH INTERVIEW GUIDE


Confidential Study Participant Number:

Interview Date: Start Time Completion Time:

In-depth Interview Questions:

[Eight visual display boards will be utilized to introduce smart technology and help
subjects visualize the differences between automating, monitoring,
prompting/reminding, predicting, and remote controlling technologies in smart home
design.]

What are your initial thoughts about smart home technology? Prompt Questions:
How do you feel about smart home technology? Do you feel it will help save you time,
allow you to conserve energy, you connect with people, or make you feel detached,
frustrate you, be too expensive)? What role do you see technology having in your
future?

What are your thoughts on having a house that can be operated by a remote
(voice or touch screen) control? Prompt Questions:
Would having remote control abilities in your home enhance your daily activities?
Is there a task that you are no longer able to perform in your home that a voice
control device would be able to assist? (blinds, lights, thermostat, security)
Do you currently have difficulty getting around your home to (answer the door,
phone, turn onloff lights etc.)?
Do you feel unsafe or rushed when getting around in your home?
Would you prefer voice interface or touch screen interface?

What are your thoughts on having a house that is more automated (smartwave,
TVIStereo, vacuum)? Prompt Questions:
Do you currently have any tasks in your home automated (lights, sprinkler
system, security system, water heater, and thermostat)?
What if your front door could be automated?
Microwave that was automated?
Robot that would help you dress?
Robot that would help you bathe?
Robot that would help you get in and out of the bath tub?
How about windows and doors that were automated?
Automated lawn mower?
Personal robot that would help bring things to you or open things?









What are your thoughts on having a house that is able to monitor you? Prompt
Questions:
Do you currently have any monitoring devices in your home (security system,
PERS, BP machine, blood glucose machine)?
What are your thoughts on having a house that could monitor for falls?
What about a house that could monitor your sleep patterns?
Or check to see how many times you have been getting up to use the bathroom?
Medication use?
Monitor your blood sugar (via commode)?
Monitor what you were eating?
Monitor the items in the refrigerator and let you know if something was about to
expire?
Monitor if you left your stove or oven on?
Monitor for water leaks?
Monitor if someone is at the door?
Monitored how much you were exercising?
Monitor all your doors and windows?
Monitor if your mail has arrived?

What are your thoughts on having a house that is able to prompt you? Prompt
Questions:
Do you currently have any problems remembering to do things while at home?
What methods do you currently employ (post-it notes, spouselfamily do the
reminding, have a check system)?
Do you have problems remembering you put something in the microwave, oven,
on stove top, in WID?
Do you frequently have to throw out expired food items?
Do you feel you are able to do all the things that you want to do in a day?
Is their anything that you wish you had more time to do?
How do you feel you are managing your health?
What type of role would you say you play in maintaining your health (passive,
active, don't know)?
Do you feel having a house that would remind you when to take medications
could benefit?
What about diet choices?
What if a house were to schedule exercise appointments with you each day?
Or if it were to remind you of someone's birthday or automatically let you know it
has been a month since you talked to a particular friend?

What are your thoughts on having a house that is able to make predictions and
suqqestions? Prompt Questions:
*Do you feel that you would not want to have to interact with your house, would
rather have your house make suggestions for you? (let you know when a favorite
TV program is about to start, let you know of storm that is approaching).









VWhat about a house that learns what bath water temp. you like and sets it for
you?
Or learns when you use hot water during the week and turns onloff your water
heater automatically.
VWhat if you did not have to manual turn onloff your lights the house knows when
you are in the room and what lighting you need?
VWhat do you think about a house that could monitor your walking pattern and if it
changes in negative way make predictions?
Or a house that can monitor if your hands shaking is changing (when you use
your mouse, remote control) and lets you know?
Do you foresee yourself having smart technology installed in your home in the
future? Prompt Questions:
If so, what would it be for (physically helping, reminding you, monitoring your
health)?
If not, what are the barriers (no need, too expensive, too hard to learn)?

































Prediction Technologies




Behavior Learln~~ingArifiia Early Detection of
IntelignceHealth Condition
-automatic lighting programmed
-automatic temperature setting
-automatic ruater heater setting





Prompti ng/Remincli n Technol ogi e



Health Prompting
-Physical E.:ercise Household Prompting Soolalization
Aknal E.:ercise 4pliance falaintenance Prmmtng1
..dication Prompting allyNI/~eeklyI Important event
Asdical .4.pointments appointments reminders
iet Choice Prompting -Food Supply LowuI Family Calendar
(report tuhat items in entire --gtem
kitchen)



MonitorinqI Technoloqies




Household Sft eur Health F..4:nitoring
Tra -in Fall Detectior s Doorful.ndow tivity Trackting au
-I aflDEvromn dictation h.mrt monitor (.isrts to bathroom/ ae erFml
O sh e aton E:.temal kitehere seep k 18

-uac le rhtll aa aea .tal Sign Ahtnitonng
(maintenance/ fte ek
food inventory)-mi r



.4.rtomation

different Scenarios A..ailable C('lieekday? /acationfP.. vieruing)



T~~~ln -Atc nowEte set- Laru o~ur
H. AC: -curtain -Stereo -Opening Jar






Remote Control


Smart House


APPENDIX D

SMART TECHNOLOGY DEVELOPMENT FRAMEWORK


Remote location control of house
Hand Recoqnition cell phone
-car


I --- I -

Figure D-1. Smart technology development framework.









APPENDIX E
SMART HOME TECHNOLOGY VISUAL INFORMATION BOARDS







SmartHome

*Home capable of intelligently supporting
residents in their daily activities.
Such as:
Voice activated lights and blinds
Automated front door
Monitoring support (fall detection, sleep
patte rns)
Reminders to take medications


*Early detection of health conditions


Figure E-1. Smart home description display board.














Remote Control (voice recog nition)


TV set


,,r
.**


Thern10sltat


..... 1
-*-




Micowve


IB linds


Recognition Unit


Washer & D~ryer


Lights


OV~en


Figure E-2. Remote control voice recognition display board.


Security systern





Touch Pacl
Recognition Unit


Figure E-3. Remote control touchscreen display board.


Security system






Microwave oven


Thermostat


TV set


Washer & Dryrer


Remote Control (touchscreen)


Lights





















TV set


Household
A4u to rna tilon


Bli nds


A~utomnatic
front door


LightsMicrowave
ov~en

Figure E-4. Household automation/monitoring display board.


VWas hrer & dryer


Household Automation/M on itoring


Thermostat


Security systern


r











Exam ple of Robotic
Bath ing Aid
Station




Exam ple of Robotic
Carrying Aid and
Dressing Aid


Exam ple of
Exo skelIeto n
Walkingr Aid




Exam ple of
Transfer Aid
Robot


Figure E-5. Personal robotic assistance display board.


Personal Robotic Assistance























Blood Pressure W~h


Visits to the bathroom


~;===,


Walkig paternsCooking patterns


Fall Detection


Figure E-6. Monitoring technologies display board.


Monitoring Technologies


Medication
man age ment









Sleep patterns























Mental exercise


Important event reminder
(birthdays, medical appointments,
and socila events)


Health condition management
(high blood pressure, diabetes,
heart condition, arthritis)


PFrOmptingl
Reminding
Technology ies


Food Recommendations


Physical exercise


Figure E-7. Prompting/reminding technologies display board.


Prompting/Reminding Technologies


1

2


Medication reminding























Early detection of memory loss


Early detection changes in
activity level


Early detection of
tremors


Early detection of changes in
eating/drinking patterns


Early detection changes in
walking patterns


Figure E-8. Prediction technologies display board.


Prediction Technologies


~--f












APPENDIX F
PARTICIPANT OBSERVATION GRID GUIDE











PARTICIPANT OBSERVATION GRID GUIDE


Confidential Study Participant Number:

Interview Date: Start Time Completion Time:



1. Who is present in the house?
a) Friends/family/pets
2. What are their roles?
a) Participant caring for others?
3. How do the people behave toward one
another?
a) Who makes the decisions for whom?
b) What nonverbal communication do
they use?
4. How does participant move in home?
a) Furniture walking, alternating between
cane and walker, frequently bumps into
furniture.
5. How has the space in the home been
allocated?
a) Clear pathways vs. aesthetics
b) Majority of time spent in which room
c) Are commonly used items centered
around a favorite chair?
d) Safety concerns overridden for aesthetics
(smoke alarms, fire extinguisher)











6. How has the Al been Integrated?
a) Walker, scooter, cane, grab bars,
in prominent locations (safety is priority?)
b) A lot of environmental modifications?
c) Any homegrown modifications?
7. How has the technology been integrated?
a) Multiple or separate computer room(s)?
b) Highly used Tivo, PDA, cell phone









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Blomberg, J., Burrell, M., & Guest, G. (2003). An ethnographic approach to design. In J. Jacko
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Blueroof Technologies. (2006). Smart technologies for smart living. Retrieved July 14, 2006,
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BIOGRAPHICAL SKETCH

Rick D. Davenport entered the University of Florida' s Rehabilitation Science Doctoral

Program in August of 2002. The past 5 years of work as a research assistant in the Rehabilitation

Engineering Research Center on Technology for Successful Aging has set the foundation for

Rick' s dissertation area in smart home technology. Having shared authorship on four peer-

reviewed articles, authored a book chapter, and led a conference workshop, Rick' s interests lie

primarily in designing elder friendly technology.





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1 PERCEIVED SMART TECHNOLOGY NEEDS AMONG ELDERS WITH MOBILITY IMPAIRMENTS: AN ETHNOGRAPHIC APPROACH By RICK DEAN DAVENPORT A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2007

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2 2007 Rick Dean Davenport

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3 To my parents, brother, and all who nurtured my intellectual curiosity, academic interests, and sense of scholarship making this milestone possible.

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4 ACKNOWLEDGMENTS I would like to first thank my parents, John and Misako Davenport; and my brother, George Davenport for being there by my side, a nd understanding the sacrific es needed for me to succeed with this milestone. Their support meant the world to me. I would like to extend my sincere apprecia tion to my doctoral committee (Dr. William Mann, Dr. Barbara Lutz, Dr. Linda Shaw, and Dr. Benjamin Lok) whose support, guidance, and wise counsel kept me on track in my educati onal endeavors. I also would like to thank the members of the faculty and staff of the College of Public Health and Health Professions at UF for their individual insights and broade ning of my perspective in academia. I am also indebted to my RSD family of gr aduate students, Bhagwa nt, Jessica, Patricia, Megan, Pey-Shan, Sande, Leigh, Jia-Hwa, Eric Cristina, Sandy, Michelle, Inga, Roxanna, Michael, Dennis, and Arlene who provided frie ndship, camaraderie, and encouragement for the last 5 years. Finally, I woul d like to thank my SGI family who have provided cheerful motivation, spiritual encouragement, and in spirational human revolution in my life.

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5 TABLE OF CONTENTS page ACKNOWLEDGMENTS...............................................................................................................4 LIST OF TABLES................................................................................................................. ..........8 LIST OF FIGURES................................................................................................................ .........9 ABSTRACT....................................................................................................................... ............11 CHAPTER 1 INTRODUCTION..................................................................................................................13 Introduction................................................................................................................... ..........13 Problem........................................................................................................................ ...........13 Purpose........................................................................................................................ ...........15 Conceptual Framework...........................................................................................................16 Summary........................................................................................................................ .........17 2 REVIEW OF LITERATURE.................................................................................................20 Introduction................................................................................................................... ..........20 Assistive Technology........................................................................................................... ...20 Smart Technology............................................................................................................... ....21 Smart Home Technology........................................................................................................23 State of Smart Technology Development...............................................................................23 Prototype Smart Technology Development............................................................................27 Summary........................................................................................................................ .........32 3 METHODOLOGY.................................................................................................................44 Introduction................................................................................................................... ..........44 Research Approach.............................................................................................................. ...44 Rationale for Research Approach....................................................................................44 Ethnographic Decision Tree Modeling...........................................................................45 Ethnography and Technology Development...................................................................46 Advantages and Disadvantages of Ethnography.............................................................47 Role of Researcher............................................................................................................. .....48 Sample......................................................................................................................... ...........48 Inclusion and Exclusion Criteria.....................................................................................48 Recruitment.................................................................................................................... .49 Data Collection Techniques Used..........................................................................................49 Interviewing................................................................................................................... ..49 Participant Observation...................................................................................................50 Use of Camera.................................................................................................................51

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6 Field Notes.................................................................................................................... ...51 Data Collection Protocol....................................................................................................... ..52 Data Analysis.................................................................................................................. ........53 Bias........................................................................................................................... .......53 Data Saturation................................................................................................................54 Ethnographic Decision Tree Modeling...........................................................................54 Example Analysis Process for Participant Three............................................................55 Background information..........................................................................................55 Activity need decision model...................................................................................56 Smart technology need decision models..................................................................56 Remote control-voice decision model......................................................................57 Household automation decision model....................................................................57 Personal robotic assist ance decision model.............................................................58 Participant smart technology overall decision model...............................................58 Elder smart technology decision tree model............................................................58 Summary........................................................................................................................ .........58 4 FINDINGS....................................................................................................................... .......78 Introduction................................................................................................................... ..........78 Description of Participants.................................................................................................... .78 Research Question 1: What Do Elders with Mobility Impairments Perceive as Their Areas of Difficulty in Maintaining Independence?.............................................................80 Activities of Daily Living................................................................................................80 Instrumental Activities of Daily Living..........................................................................81 Research Question 2: Which Smart Technol ogy do Elders with Mobility Impairment Perceive as Solutions in Ma intaining Their Independence?...............................................81 Research Question 3: How do Elders with Mobility Impairments Make Decisions in Choosing Which Smart Technology is Needed?................................................................83 Elder Smart Technology Decision Tree Model...............................................................83 Key Barrier Themes........................................................................................................84 Do I desire to start performing a ll or part of the activity again?..............................84 Satisfied with current activity performance?............................................................87 Is ST a practical solution?........................................................................................91 Can I physically use the ST device?.........................................................................93 Is the ST easy to learn and use?...............................................................................94 Will using the ST create more stress/problems?......................................................94 Is the ST reliable?.....................................................................................................99 Key Facilitator Themes...................................................................................................99 Decrease imposition on family/friends..................................................................100 Increase sense of autonomy....................................................................................102 Assist with a difficult activity.................................................................................103 Assist with an activity currently unable to perform...............................................106 Replace existing technology to perform activity more safely................................107 Add a safety net......................................................................................................108 Enhance ability to monitor health..........................................................................109 Summary........................................................................................................................ .......110

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7 5 CONCLUSIONS AND RECOMMENDATIONS...............................................................130 Introduction................................................................................................................... ........130 Major Findings................................................................................................................. .....130 Barrier Themes..............................................................................................................131 Do I desire to start performing a ll or part of the activity again?............................131 Satisfied with current activity performance?..........................................................132 Is ST a practical solution?......................................................................................132 Can I physically use the ST device? Is the ST easy to learn and use?...................133 Will using the smart technology device create more stress/problems?..................133 Is the ST reliable?...................................................................................................133 Facilitator Themes.........................................................................................................134 Decrease imposition on family/friends..................................................................134 Increase sense of autonomy....................................................................................134 Assist with a difficult activity/Assist with an activity currently unable to perform...............................................................................................................135 Replace existing technology to perform activity more safely................................135 Add a safety net......................................................................................................135 Enhance ability to monitor health..........................................................................136 Limitations.................................................................................................................... ........136 Implications................................................................................................................... .......137 Future Research................................................................................................................ ....138 Conclusions.................................................................................................................... .......139 APPENDIX A INITIAL INTERVIEW GUIDE...........................................................................................140 B CURRENT ACTIVITY PERFORMANCE GUIDE............................................................149 C IN-DEPTH INTER VIEW GUIDE.......................................................................................157 D SMART TECHNOLOGY DEVELOPMENT FRAMEWORK...........................................160 E SMART HOME TECHNOLOGY VIS UAL INFORMATION BOARDS..........................161 F PARTICIPANT OBSERVAT ION GRID GUIDE...............................................................170 LIST OF REFERENCES.............................................................................................................173 BIOGRAPHICAL SKETCH.......................................................................................................181

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8 LIST OF TABLES Table page 2-1. Smart home technology definitions.......................................................................................34 2-2. Smart technology development around the world categorized by the five technology component areas................................................................................................................ .35 3-1. Advantages and disa dvantages of ethnography.....................................................................60 3-2. Description of research roles............................................................................................ .....61 3-3. List of Activities of Daily Living (ADL) assessed................................................................63 3-4. List of Instrumental Activi ties of Daily Living (IADL) assessed.........................................64 4-1. Demographic, health, and activity status information.........................................................113 4-2. Itemization of smart technology cited as needed by participants........................................126 4-3. Key need barrier themes.................................................................................................. ....128 4-4. Key facilitator themes................................................................................................... .......129

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9 LIST OF FIGURES Figure page 1-1. User research in product development cycle.........................................................................18 1-2. Research questions 1, 2, and 3 inputted into the ICF Model.................................................19 2-1. Example elements of smart technology that produce a smart structure................................33 2-2. Six primary themes reported in lit erature incorporated into ICF model...............................43 3-1. Techniques in user participatory design................................................................................60 3-2. Interview data collected by topic and subtopic question areas..............................................62 3-3. Early decision model re garding activity limitation...............................................................65 3-4. Participant 3s assistance with activity decision model.........................................................66 3-5. Early decision model attempt at categoriz ing 26 ST devices within one decision model.....67 3-6. Participant 3s background information sheet.......................................................................68 3-7. Participant 3s smart technology remote control voice recognition need analysis information sheet.............................................................................................................. .69 3-8. Participant 3s smart technology remote c ontrol touchscreen need analysis information sheet.......................................................................................................................... .........70 3-9. Participant 3s smart technology household automation need analysis information sheet...71 3-10. Participant 3s smart technology personal r obotic assistance need analysis information sheet.......................................................................................................................... .........72 3-11. Participant 3s smart t echnology monitoring technologies need analysis information sheet.......................................................................................................................... .........73 3-12. Participant 3s smart technology prompting/reminding technologies need analysis information sheet.............................................................................................................. .74 3-13. Participant 3s smart t echnology prediction technologies need analysis information sheet.......................................................................................................................... .........75 3-14. Participant 3s smart t echnology overall views need an alysis information sheet...............76 3-15. Composite elder smart t echnology decision tree model......................................................77 4-1. Participants with deficits in activities of daily living.........................................................114

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10 4-2. Report of ADL tasks with /without difficulty and whethe r need was met/unmet for the sample......................................................................................................................... .....115 4-3. Report of how ADL-diffi culty needs are being met............................................................116 4-4. Report of unmet ADL-difficulty needs...............................................................................117 4-5. Perceived unmet ADL assistance areas that participants cited c ould be replaced or improved to resolve unmet need......................................................................................118 4-6. Participants with deficits in in strumental activities of daily living.....................................119 4-7. Report of IADL tasks with/without diffi culty and whether need is met/unmet for the sample......................................................................................................................... .....120 4-8. Report of how IADL-diffi culty needs are being met..........................................................121 4-9. Report of unmet IADL-difficulty needs..............................................................................122 4-10. Perceived unmet IADL assistance areas th at participants cited could be replaced or improved to resolve unmet need......................................................................................123 4-11. Percentage of sample that cited a major smart technology component area need............124 4-12. Percentage of need cited by sample regarding smart te chnology applications.................125 4-13. Comparison of average smart t echnology device need cited per group............................127 D-1. Smart technology de velopment framework........................................................................160 E-1. Smart home description display board................................................................................162 E-2. Remote control voice recognition display board................................................................163 E-3. Remote control touchscreen display board.........................................................................164 E-4. Household automation/monitoring display board...............................................................165 E-5. Personal robotic assistance display board...........................................................................166 E-6. Monitoring technologies display board...............................................................................167 E-7. Prompting/reminding t echnologies display board..............................................................168 E-8. Prediction techno logies display board................................................................................169

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11 Abstract of Dissertation Pres ented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy PERCEIVED SMART TECHNOLOGY NEEDS AMONG ELDERS WITH MOBILITY IMPAIRMENTS: AN ETHNOGRAPHIC APPROACH By Rick Dean Davenport December 2007 Chair: William C. Mann Major: Rehabilitation Science Comparatively little research has been conducted regarding the smart technology needs of the elder population despite the proliferation of smart technology prototypes. The purpose of this study was to explore the perceived smart technol ogy needs of elders with mobility impairments while constructing a preliminary decision tree model of how these decisions are made. An ethnographic research approach, with a decisi on tree modeling component, was utilized to explore the complex variables surrounding the el der ST need decision process. In-depth individual interviews with 11 el ders aged 65 and older with mob ility impairments, and their inhome observations, provided insight into how elders perceived smart technology. Audio-taped interviews were transcribed verbatim and then analyzed for key phrases that represented participant decision criteria. Decision criteria concepts were combined to construct an elder smart technology decision tree model. The model identifies that elder participants must first determine if they are satisfied or not satisfied with their current activity performance le vel. If satisfied with their activity performance level then the elders do not critically consider the ST device. However, dissatisfaction with current activity level is no assurance that elder pa rticipants will desire ST to assist with their daily activity needs, due to the numerous other po tential barrier criteria identified in the model

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12 (i.e., not practical, not easy to use/learn, not reliable, or whethe r it may add more problems). If any of the other barriers are a concern then elde rs will not desire the ST device. The model also identifies important facilitator criteria (i.e ., decreasing imposition on family/friends, increasing sense of autonomy, assisting with difficult ta sks, replacing existing technology in order to perform task safely, providing a safety net, a nd enhancing the monitoring of their health) that could motivate elders to adopt ST assistance. This decision mode l adds to the elder ST needs literature and potentially will help future designe rs create appropriately matched technological devices that will assist in the care of aging baby boomers with mobility impairments.

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13 CHAPTER 1 INTRODUCTION Introduction This chapter includes three sections. The first section introduces smart technologys potential to help elders and how the private smart technology i ndustry is expected to have a technology boom over the next 20 years. The sec ond section examines the product development cycle and how todays technology devices have not been designed well for elder needs. The third section outlines the purpose of the study and the specific research questions addressed in the study. The last section describes how suited the c onceptual model is in exploring the complex nature of an elders perception of his/her problems and the solutions. Problem The potential to help elders (> 60 years old) maintain independence has increased extensively with recent advancements in sm art technology (Eriksson & Timpka, 2002; Haigh, 2002; Said, 2005). Future smart technology (ST) w ill assist elders in their homes by providing medication, hydration, and activity reminders; mon itoring body temperature, heart rate, sleep patterns; detecting falls; and assisting with meal preparati on and transfers (Carnegie Mellon University, 2004; Said, 2005). In the near future elders with mobility impairments (MI) may no longer need a cane or a walker, a nd instead will don a lower extremity exoskeleton to assist with ambulation (Kawamoto, Lee, Kanbe, & Sankai, 2003). In the distant future high-level quadriplegic patients will benefit from advances in experimental implantable electrode arrays that will allow their mind to control a robotic arm (Duke Med News, 2003, 2004). ST innovation will provide one of the solutions to th e growing needs of the aging population. While early prototype ST is cost ly and unwieldy, the private s ector ST industry of today is expected to have a boom similar to advancements seen over the past 20 years with the personal

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14 computer industry (Kanellos, 2004 ; Valigra, 2004). With a technol ogy boom there is a projected natural reduction in a ssociated manufacturing costs (Kanellos, 2004; Said, 2005; Valigra, 2004). However at present the mass produced techno logy products for busin ess and communication have primarily benefited younger cohorts (Eri ksson & Timpka, 2002). As a result elders commonly use devices that have not been desi gned for their needs (Eriksson & Timpka, 2002; Lee & Liao, 2003). For example: cell phone interface designs and feature options are targeted at younger populations (Davenport, Mann, & Helal, 2005; Lee & Liao, 2003; Mann et al., 2004); and software and web page designers continue to use non-elder friendly small font sizes, along with pull down menus that may be difficult for elde rs with an unsteady hand to navigate (Becker, 2004). Commonly, designers choose to address the physical interface proble ms of their products, while failing to address the underlying design needs for the elder population. For instance while designers of the web interface for the new Medi care Part D prescription drug program included both an alternative larger font and screen reader versions (Centers for Medicare & Medicaid Services, 2006), elders found the overall web in terface to be confusing and frustrating, which deterred many from enrolling in the new federa l government prescription drug program (AlonsoZaldivar, 2005; Basler, 2006; Eastern Virginia Medical Sc hool, 2006). To avoid future technology-person mismatches a better understandi ng of ST design needs of the elder population is essential. Product development is costly and it takes a long time to bring a pr oduct to market, with no guarantee that the technology will not b ecome obsolete during the development cycle (Dekker, Nyce, & Hoffman, 2003). Therefore desi gners must decide on the amount of time and resources that will be invested in research during the developm ent cycle. Figure 1-1 illustrates

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15 where user research (needs analysis and protot ype evaluation) could be used to improve product design and validate design choices (Anderson, 2001; Fleck, 2002). As Figure 1-1 illustrates the product development cycle ideally begins with needs analysis research, however developers typically end up investing a majority of resources during the prototype evaluation phase. Path A in Figure 1-1 illustra tes how usability testing can be used to guide the refinement of a protot ypes design. Usability testing (Pat h A) is ubiquitous in the ST literature and typically involves quantitatively evaluating the inte raction between the user and prototype. Path B illustrates how needs analysis research could be used to provide guidance for major revisions if a product has been released and receives ex ceedingly poor usability ratings. Needs analysis research can he lp reveal any missed consumer needs and guide development of future prototype concepts (Anderson, 2001; Fl eck, 2002). A resourceful way to avoid major problems late in the development process is to initially perform a compre hensive needs analysis to gain clues on any unmet needs and how to address the needs (Ande rson, 2001). However the problem lies in the fact that there is a deficien cy of needs analysis re search on what prototypes should be created in the ST litera ture, particularly pertaining to the needs of the elder population (Baillie, 2003; Mihailidis Cockburn, & Longley, 2005). Purpose The purpose of this study was to explore th e perceived smart technology needs of elders with mobility impairments while constructing a preliminary decision tree model of how these decisions are made. The three resear ch questions in this study were: Research Question 1: What do elders with MIs perceive as their areas of difficulty in maintaining independence? Research Question 2: Which ST(s) do elders with MI s perceive as solutions (or encumbrances) in helping maintain their independence?

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16 Research Question 3: How do elders with MIs make d ecisions in choosing which ST is needed or not needed? Conceptual Framework A conceptual model recognized in rehabilita tion science was utilized to provide a basis for exploring the various health, psychosocia l, and environmental factors surrounding the perceived ST needs of elders with MIs. The World Health Organization International Classification of Functioning, Disa bility and Health (ICF) model was used as the framework for this study (Schneidert, Hurst, Miller, & Ustun, 2003). The ICF model was well suited to explore the complex nature of an elders perception of problems and the solutions. The ICF model classifies disability as a dynamic multidimen sional phenomena (Schneidert et al., 2003; World Health Organization, 2001). This dynamic nature of the ICF model assisted when exploring elders with MIs perception of their areas of difficulty in maintaining their independence (research question 1). Figure 1-2 illustrates where the research questions 1-3 fit into the ICF model. The ICF is able to document a barrier whether located at the body structure, activity limitation, or participation restri ction level (Schneider t et al., 2003; World Health Organization, 2001). If the solution to a barrie r is perceived to be at the environmental level it can be documented within the contextual factors compone nt of the ICF model (research question 2). For example if a participant cited difficulty climbing stairs, a robotic walking aid may be perceived as a solution to this activity. The dynamic nature of the ICF model assisted in exploring how elder participants made decisions in choosing which ST de vice was needed or not needed (research question 3). The ICF was able to illustrate how a smart technology device may be aff ected by the various component areas (i.e., body structure or function, the imp act of personal factors, and an individuals

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17 immediate or surrounding environment) of the IC F model. For example when a participant is deciding if a robotic walking aid device is needed, the ICF model i llustrates that the participants decision could be affected by either the body struct ure component area in th e form of a previous stroke, or the personal factors co mponent area in the form of a pe rceived stigma associated with wearing the robotic walking aid. The multidimensi onal nature of the ICF model was one of the primary reasons it was chosen as the overall conceptual framework for this study. Summary Smart technology is being looked towards as a possible solution to the growing needs of our aging population. At present th ere is a deficiency of needs analysis research on what ST prototypes should be created, part icularly pertaining to the need s of the elder population. Further exploration is needed into how elders perceive their ST need. This study explored the perceived smart technology needs of elders with mobility impairments and constructed a preliminary decision tree model of how these decisions were made. The decision model will add to the elder ST needs literature and potentially will help future designers create appropriately matched technological devices that will assist in th e care of aging baby boomers with mobility impairments.

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18 Figure 1-1. User research in product development cycle. [Adapted from Anderson, G. (2001). Making use of user research. Retrieved July 20, 2006, from http://www.cooper.com/newsletters/2001_09/ making_use_of_user_research.htm.]

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19 Figure 1-2. Research questions 1, 2, a nd 3 inputted into the ICF Model.

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20 CHAPTER 2 REVIEW OF LITERATURE Introduction This review focuses on the issues related to smart technology. This chapter reports on the various terms associated with smart technol ogy (including assistive device and assistive technology); emergence and definition of the te rm smart technology; and multiple definitions of smart home technology. It also looks at the state of smart technology development around the globe, including both commercial and unive rsity-based smart technology ventures. The chapter concludes with a review of needs analysis research that focuses on prototype smart technology development. Assistive Technology Assistive technology (AT) and assistive devi ces (AD) have multiple meanings in the literature (Mann, Hurren, Tomita, & Charvat, 1995). This study will use the term AT as entailing a broad range of devices, services, strategies, and practices that are conceived and applied to ameliorate the problems faced by individuals who have disabilities (Cook & Hussey, 2002, p. 5). The specific definition used in the 1998 Assistive Technology Act Public Law 105-394 states an AD is, any item, piece of equipment, or product system, whether acquired commercially, modified, or customized, that is used to increase, maintain, or improve functional capabilities of individuals with disabilities ("Assistive Technology Act," 19 98). The Assistive Technology Act broadly defines the term AD, and what might be an AD for one person may not be considered an AD for another person. An oversized universal remo te control or large button telephone may be considered a standard product marketed to the general public (the overs ized buttons would be viewed as a convenient feature). However an elder individual with fine motor impairment would consider the same oversized universal remote c ontrol or large button telephone an AD. ADs and

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21 the application of the devices are unique to every circumstance (Cook & Hussey, 2002). Therefore ADs are challenging to categorize (C ook & Hussey, 2002). This study will potentially explore many forms of ADs, therefore the more global term AT will be utilized. One way researchers have attempted to categor ize AT is by grouping them as either high or low tech. This clarifica tion scheme reflects the rapid ad vancement of electronic technology over the past two decades (Cook & Hussey, 1995). The number of AT that employ electronics has increased while the cost has decreased (Cook & Hussey, 1995). Low technology devices are typically simple to create and easy to ac quire (Cook & Hussey, 1995). High technology devices are often high-priced, more challenging to make and more difficult to acquire (Cook & Hussey, 1995). Examples of low-tech AT are transfer benc hes, sock aids, modified eating utensils, and communication boards. Examples of high-tech AT are powered wheelchairs, electronic communicative devices, and environmental control un its. A rapidly growing sector of AT is in the field of smart technology (Eriksson & Timpka, 2002; Said, 2005) Smart Technology The term smart technology (ST) is said to have emerged during the early 1980s when researchers working within the United States defense system were combining computer systems with advanced sensors and materials (Goddar d, Kemp, & Lane, 1997). These compact computer systems could monitor their environment in real-time and independently counteract (Goddard et al., 1997). While the technology has improved since the 1980s the definition of ST still remains imprecise (Goddard et al., 1997; Worden, Bu llough, & Haywood, 2003) and at times is used strictly for marketing purposes (Worden et al ., 2003). After considerable research of the literature databases: (ISI Web of Knowledge), (National Library of Medicine and the National Institutes of Health), (CINAHL Information Sy stems), (IEEE Publications Online), (Association for Computing Machinery), (CiteSeer), (NetLi brary), (Books24x7), and online websites: online

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22 technology dictionaries and smart technology related websites, only a few definitions of ST were discovered. Caldwell (2001) globally defines ST as a design philos ophy concerned with integrating materials, sensing, pr ocessing, actuation and control in to structures which should be able to adaptively respond to their environmen t to optimize their operating conditions (p. 965). Worden (2003) stresses that in order to be cl assified as smart technology the devices should possess an awareness of their situation.capable of reacting to it (p. 1). For the purposes of this study Goddards 1997 categorization of the term ST will be utilized. Goddard (1997) classifies ST as any enabling technologies that intermingle to produce a smart structure. Goddard defines all structures, such as actuators sensors, control hardware, control algorithm, and structural members, that a ssist a structure in becoming aw are and automatically optimizing and reacting as smart technology (Fi gure 2-1) (Goddard et al., 1997). Goddard emphasizes that there are not any co mmercially available smart structures on the market and for a structure to be classified as smart it must have the ability to improve its performance over years of adapting to change s in its environment by learning from past operating experience (1997, p. 131). While there are not any smart structures in product form, there are plenty of ST that can intermingle to produce structures that are moving closer to meeting the definition of a smart structure. For ex ample ST exists in: automobiles that can sense an object in its path and alerts the driver by beeping or shakin g the drivers seat (McCormick, 2005); movie theaters that can de tect how many people are in the theater with carbon-dioxide detectors and automatically adjust the climate controls, as well as automatically be notified if bathroom supplies are low (Dyer, 2006); and elem entary schools that can automatically take attendance and monitor bathroom use with radio frequency identification (RFID) tags (Bradner,

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23 2005; Gibbs, 2005). The remainder of this literatu re review will concentrate on the broad range of ST that can be applied in the home to assist elders in their daily tasks. Smart Home Technology While definitions of ST may be insufficient, definitions of ST for the home are reported more frequently in the literat ure. Table 2-1 documents various definitions of smart home technology. For the purpose of this study smart home tec hnology was defined as any ST (including but not limited to actuators, sensors, computer processors/s oftware, and supporting structures) that creates an integrated home capab le of monitoring and supporting residents in real-time. This study focused on ST that can assist elders with mobility impairments (MI) in their homes whether the technology was limited to the infrastruc ture of the home (fall detection system) or moves with the resident (powered smart walker /scooter). Therefore the terms smart technology and smart home technology were used interchangeably. State of Smart Technology Development We can expect commercial ventures in connection with smart home technology to extensively grow over the next few years a nd expand into mainstream population. This can already be seen in the private smart home residences constructed in Roanoke, Virginia (Lawson, 2003; Zurier, 2003) and Stockholm, Sweden (Ele ctrolux, 2005; Gieseck e et al., 2005) where residents can remotely control their home through the internet. Residents at the IT Condominiums, in Stockholm Sweden can utilize a terminal with a touch screen, or a personal computer for food management (including shopp ing and meal preparation); access a family calendar system for scheduling activities of al l family members; and access the safety and security systems that detect a nd reports fires, water leakage, and intruder alarms (Electrolux, 2005; Giesecke et al., 2005). Comm ercial ventures by assisted living facilities have already

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24 begun to incorporate ST into their care manageme nt, as seen in Miwaukie, Oregon (Elite Care, 2006). Residents and staff wear a small locator ba dge clipped onto their clothing to help record response time of staff-to-resident request to en sure timely responses. Residents weight, sleep patterns, movements and interacti ons with other residents are co llected and family members can monitor this data via secure web portal (Elite Care, 2006). Commercial companies are joining together to develop and test smart home technologies and have built demonstration smart homes in Duisburg, Germany (inHaus, 2006), Eindhoven, The Netherlands (Philips, 2006), and Hunenberg, Switzerland (FutureLife, 2006). The largest of the three commercial smart home technology colla borations is in Hune nberg, Switzerland where over 60 companies have installed prototype a nd product smart technology in the FutureLife Smart Home (FutureLife, 2006). A family of four have been residents of this home and have been evaluating it for the last 5 years. The house in cludes: a smart refrigerat or that is able to download recipes and cooking progr ams from the internet; a solar powered lawnmower that follows an underground induction loop that autono mously cuts the grass; an automatic door opening system that recognizes a ch ip in the residents wrist watch and opens and locks the door automatically; sensors throughout the house wher e voice commands can prepare the room for TV viewing by lowering the blinds, closing th e curtains, dimming the lights, and lowering a projector; and appliance sensors that can send messages to the residents when the washers spin cycle or dryer is done (FutureLife, 2006). While the commercial ventures in smart home technology have been increasing, the majority of ST research has primarily been conducted by university-based institutions. At Georgia Institute of Technologys Aware Home researchers are devel oping prototype smart home technology systems to assist elders with impairments includ ing: a Gesture Pendant with an

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25 embedded wireless camera that can translate simple hand motions made to control house functions; Cooks Collage that utilizes cameras placed in specific locations to record steps performed when preparing a meal or doing laundr y and, when prompted, displays the last few steps performed so the resident would be aware if the detergent was already been inserted or a cup of flour was already added; a nd Digital Family Portrait that displays daily activity performed by an elder resident in the form of various icons on a digital picture frame so family members at another location can check in on their family members by viewing this portrait in their home (Georgia Institute of Technology, 2006; M ynatt, Melenhorst, Fisk, & Rogers, 2004). At University of Virginia Medical Au tomation Research Centers Smart House researchers are developing a sensor suite and data analysis system that can gather activity and health status of elder residents. Wireless se nsors on stove-top, bed pa d, shower, and a floor vibration sensor sends information to computer-b ased data manager where caregiver or family can monitor residents behavior. Researchers ha ve constructed a 3.5 lb. prototype fall detector that when placed on the floor can distinguish be tween a person falling and a 5-15 lb. object that has been dropped. At University of Rochesters Smart Medical Home researchers are developing systems that can potentially detect residents symptoms befo re the resident is aw are, thereby providing support before a crisis arises (Medical Auto mation Research Center, 2006). By installing accelerometers, gyroscopes, and RFID sensors that monitor speech patterns, breathing patterns, computer mouse activity, body motion, and gait patte rns, early detection of a health condition could be successful (Medical Au tomation Research Center, 2006). At MITs PlaceLab sensors are located througho ut an apartment which can detect whether an object is moved, opened/closed, turned on/off, and also detect residents limb motion with

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26 wearable accelerometers (Massa chusetts Institute of Technology, 2006). A residents activities and behaviors can be recorded with one of th e 9 infrared cameras, 9 color cameras, and/or 18 microphones distributed throughout. Researchers are working on a prototype system that promotes healthy lifestyles in the home. These prototype sy stems use social science and behavioral science techniques to motivate change in a residents beha vior (Massachusetts Institute of Technology, 2006). At University of Colorados Adaptive Hous e researchers are developing a system that will program itself, therefore no speech i nput, hand gesturing, gaze tracking, touch pad interfaces are used in the home (Mozer, 2005, 2006). Over 75 sensors monitor indoor/outdoor temperature, ambient light, audio level, m ovement in home, and door/window position. The house attempts to learn and anti cipate the residents needs a nd automatically sets the HVAC (heating, ventilation, and air cond itioning), water heater, and inte rior lighting levels (Mozer, 2005, 2006). The ST field is expanding and progressing rapi dly both in the privat e and university-based sectors. Researchers are looking towards smart ho me technology as one of the solutions to the projected strains on the healthcar e system during the future popul ation shift (Eriksson & Timpka, 2002; Said, 2005). An important role of university-based research wi ll be to address the need for further user research exploring the pr ototype ST needs of the elder population. For this study ST development research ha s been divided into five component areas: Remote control technologies (voice activated: lights, blinds, and temperature) Automation technologies (automated: microwave, temperature, safety lighting) Monitoring technologies (vital signs, falls, securit y, and activity/sleep patterns) Prompting/Reminding technologies (physical exercise, medi cation management, and diet choices)

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27 Prediction technologies (behavior learning and early de tection of hea lth conditions). An extensive review of the state of smart t echnology development is summarized in Table 2-2. Table 2-2 categorizes each example of ST development research, by the five technology component areas listed above, in both the private sector and university settings around the world. Prototype Smart Technology Development In trying to provide a better technology-person match, develope rs typically conduct studies (interviews, surveys, focus groups, field trials, lab testing, live-in tria ls, etc.) to evaluate prototypes during the development process. Protot ype trials have been conducted on: intelligent thermostats (Freudenthal & Mook, 2003), smart fr ont door reminder systems (Kim, Kim, Park, Jin, & Choi, 2004), smart shirts (Shant, 2006), ex oskeletons (Kawamoto, Lee, Kanbe, & Sankai, 2003), robotic home personal assistants (Carne gie Mellon University, 2004; Rotstein, 2004), infrared home health monitoring systems (Baner jee, Steenkeste, Couturier, Debray, & Franco, 2003; Ohta, Nakamoto, Shinagawa, & Tanikawa, 2002) tele-surveillance se nsors in care rooms (Banerjee et al., 2003), tele-h ealth home monitoring and e ducating devices (Kobb, Hoffman, Lodge, & Kline, 2003), a virtual health counselor (Kaplan, Farzanfar, & Friedman, 2003), and robotic home companion pets (Libin & Libi n, 2003; Omron, 2001; Wada, Shibata, Saito, & Tanie, 2002, 2003). The majority of ST literature centers on prototype evaluations. In 2004 consumers evaluated five prototype smart technology devices at Georgia Tech (Mynatt et al., 2004). Forty-four elder participants, who were living independently (no demographics on disability status were reported ) were given individual to urs of Georgia Techs Broadband Institute Residential Laboratory-The Aware Home followed by a structured interview (Mynatt et al., 2004). While the tour showcased 5 prototype smart technology devices only 3 were discussed in the manuscript: 1) Gesture pendant simple hand motions interpreted by a pendant that can control blinds doors, lights, and a thermostat 2) Cooks Collage cameras

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28 placed in specific locations to record steps pe rformed when preparing a meal or doing laundry and when needed could display the last few step s performed so the resident would be aware if the detergent was already placed or a cup of fl our was already added, and 3) Digital Family Portrait digital picture portrait displays daily ac tivity performed by an elder resident in the form of various icons (up to 4 weeks of data can be displayed). A family memb er at another location could check in on their family member by viewin g the digital portrait located in their home. While the authors obtained data on the elder participants perception of Georgia Techs Aware Home prototype ST that have already been created, they did not specifically explore the participants need for any further ST devices to be created. In fact the authors discovered that most of the elders felt the existing Gesture Pend ant may be good for them in the future but not needed now. The authors acknowledge the complexity of the elder rationale when deciding if the existing prototypes at Georgia Tech were desirabl e. At times elders were willing to trade off privacy concerns for a device that would allow fo r more independence in their home, but at the same time they would easily reject a device due to concerns of over reliance on technology. Future research resources may be conserved if a thorough needs assessment study determines that elders are resistant to specific ST de vices due to concerns of over reliance. While the prototype evaluation phase can invol ve the consumer in the design process, typically it is only after the initial concept and working prototype has been established. Usually after the prototype has been crea ted too many resources have been committed to scrap the overall concept (if needed) and to construct a ST app lication in a new direc tion (Dekker, Nyce, & Hoffman, 2003; Woods & Dekker, 2000). Therefore the prototype evaluati on phase is typically limited to investigating the ergonomic s or usability aspect of a pr ototype and not able to fully

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29 reevaluate the overall concept of the ST. Woods (2000) reinforces the dilemma of involving the user at the later stages of prot otype development when stating: Late testing studies are not able to tell deve lopers how to use those degrees of freedom to create useful and desirable systems. The problem in design today is not can it be built but rather what would be useful to build give n the wide array of po ssibilities new technology provides. (p. 275) Baillie (2003) reports this has b een a longstanding issue, stating: The call from the early 1980s to include users in design has still not been heeded. What we see in the household is exactly the problems we have seen and continue to see in the workplace. For that reason the home is likely to become a crucial proving ground for all those interested in developing a HCI (human co mputer interaction) that includes users as full partners in the desi gn process. (p. 42) Inadequate user involvement prior to th e conception of the prototype creates an environment where technology is the principal guiding force in product development cycle, which can lead to countless person technology mismatches. Mihailidis (2005) interviewed 15 baby boo mers (born between 1946-1965) and 15 elders (aged 65 and older) to explore: their willingn ess to accept smart home technology, which types of smart home technology they preferred, and if there was difference between groups. An overall trend of higher acceptability/w illingness scores were noted by the baby-boomer group. Their top five device areas were: health monitoring devi ces(100%), environmenta l control units(100%), personal emergency response system(85%), fall detection(78%), and lifestyle monitoring(62%) (Mihailidis et al., 2005). The top five device areas the elder group was willing to have in their home were: personal emergency response system (90%), health monitoring devices(80%), environmental control units(78%), fall detec tion(64%), and lifestyle monitoring(54%). These results suggest that baby boomers and elders mo st prefer to have environmental control units, personal emergency response syst ems, and health monitoring de vices, which could be designed and built into smart homes. However Mihailidis po ints out further exploration is needed into the

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30 rationale (perceived abilities, pr evious falls, loneliness/death) that was given for choosing one device over another (Mihailidis et al., 2005). Exploring the elde rs attitudes and perceptions further would potentially help developers determine their ST needs and what device would match that need. Mihailidis also relate s suggestions for developers of future smart home technology: keep cost low keep devices small, discreet, and comfortable keep maintenance low allow user control follow principles of universal design protect privacy from outside intruders minimize false alarms and ensure technical support available have a back-up system in the event of power failure (Mihai lidis et al., 2005). However these concrete suggestions primarily focus on cost and usability and do not add to the needed literature on revealing which prototypes need to be created. Demiris et al. (2004) used a focus group form at when evaluating 15 elder participants perceptions and expectations to ward smart home technologies. Three focus group sessions (six, five, and four participants) each lasting 1hour were conducted. The focus groups explored residents (in a continuing care retirement f acility) perspectives on future smart home applications (Demiris et al., 2004). Demiris ( 2004) reports potential elder smart home technology needs as: Emergency help Assistance with hearing and visual impairment Prevention and detection of falls Temperature monitoring Automatic lighting Monitoring of physiological parameters (e.g., blood pressure, glucose levels) Stove and oven safety control Property security Intruder alarm Reminder system announcing upcoming appointments or events

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31 Timely and accurate information on adverse drug events and contraindications. (p. 91) Demiris reported five areas of concern e xpressed by elder participants on smart home technologies: Possible privacy violation resul ting from the use of cameras Lack of human responders or possible repl acement of human assistance by technology The user-friendliness of the devices, and The need for training tailored to older learners. (p. 91) Participants also revealed privacy concerns regarding the use of cameras within their homes to detect falls or other accidents (Demiris et al., 2004). However elders felt that if the data being collected by the camera was in the form of a shadow or moveme nt without identifying characteristics then privacy would not become an issue (Demiris et al., 2004). All participants had positive attitudes toward ha ving smart technology enhance th eir lives (Demiris et al., 2004). The author noted that this sample may be mo re accepting of technology in their everyday lives due to 97% of participants curr ently used personal computers in their home and 66% regularly used their computers for surfing the Internet and sending emails. The elder group revealed that they might not be representative of their older fr iends; stating that some of their friends may not welcome technology into their homes as easil y. The group suggested installing non-obtrusive devices that do not require user s to operate or control them (such as automatic sensors). Demiris was able to compile a list of smart t echnology areas elders perceive as important, such as providing for emergency help, detecti on of falls, automatic li ghting, security, and oven control. However in agreement with previ ous research conclusi ons by Mynatt (2004) and Mihailidis (2005) further explorat ion of how the elder participants came to choose this list of ST is of most importance. The them es (surrounding the elder ST need decision process) that have been reported in this (prototype ST development) literature section have been integrated into the

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32 ICF model and are illustrated in Figure 2-2 (Demiris et al., 2004; Mihailidis et al., 2005; Mynatt et al., 2004). Summary Scores of commercial companies are joining together to develop and test ST devices. Commercial ventures in connecti on with ST are expected to ex tensively grow and expand into mainstream population. Presently th ere are very few studies addres sing the deficiency of needs analysis research on what ST prot otypes should be created, particul arly pertaining to the needs of the elder population. An important role of univers ity-based research is to address the need for further user research exploring the prototype ST needs of the elder population. The existing elder needs analysis literature has made recommendations for further exploration into how elders perceive their ST need. At pres ent the terminology cited in the literature is very limited. Terms such as favorable, open to th e idea, convenient, willingness to accept or have in home is frequently used to describe elder ST need. Howe ver these terms do not fully capture the elder ST need decision criteria. Constr ucting a preliminary decision tree model of how elders make ST need decisions may assist future designers in creating appropriately matched technological devices.

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33 Figure 2-1. Example elements of smart technolo gy that produce a smart structure. [Adapted from Goddard, N., Kemp, R., & Lane, R. (1997). An overview of smart technology. Packaging Technology and Science, 10, 129-143 (Page 132, Figure 1).]

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34 Table 2-1. Smart home technology definitions Source Description/definiti on -smart home technology Medical engineering and physics journal The term Smart House is commonly used to refer to a living or working environment, carefully constructed to a ssist people in carrying out required activities, using various tec hnical assistive systems. This idea can be applied to the needs of a wide range of people, but presents particular potential benefits to elderly, or handicapped people. (Allen, 1996, p. 203) Scottish government publication In most homes, heating, lighting, secu rity and entertainment systems all operate independently. Smart technology br ings these systems together through a communication network providing new wa ys of managing and living in the home. Such inter-linked command and cont rol systems have been extensively used in commercial buildings for years but have only recently started appearing in the home. (Scottish Executive, 2005, p. 54) Information technology online resource A home that is highly automated. It uses a common network infrastructure for lights, appliances and other devices (TechWeb, 2006). Scottish environmental design research center paper Homes that contain devices that are able to operate complex tasks that are preprogrammed either into the devices them selves (via a bus line) or through a computerized operating system (X10). (Dewsbury, 2001, p. 4) Artificial intelligence conference workshop Systems that have sensors and actua tors that monitor the occupants, communicate with each other, and intel ligently support the occupants in their daily activities. For elders, tasks can range in complexity from reminders to take medication to monitoring the genera l deterioration in functional capacity. (Haigh, 2002, p. 40)

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35Table 2-2. Smart technology development around the worl d categorized by the five t echnology component areas Name/location Structure description Technology component Description of smart technology development Commercial ventures Remote control: Handheld remote control interface, personal computer (PC) interface, and remotely control home via internet portal. Automation: Appliances, lighting, keyless entry, heating ventilation air conditioning (HVAC), backup natural gas generator, and, security. Monitoring: Security, water leaks, and pe rsonal emergency response system (PERS). Internet capable cameras in home and at front door. Prompting/ reminding: None reported on home website. Blueroof Technologies, McKeesport, Pennsylvania (Blueroof Technologies, 2006; Carnegie Mellon University, 2005). 3 free standing single-storied model smart homes completed. Buyers have 4 styles of smart cottages to choose. Prediction: None reported on home website. Remote control: Touch screen, personal computer (PC) and remotely control home via internet portal. Automation: Lighting, heat, and, security. Monitoring: Security front door camera and smoke/fire. Prompting/ reminding: None reported on home website. e2-home ITcondominiums, Ringblomman, Stockholm, Sweden(Electrolux, 2005; Giesecke et al., 2005). 59 private residence condominiums. Prediction: None reported on home website. Remote control: Touch screen utilized by resident to check daily weather, facility activities, email, and call for assistance. Automation: Doors auto open (via ve rification by infrared/RFID pendant) Monitoring: Staff utilizes touch screen to monitor weight/sleep pattern (recorded via bed sensors). Tracks residents activity in room and on grounds (via bracelet). Family members remotely monitor resident activity patterns, vital signs, and track response time of staff via internet portal. Prompting/ reminding: None reported on home website. Oatfield Estates, Miwaukie, Oregon (Elite Care, 2006). Six assisted living smart homes housing 68 elder residents. Prediction: None reported on home website.

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36 Table 2-2. Continued Name/location Structure description Technology component Description of smart technology development Commercial ventures Remote control: Handheld remote control interface, personal computer (PC) interface, and remotely control home via internet portal. Automation: Appliances, lighting, keyless entry, heating ventilation air conditioning (HVAC), backup natural gas generator, and, security. Monitoring: Security, water leaks, and pe rsonal emergency response system (PERS). Internet capable cameras in home and at front door. Prompting/ reminding: None reported on home website. Blueroof Technologies, McKeesport, Pennsylvania (Blueroof Technologies, 2006; Carnegie Mellon University, 2005). 3 free standing single-storied model smart homes completed. Buyers have 4 styles of smart cottages to choose. Prediction: None reported on home website. Remote control: Touch screen, personal computer (PC) and remotely control home via internet portal. Automation: Lighting, heat, and, security. Monitoring: Security front door camera and smoke/fire. Prompting/ reminding: None reported on home website. e2-home ITcondominiums, Ringblomman, Stockholm, Sweden(Electrolux, 2005; Giesecke et al., 2005). 59 private residence condominiums. Prediction: None reported on home website. Remote control: Touch screen utilized by resident to check daily weather, facility activities, email, and call for assistance. Automation: Doors auto open (via ve rification by infrared/RFID pendant) Oatfield Estates, Miwaukie, Oregon (Elite Care, 2006). Six assisted living smart homes housing 68 elder residents. Monitoring: Staff utilizes touch screen to monitor weight/sleep pattern (recorded via bed sensors). Tracks residents activity in room and on grounds (via bracelet). Family members remotely monitor resident activity patterns, vital signs, and track response time of staff via internet portal.

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37Table 2-2. Continued Name/location Structure description Technology component Description of smart technology development Prompting/ reminding: None reported on home website. Prediction: None reported on home website. Remote control: Remotely control home via internet portal. Automation: Lighting, heating ventilati on air conditioning (HVAC), and security. Monitoring: Appliance, gas meter, panic button, and indoor web cameras. Prompting/ reminding: None reported on home website. Village at Tinker Creek in Roanoke, Virginia (Lawson, 2003; Village at Tinker Creek, 2006; Zurier, 2003). 20 free standing private residence smart homes in a 170-unit development. Prediction: None reported on home website. Demonstration/ Model Homes Non-University-Based Remote control: Voice interface, touch screen, smart phone, and smart car remotely control the house. Automation: Lighting, blinds, curtains, auto open/close windows, keyless auto front door, saves preferred shower water-temp erature, smart refrigerator that is able to download recipes and cooking programs from the internet, and a solar powered lawnmower that follows an underground induction loop. Monitoring: Washing machine that notifies re sident when washer spin cycle is done. Prompting/ reminding: None reported on home website. FutureLife Smart House, Hunenberg, Switzerland (FutureLife, 2006). Live-in/ development/ demonstration 3story smart home *Past 5-years have had a family of four permanently residing in the smart home. Prediction: None reported on home website. Live-in/ development/ demonstration smart home. Remote control: Voice interface, gesture recognition, interactive mirror (allows you to check the traffic/weather condition, examine your weight, try different hairstyles, and both show your backside or magnify). HomeLab, Philips, Eindhoven, The Netherlands (Philips, 2006). Automation: Lighting and blinds.

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38Table 2-2. Continued Name/location Structure description Technology component Description of smart technology development Monitoring: Resident trac king via sensors in carpet, pa rticipants liv e in the house between 1-14 days to test prototype smart home technology. Researchers observe participants through two-way mirrors, cameras, and with microphones. Prompting/ reminding: A virtual fitness coach that monitors physiological data while calculating intensity and provides en couragement to meet exercise goals. A robot cat assistant in kitche n that monitors residents weight, daily activity, personal preference s and gives exercise and diet suggestions. Prediction: None reported on home website. Remote control: Touch screen, web pad, and remotely control home via internet portal. Automation: Door lock, lighting, thermostat water flow, and prepare grocery list. Monitoring: Mobility, falls, toileting patte rns, temperature, camera, infrared, blood pressure, heart rate, glucose level, medication use, eating patterns, pressure pads, microphone, monitor cogni tive decline, fires, burns, and poisoning. Prompting/ reminding: Medication use, health care appoin tments, plan nutritionally balanced meals. Independent LifeStyle Assistant, Honeywell Laboratories, Minneapolis, Minnesota (Honeywell, 2006). Development -of smart home automation systems. Prediction: An alert is sent when elder is behaving in an unusual way (not taking medications, wandering, not moving). Remote control: Touch screen, PC, smart car, and re motely control home via internet portal. Automation: None reported on home website. Monitoring: Appliances (including pantry/r efrigerator tracking contents/expiration dates), fire, water leaks, and humidity. The Intelligent House Duisburg Innovation Center (inHaus), Duisburg, Germany (2006). Development/ demonstration smart home includes a residential home, with a workshop, and networked Prompting/ reminding: None reported on home website.

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39Table 2-2. Continued Name/location Structure description Technology component Description of smart technology development car/garden. Prediction: None reported on home website. Demonstration/ model homes university-based Remote control: Opposes any alternative interface (i ncluding voice, gesture, and touch screen). Automation: Lighting, ceiling fans, fu rnace, space heaters, water heater. Monitoring: Over 75 sensors monitor indoor /outdoor temperature, ambient light, audio level, movement in home, and door/window position. Prompting/ reminding: None reported on home website. Adaptive House, University of Colorado, Boulder, Colorado (Mozer, 2005, 2006). Live-in(principle investigators residence) /Development/ demonstration 4 room smart home. Prediction: The house attempts to learn a nd anticipate the residents needs and automatically sets the HVAC, water h eater, and interior lighting levels. Remote control: Gesture and touch screen. Automation: Lighting, blinds, keyless entry/automatic front door, and HVAC. Monitoring: Family members remotely monito r resident activity patterns, vital signs via internet portal picture frame. Came ras placed in specific locations to record steps performed when pr eparing a meal or doing laundry. Prompting/ reminding: When prompted, displays the last few steps of select tasks performed so the resident would be aware (i.e., if the detergent was already placed or a cup of flour was already added). Aware Home, Georgia Institute of Technology, Atlanta, Georgia (Georgia Institute of Technology, 2006; 2004). Development/ demonstration three-story, 5040square-foot smart home. Prediction: Monitoring hand gestures possi ble prediction of Parkinsons disease. Remote control: Voice, touch screen, PDA, and remo tely control home via internet portal/smart phone. GatorTech Smart House, University of Florida, Gainesville, Florida (RERC on Live-in/ development/ demonstration one-story, 2,400Automation: Lighting, blinds, keyless entry/automatic fron t door, and auto-program microwave.

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40Table 2-2. Continued Name/location Structure description Technology component Description of smart technology development Monitoring: Tracking residents movement and falls (via floor sensors), mailbox, microphone/camera at front door, body we ight, temperature, water leak, toilet paper, water temperature, soap dispenser, and bed sensors monitor sleep patterns. Prompting/ reminding: Microwave prompts food preparatio n steps, and reminders in home provided to take medications and upcoming appointments. Technology for Successful Aging, 2006). square-foot, 3bedroom smart home. Prediction: None reported on home website. Remote control: Voice, touch screen and remotely control home via internet portal. Automation: Lighting, kitchen automatically re trieves recipes online, robot cuts grass and vacuums, and auto bath water temperature/filling. Monitoring: Weight, appliances (includi ng refrigerator trac king contents and automatically ordering food online). Prompting/ reminding: Dietary recommendations based on resident ideal weight. MavHome, University of Texas at Arlington, Arlington, Texas(2006). Development/ demonstration two-story, 5,500square-foot smart home/banquet hall/meetingclassroom complex. Prediction: Emphasis is on developing comput er prediction algorithms to assist in adjusting the home environment (i.e. temp) and predicting health needs of residents (monitoring short and long term changes in health). Remote control: None reported on home website. Automation: None reported on home website. PlaceLab, MIT, Cambridge, Massachusetts (Massachusetts Institute of Technology, 2006). Livein/development/ demonstration 1,000-square-foot smart apartment. Monitoring: Sensors are located throughout the apartment which can detect whether an object is moved, opened/closed, turned on/off, and also detect residents limb motion with wearab le accelerometers. A residents activities and behaviors can be recorded with one of the 9 infrared cameras, 9 color cameras, and/or 18 microphones.

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41Table 2-2. Continued Name/location Structure description Technology component Description of smart technology development Prompting/ reminding: Prototype system that promotes he althy lifestyles in the home. These prototype systems use social scien ce and behavioral science techniques to motivate change in a resident s behavior. Examples promoting healthy eating, energy conservation, increase physical activity, and safety practices. Prediction: None reported on home website. Remote control: None reported on home website. Automation: None reported on home website. Monitoring: Bed pads/loading cells to asse ss quality of sleep (restless leg syndrome, COPD), and development of algorithms to detect when medication regimens are not adhered. Prompting/ reminding: Developing interactive computer games as cognitive exercises. Reminding of medication administration times. Point of Care Laboratory, Oregon Health & Science University, Portland, Oregon (2006). Development of smart technologies. Prediction: Developing technology syst ems that through monitoring elder movements may detect early onset of cognitive impairments. Remote control: Voice. Automation: Lighting, temperature, music, television, and security. Monitoring: Facial recognition security cameras. Prompting/ reminding: None reported on home website. Smart House, Duke University, Durham, North Carolina (2006). Livein/development/ demonstration 4,500-square-foot smart home. Prediction: None reported on home website. Remote control: Family members remotely monitor re sident health status and sleep conditions. Smart House, University of Virginia Medical Development/ demonstration smart home. Automation: None reported on home website.

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42Table 2-2. Continued Name/location Structure description Technology component Description of smart technology development Monitoring: Stove-top, bed mattress pad (b reathing, pulse, room light level, and body temp/position). Gait pattern sens or and a fall detector (floor vibration sensor). Prompting/ reminding: None reported on home website. Automation Research Center, Charlottesville, Virginia (2006). Prediction: None reported on home website. Remote Control: None reported on home website. Automation: None reported on home website. Monitoring: Vital signs (blood pressure, pul se, and respiration), speech patterns, breathing patterns, computer m ouse activity, body motion, and gait patterns are monitored. Prompting/ reminding: None reported on home website. Smart Medical Home, University of Rochester, Rochester, New York (2006). Development/ demonstration 5 room smart home. Prediction: Developing a smart home system that potentially could detect various health problems before the resident is aware.

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43 Figure 2-2. Six primary themes reported in literature incorporated into ICF model

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44 CHAPTER 3 METHODOLOGY Introduction In this chapter the methodology for this study is presented in detail. The rationale for the research approach, a review of the ethnographi c decision tree modeli ng method, role of the researcher, sampling criteria, participant recrui tment, are presented. Data collection techniques and analysis process are also de scribed. Finally, an exemplar of the analysis process conducted for participant three is described in detail to il lustrate the process of analysis completed with each study participant. Research Approach Few studies have explored elde r perceptions of needs in sm art technology (ST). Therefore an ethnographic research approach was utilized to explore elders perceptions of ST solutions. This study was designed to addr ess the following questions: 1. What do elders with mobility impairments (MIs ) perceive as their areas of difficulty in maintaining independence? 2. Which ST(s) do elders with MIs perceive as solutions (or encumb rances) in helping maintain their independence? 3. How do elders with MIs make decisions in c hoosing which ST is needed or not needed? Rationale for Research Approach A practical means of explori ng end-users needs is to i nvolve the elder in the design process. User participation can be performed ear ly or late in the product development cycle and can be studied in a controlled lab setting and/ or in a naturalistic environment. Figure 3-1 illustrates techniques involving user particip ation along the development cycle (Muller, Wildman, & White, 1993). The horizontal axis of Figure 3-1 provides an approximate guide to

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45 when a technique might be most us eful during the development cycle (early or late). The vertical axis illustrates when the designer participates more directly in the users world and vice versa. Suitable group sizes for each techni que are indicated in the figure with superscript letters (Muller et al., 1993). Customization technique, collabor ative prototyping for de sign technique, and participatory analysis of usability data tech nique are typically empl oyed later in the product development cycle. In contrast, co-developmen t technique, envisioning future solutions technique, and ethnography technique are approaches that would allow designers to get a better understanding early in the development cycle (whi ch helps guide early pr ototype creation). Codevelopment technique, mock-up technique, and participatory ergonomics technique typically have users participate in a lab setting. While envisioning future solutions technique, contextual inquiry technique, and et hnography technique generally have th e designers participate more in the users world (which provides a richer dialogic context of their world). A rich dialogic context is important because it helps categor ize the end-users perspective of their situation in terms that are meaningful to the participant (Blomberg, Burrell, & Guest, 2003). U nderstanding the terms and categories utilized by the end-user can improve upon the validity of future quantitative studies (i.e., survey design) wh ere the terms and categories have to be known in advance (Blomberg et al., 2003). Ethnographic Decision Tree Modeling Data analysis related to ethnographic produc t design should go beyond simple structured reporting of the interviews and observations (Mariampolski, 2006). They should produce interpretations of the data that potentiall y help developers in the design of products (Mariampolski, 2006). Developers would find it useful to know the types of ST devices perceived as needed by elders and how these ne ed decisions are made. The goal of ethnographic decision tree studies is to pred ict decisions that will be made by modeling and identifying the

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46 specific decision criteria used by most indi viduals in a group (Gladwin, 1989). Ethnographic decision tree modeling elicits why people in a certain group do what they do (Gladwin, 1989, p.7). Knowing a groups decision making proce ss may enhance the success of the (ST) intervention being implemented (Gladwin, 1989). There are two phases in building ethnographi c decision tree models. Phase one, the model building phase, is an inductive process consis ting of a series of ethnographic interviews and participant observations. Through these ethnogr aphic field techniques decision criteria are elicited from each decision maker (i.e., elder cons umer) and then combined to form a diagram (i.e., decision tree) of their ch oices. A composite decision model of all the individual decision trees is then constructed to re present a group model. Phase two, th e model testing phase, utilizes a formal questionnaire to test the predictive accuracy of the composite model (created during phase one) on a separate group of decision make rs from the same population. In this study, the initial stages of phase one were carried out which resulted in a preliminary ethnographic decision model of the elder ST decision process. This preliminary model could be utilized by future researchers to more thoroughly explore the d ecision criteria surrounding the elder ST need decision process. In summary an ethnographic re search approach, with a decision tree modeling component, was chosen to explore the complex va riables surrounding the crit eria elders utilize when selecting ST prototypes early in the development cycle. Ethnography and Technology Development While ethnographic research comes from the di scipline of cultural anthropology beginning in the early 1900s (Creswell, 1998), it was not until the 1960s that companies utilized ethnographers to understand their customers (A nte & Edwards, 2006), and early 1980s that ethnographers were utilized to assist in examin ing human-computer interactions (Blomberg et al., 2003). The impetus for utilizing an ethnogr aphic approach was due to technology moving

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47 from engineering and research labs into the mainstream workplace environments (Blomberg et al., 2003). Designers realized that th ey could not solely rely on th eir own expertise as a guide for user requirements, they immersed themselves in r eal work situations to learn as much as possible from the users point of view (Blomberg et al., 2003; Preece et al., 1994). Today large corporations are frequently uti lizing ethnographers to help reveal consumer needs, for example: Sirius Satellite Radio had cons ulting ethnographers shadow 45 participants for four weeks studying how they interacted with entertainm ent technology prior to designing a new portable satellite-radio player; Gene ral Electric Company consulted ethnographers who conducted interviews over a period of four months to break into the plastic fiber industry; Intel Corporation had consulting ethnographers help devise a $500 community computer that would operate on a truck battery in 113 degree temperatures. Furtherm ore Intel is currently utilizing ethnographers to perform a needs assessment to prepare for the wave of aging baby boomers (Ante & Edwards, 2006; Berner, 2006; Loudon, 2005). Advantages and Disadvantages of Ethnography An advantage of using an ethnographic methodol ogy to initially explore elders perception of ST is its underlying assumption that in orde r to understand a world that you know little about, you must explore elders everyday realities firsthand (Blomberg et al., 2003). The advantage of the holistic empirical nature of the ethnographic method will assist in understanding the cultural forces that shape the elder participants everyday realities (attitudes, beliefs, and perceptions) in regards to ST needs (Portney & Watkins, 2000) Table 3-1 describes va rious advantages and disadvantages of utilizin g an ethnographic approach. An additional advantage of the ethnographic met hod in this study is that context rich data may potentially provide an initial framework that describes the elders pe rceptions of their ST needs. Disadvantages of using the ethnogr aphic method are the di sruption caused by the

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48 researchers presence in the home and poor gene ralizability of results. However the emphasis on discovery and context rich data made ethnography best suited method for exploring any unmet ST user needs (Martin, Murphy, Crowe, & Norris, 2006). Role of Researcher Prior to data collection th e ethnographic researcher determ ined which researcher role (observer-participant, participan t-observer, insider-observer, a nd interviewer) was appropriate during the study (Table 3-2) (Blomberg et al., 2003; McMillan & Schumac her, 1997). The effect on the participant, researcher and event varies with each role (Blomber g et al., 2003; McMillan & Schumacher, 1997). As Table 3-2 illustrates bot h pure participant or observer roles were inappropriate as neither were interactive (M cMillan & Schumacher, 1997) Participant-observer role (i.e. spouse-assistant) and insider-observer role (i.e. therapist, nurse) would both require time and resources to assimilate into the home and would take from the abi lity to interact with the elder participant. However both observer-participant and inte rviewer role were found to be appropriate for this study. An observer-participant role provide d rich context specific data on how elder participants performed activities in their home environment. Interviewer role produced an in-depth understanding of any unmet elder needs and perceptions of ST solutions. Sample Inclusion and Exclusion Criteria Inclusion criteria for this study included age > 60 years, self-report of mobility impairment, and English-speaking. Exclusion criteria included participants who were unable to complete the interview session (d/t marked comm unication or cognitive deficits), reside in a skilled nursing facility, or nursing home. For this study mobility impairment was defined as a limitation in the execution of: carrying/manipulating objects, ch anging body position, or transferring from one place to another by walking or climbing stairs due to a physiologic abnormality or loss. The

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49 definition of mobility impairment was compos ed from the World Health Organization ICF (2001) definition in which mobility is defined as, moving by ch anging body position or location or by transferring from one place to another, by carrying, moving or manipulating objects, by walking, running or climbing, and by using va rious forms of transportation (p. 138) and impairment is defined as, a loss or abnormality in body structure or physiological function (p. 213). Recruitment Subjects were recruited from the Rehabi litation Engineering Research Center on Technology for Successful Aging (RERC-Tech ) research sample pool. Participants demographics, health, and functional status in formation were screened for inclusion and exclusion criteria prior to being recruited via phone call. A tota l of 11 elders were recruited through purposive sampling method. Data Collection Techniques Used Interviewing Interviewing is the most important da ta gathering technique for the ethnographer (Fetterman, 1998a) and is essential in understandi ng the participants pers pective (Blomberg et al., 2003). Ethnographic interviews were the primar y data collection stratagem during the study and were a secondary outgrowth from pa rticipant observation sessions (McMillan & Schumacher, 1997). Interviewing was vital for this study due to the limited a ccess this researcher had to observe participants performing their ADLs/IADLs and the conceptual nature of the study. This researcher conducte d all in-depth interviews. Structured and semi-structured intervie w approaches with open and closed-ended questions were utilized to obtain background info rmation, descriptions of daily activity levels,

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50 and participant perceptions of ST component area s (Figure 3-2). Figure 3-2 illustrates data that was collected by topic and subtopic areas. The Initial Interview Guide (Appendix A) was used to compile information such as basic demographic, health activity, aging in place, and technology experience information. This background information provided contextual info rmation that assisted in describing the participants views on smart technology. The Current Activity Performance Guide (A ppendix B) was utilized to document the participants description of their daily task (e.g. bathing, gr ooming, dressing, sleeping, and health management) execution. These activ ities are adapted from the O ccupational Therapy Practice Frameworks categorization of the Areas of Occ upation (ADLs, IADLs, wo rk, play, leisure and social participation) (Youngstrom et al., 2002). Th is activity performance information assisted in describing the participants daily difficulty areas in maintaining independence (research question #1). Table 3-3 and Table 3-4 summarize all ADL and IADL activities assessed during the study. The In-depth Interview Guide (Appendix C) was utilized to probe participants perceptions of various component areas of ST (research questi on #2). The ST component areas are based on a Smart Technology Development Fr amework (Appendix D) that was created for this study to illustrate the central ST compone nt areas in development around the world. Eight visual display boards (Appendix E) were uti lized to introduce smart technology and help participants visualize the differences betw een automating, monitoring, prompting/reminding, predicting, and remote controlling te chnologies in smart home design. Participant Observation Typically ethnographers utilize multiple methods and sources to collect and validate data (McMillan & Schumacher, 1997; Portney & Watk ins, 2000). A fundamental assumption of anthropology is what people say they do may not always represent what they do in reality

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51 (Blomberg et al., 2003). Therefore to verify and enhance the interp retation of the interview data participant observation technique were utilized. Participant observ ation helped capture behavior that participants were unaware of due to the habitual nature of tasks and relevant details that were missed due to dynamic nature of the home (Blomberg et al., 2003). A participant observation grid was utilized due to the limited observation time and the complex nature of the home environment (Appendix F). Ut ilizing a participant observation grid allowed the researcher to remain focused on descriptiv e details salient to the phenomena under study, which later led to more subtle information surrounding the phenomena (McMillan & Schumacher, 1997). Use of Camera Cameras enabled the ethnogr apher to document field obs ervations, which acted as mnemonic devices during analysis phase (Fet terman, 1998a). Photographs captured during the beginning of the study were retroactively examined for themes (Fetterman, 1998a). Still camera photography was utilized to capture elder proble m areas and success areas in their environment. Photographs of environmental modi fications (i.e., ramps, grab ba rs, railing), hom emade assistive devices (i.e., jar/soda can hol der, yogurt cup holder), and problem areas (narrow door frames, uneven floor tiles, steep stairs) were recorded. Field Notes Ethnographic observations and interviews can be exhaustive (Fetterman, 1998b); therefore field notes were needed to capture the content ri ch data before subsequent events overshadowed the experience (Fetterman, 1998b). Fi eld notes were indispensable in this study as they formed the building blocks necessary for the in-depth analysis process (Fet terman, 1998b). There are many styles of recording fiel d notes in ethnography (Spradley, 1979). This study utilized three formats (condensed account, expanded account, and fieldwork journal) to record field notes (Spradley, 1979). A condensed account is comprised of field notes taken during the interview

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52 and observation process (Spradley, 1979). Conde nsed field notes included short phrases, abbreviations, unconnected sentences, and mnemonics that later assisted the researcher in the reconstruction of events (Fetterman, 1998b; Sp radley, 1979). After the field observation and interview session ended, the expansion account of recording field notes was initiated to expand upon the condensed field notes (Spradley, 1979). E xpansion field notes in cluded filling in all needed details surrounding the events not reco rded on the location (S pradley, 1979). The final method of field note recording involved th e researcher keeping an introspective fieldwork journal which accounted for any biases or feelings that may have influenced the research process (Spradley, 1979). Fieldw ork journal descriptions in cluded recording problems, breakthroughs, confusion, mistak es, and ideas (Spradley, 1979). Data Collection Protocol Study sessions began with an initial interview phase to gather background information, including specific information on participants current activity status. This was followed by an in-depth interview phase to explore participants percepti ons of smart technology. During the indepth interview phase, visual di splay boards were utilized to introduce smart technology and help participants visualize the different technologies in smart home design. A brief participant observation phase followed to document the participan ts use of space and integration of technology into their home. During the particip ant observation stage, still camera photography was utilized to help capture any problem or success areas in the home environment. Outline and time that was allotted for each phase of data collection is listed below: Phase 1 Initial interview (45-90min.) Initial Interview Guide A structured interview appro ach with closed-ended questions were utilized to gather basic demographic, health activity, aging in place, and technology experience information (Appendix A).

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53 Current Activity Performance form (Appendix B) was utilized to document the status of participants description of their daily task (e.g. bathing, grooming, dressing, sleeping, and health management) execution. Phase 2 In-depth interview (45-90min.) In-depth Interview Guide Semi-structured open-ended que stions (Appendix C) along with eight visual display boards (Appendix E) were utilized to thoroughly explore participants perceptions of various component areas of ST. Phase 3 Participant observation (20-30min.) Participant Observation Grid (Appendix F) helped document observations while having the participant give a tour of their home and point out their success and problem areas. Utilizing the participant observation grid allo wed the researcher to remain focused on descriptive details, wh ich later led to more subtle information. Interview and participant obs ervation phases were audio recorded and transcribed verbatim. Field notes were written during in terview sessions (condens ed field note account), following interview (expanded fi eld note account), and throughout the study (fieldwork journal account). Still camera photography was utilized du ring the participant observation phase (phase 3) to capture elder problem and su ccess areas in their environment. Data Analysis Qualitative data analysis begins the moment a research problem is selected and builds on insights throughout the study (Fetterman, 1998a). Dem ographics, health, activity status, previous experience with technology, and vi ews on aging in place were analyzed to help determine any trends in the study sample. Categorical variab le (frequencies) and noncategorical variable (means, standard deviations, and range) background data were evaluated. A ll In-depth interviews were transcribed verbatim. Bias To help avoid researcher bias, during the an alysis process multiple meetings with a qualitative advisor were conducted to analyze the researchers in terpretation of the findings. An

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54 open coding process (as opposed to a preexisting list of codes) was utilized to capture all emerging decision criteria during th e analysis process. Preliminar y findings were also presented to a qualitative data analysis group, where the researchers inte rpretations of the data were examined. Data Saturation In qualitative resear ch the sample size varies due to th e flexible nature of sampling. Data collection continues unt il data saturation (when no new th emes emerge from the data) is achieved (Ploeg, 1999). Typically in ethnographic re search themes begin to emerge within the first few interviews (Anderson, 2001; Muller et al., 1993) and data saturation almost completely occurs within the first 12 interviews (Guest, Bunce, & Johnson, 2006). For this study the majority of new themes emerged within the fi rst four in-depth interviews. A couple of new themes were revealed during in terview #7; however no new themes emerged in the last four interviews. Ethnographic Decision Tree Modeling As the goal of this study was to explore how participants made thei r decisions regarding ST, an ethnographic decision tree modeling appr oach was utilized (Gladwin, 1989). Interview transcripts, field notes, and field journal entrie s were analyzed based on this inductive approach geared toward eliciting contextual data about decision processes (Gladwin, 1989). Initial phases of data analysis involved many iterations of sorting, comparing, and identifying key phrases that both represented participant deci sion criteria, and reflected any contrasts in decision behavior (Gladwin, 1989). Decision criteria themes were then combined in the form of a decision tree to build decision models (Gladwin, 1989). Transcript s were read multiple times and expansively converted into decision models il lustrating each participants c onceptual perceptions of their activity and ST needs. The final phase of analys is involved combining all participant conceptual

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55 decision models into a broad composite conceptu al model illustrating th e issues surrounding the elder groups ST need decision process. Data analysis process involved creating numer ous drafts to reflect the participants decision process. For example early versions of participant-1s act ivity limitation decision models were basic and only illustrated cont rasts between the types of assistance (person, equipment, no assistance) utilized (Figure 3-3). La ter versions of this activity limitation decision model were more comprehensive and differentiated between types of assistance (AT, family, AT and family, no assistance) and status of the activi ties (satisfied with activ ity, problem with task completion and would like a solution, problem w ith task completion but not concerned)(Figure34). Early versions of the ST need decision mode ls were often too complex. For example during initial phases many attempts were made to illust rate contrasts between all 44 ST devices in a single decision tree. Figure 3-5 documents an attempt to illustrate contrasts made by participant1 between 26 ST devices. Example Analysis Process for Participant Three Background information An exemplar of the analysis process complete d with each study particip ant is reviewed in the following section. Each transcript was read multiple times and information regarding health condition, living arrangements, description of AT utilized, experiences with technology, and views on aging in place were synt hesized and consolidated into a single coversheet (Figure 3-6). This participant background information sheet pr ovided quick access to contextual information which assisted during the analys is process. For example a quick glance at participant-3s background information sheet illustrates that he is a 74 year old, Caucasian male, with a history of multiple strokes, who wears an orthotic brace on his left le g, owns a cell phone (and uses it

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56 daily), lives with his daughter in a rented condo, and ut ilizes a powered wheelchair for ambulation. Activity need decision model As discussed in the previous section, later versio ns of activity-need decision models were able to differentiate between types of assistan ce (AT, family, AT and family, no assistance) as well as perceived status of activit y performance levels (satisfied with activity, problem with task completion and would like a solution, problem w ith task completion but not concerned)(Figure 3-4). Utilizing a decision modeling approach, a key barrier theme of be ing satisfied with an activity performance was revealed. For example participant-3 cited being satisfied with his current activity performance leve l with regards to his assistiv e technology assisting him in his showering and walking activities. This is illustrated in his de cision process: activity limitation, assistance utilized, assistive devi ce utilized, satisfied with current performance level of activity (with assistive device) (Figure 3-4). A key facilit ator theme of wanting to decrease imposition on family was revealed by participant-3 as well, who cited not being sati sfied with his dressing activity. This is illustrated in his decision process: activity limitation, assist ance utilized, family/person assistance utilized, problems with task completion (with family assistance), and would like solution to problems of completi ng activity. Where participant-3 cites, Oh I am not comfortable, because it [donning sl acks] is awful difficult, and sometimes she [daughter] is doing something else and gets all ticked off.I dont like to have to depend on my family because they got their own lives and everything. (Transcribed Interview, pages 21, participant 3). Smart technology need decision models As discussed in the previous section, early ve rsions of the ST need -decision process were found to be too complex when attempting to illust rate contrasts between all 44 ST devices in a single participants decision model (Figure 3-5) Therefore separate decision models were

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57 constructed for each of the ST component ar eas (remote control-voice, remote controltouchscreen, household automation, personal robo tic assistance, monitoring technologies, reminding technologies, and predicti on technologies) for each partic ipant (Figures 3-7 to 3-14). Several of the smart technology decision models c onstructed for participan t-3 are discussed in the next section. Remote control-voice decision model Utilizing a decision modeling approach, a key barrier theme of being concerned about the reliability of ST was revealed by participant-3. Participant-3 cited being concerned about the reliability of a remote voice controlled device. This is illustrated in his decision process of: remote-voice control (VC), no need, additiona l problems arise with the incorporation of technology (i.e., reliability a c oncern), VC-TV set (Figure 3-7) Where participant-3 cites, They [voice recognition] act up an awful lot. And I don't think you real ly need it, hell if you can't mash the button on the remote control what's the use, I mean, it would be nice to have it [voice recognition] but I don't think it' s very important. (Transcribed Interview, pages 39, participant 3). Household automation decision model Utilizing a decision modeling approach, key ST facilitator themes were also revealed during the analysis. For example a key facilitator theme (diagram med as a red cloud icon in the decision model) of desiring additi onal assistance with a difficult ta sk was revealed (Figure 3-9). Participant-3 cited desiring further assist ance in performing the difficult activity of opening/closing his front door. This is illustrate d in his decision process: household automation, need, slight need, automatic front door (F igure 3-9). Where part icipant-3 cites, Well that [automated front door] would be nice, I could push the button and tell them to come in the front door and that would be nice. (Transcribed Interview, pages 42, participant 3).

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58 Personal robotic assistance decision model The decision modeling approach was able to reveal complex decision criteria. For example participant-3 cited needing assistance with transf erring in/out of his bathtub; however he was concerned about the size of the technology a nd the heat generated by the technology. This is illustrated in his decision process: personal robotic assistance, need, strong need, transfer aid, concerned about, size of technology, and heat generated by the technology (Figure 3-10). Participant smart technol ogy overall decision model An overall participant ST decision model, whic h represented all ST component areas, was built for each participant (Figure 3-14). This ove rall ST decision model illustrated all primary barrier themes (cost, fear of dependency, additional pr oblems, no gain, stigma, donning difficulty, reliability concerns), facilitator th emes (decrease imposition, replace unsafe activity, assist with activity that is difficult to perform, enhance ability to monitor health), as well as all ST devices (automatic front door, early detecti on of changes in activity level, voice control dialing of phone numbers, dressing aid, carrying aid, transfer aid) cited as needed by participantthree. Elder smart technology decision tree model The final phase of analysis involved combining all participant ST deci sion models into one broad composite conceptual model that repres ents the groups decision process (Figure 3-15). Barrier and facilitator decision crit eria cited in participants ST d ecision models were utilized to build the final composite model. This final composite model il lustrates the criteria surrounding ST need decision process and is discussed thoroughly in chapter 4. Summary Potential participants were pre-screened for in clusion criteria (65 or older, self report of mobility impairment) and exclusion criteria (res ide in skilled nursing facility, or nursing home)

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59 prior to being recruited via phone call. The in-depth interview/in-home observation session took 2.5 4 hours to be completed. Firstly participants were asked demographic and functional status questions. This was followed by exploring partic ipants perceptions of various smart technology component areas. During this stage, visual di splay boards were utilize d to introduce smart technology and help participants visualize the di fferent technologies in smart home design. The final stage involved the particip ant giving a tour of their hom e where still camera photography was utilized to capture any problem or success ar eas in their home environment. The interviews were transcribed verbatim and analyzed for ke y phrases that both re presented participant decision criteria, and reflected any contrasts in de cision behavior. Decision criteria themes were then combined in the form of a decision tree to build decision models.

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60 Figure 3-1. Techniques in user participatory design. [Adapted from Muller, M., Wildman, D., & White, E. (1993). Taxonomy of PD pract ices: A brief practitioner's guide. Communications of the ACM, 36 (4), 24-28 (Page 27, Figure 1).] Table 3-1. Advantages and di sadvantages of ethnography. [Ada pted from Denscombe, M. (2003). The good research guide: For smallscale social research projects (2nd ed.). Philadelphia: Open University Press. (Page 92-94).] Advantages: Disadvantages: Direct observationHave direct observation via fieldwork, rather than using only second-hand data. Stand-alone descriptionsPotential to generate depictions of isolated stories that are not linked together. EmpiricalGrounded in empirical research by direct contact with pertinent people and places. Story-tellingcan become the exclusive purpose, leaving research product which is atheoretical, unempirical and non-critical. Links with theoryCan be used as a process for developing and testing theory. ReliabilityPotential limitation of poor reliability and diminutive prospect of generalizing. Detailed dataRich data can deal with complex and subtle realties. EthicsGreater potent ial of problems linked with infringement upon privacy. HolisticFocuses on processes and associations that lie below the surface events. AccessAcute complications in gaining access to settings that would avoid unsettling the naturaln ess of the setting. Actors perceptiondeals with the way participants perceive events as seen through their eyes. Insider knowledgecan potentially overlook habitual phenomena.

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61 Table 3-2. Description of res earch roles. [Adapted from McMillan, J., & Schumacher, S. (1997). Research in education: A conceptual introduction (4th ed.). New York: Addison-Wesley Educational Publis hers Inc. (Page 437, Table-12-1).] Role Description Use Observer Researcher is physically absent (observer looking through a one-way mirror). Inappropriate for ethnographic study; may be used for other forms of qualitative research. Observerparticipant Observing events and interacting with participants from a subtle position. Does not experience the activity first hand. A typical role in ethnographic study. Participant Researcher live s through an experience and recollects personal insight. Inappropriate for ethnographic research. Participantobserver Actively involved in the events being observed. Researcher creates role (i.e. caregiver-assistant) for purpose of study. A typical role in ethnographic study. Insiderobserver Researcher has an existing formal position (i.e. superintendent, teacher, and counselor) in organization. Used in special circumstances. Interviewer Establishes role (i.e., graduate student) with each person interviewed. Primarily used in ethnographic interview studies.

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62 Figure 3-2. Interview data collected by topic and subtopic question areas.

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63 Table 3-3. List of Activities of Daily Living (ADL) assessed ADL (taking care of ones own body) Bathing and Showering Physically bathing/showering Turning on/off shower/sink faucets Adjusting water temperature of shower/sink Bowel and Bladder Management (intentional control bowel/bladder) Dressing Lower body dressing (including shoes) Upper body dressing Eating Functional Mobility Functional ambulation Getting in/out of bed Getting in/out of shower Getting in/out of tub Carrying items around the house Personal Hygiene and Grooming Brushing teeth/combing hair Toilet Hygiene Transferring to/from and maintaining toilet position

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64Table 3-4. List of Instru mental Activities of Daily Living (IADL) assessed IADL (oriented toward inter acting with the environment) Communication Device Us e: Home Establishment and Management (home, yard, garden): Cell phone/telephone Adjusting the thermostat in home Computer Checking the mail Community Mobility: Preventing food from expiring before use Driving and using public transportation -tax i, bus Keeping track of food in kitchen Financial Management Doing laundry Health Management/Maintenance: Vacuuming Monitoring vital signs (blood pressure, temp., resp. rate) Remembering appliance maintenance Monitoring sleep patterns Mowing the yard Tracking the frequency of trip s to the bathroom at night Turning on/off lights in home Physical fitness activity/routines Seeing who is at the front door Mental fitness activity/routines Open ing/closing all doors/wi ndows/blinds in home Maintaining well balanced nutritional meal choi ces Unlocking/locking all the doors/windows in home Decreasing health risk behaviors Setting the home security alarm Medication management/routines Seeing which stove t op burner is on/off Remembering physician appointments Safe ty Procedures and Emergency Responses: Meal Preparation and Cleanup: Remembering to check in with designated family/friend Planning/preparing meals Rememb ering to turn off all appliances Using a microwave to reheat items Shopping: Using a microwave to cook a prepackaged fr ozen meal Preparing grocery shopping list Cleaning up food and utensils Purchasing items at a store

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65 Figure 3-3. Early decision model re garding activity limitation.

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66 Figure 3-4. Participant 3s assistance with activity decision model.

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67 Figure 3-5. Early decision model attempt at cat egorizing 26 ST devices within one decision model.

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68 Figure 3-6. Participant 3s background information sheet.

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69 Figure 3-7. Participant 3s sm art technology remote control vo ice recognition need analysis information sheet.

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70 Figure 3-8. Participant 3s smart technology re mote control touchscreen need analysis information sheet.

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71 Figure 3-9. Participant 3s sm art technology household automation need analysis information sheet.

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72 Figure 3-10. Participant 3s smart technology pe rsonal robotic assistance need analysis information sheet.

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73 Figure 3-11. Participant 3s sm art technology monitoring technologies need analysis information sheet.

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74 Figure 3-12. Participant 3s sm art technology prompting/reminding technologies need analysis information sheet.

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75 Figure 3-13. Participant 3s sm art technology prediction technologies need analysis information sheet.

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76 Figure 3-14. Participant 3s sm art technology overall views need analysis information sheet.

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77 Figure 3-15. Composite elder smar t technology decision tree model.

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78 CHAPTER 4 FINDINGS Introduction The purpose of this study was to explore th e perceived smart technology needs of elders with mobility impairments while constructing a preliminary decision tree model of how these decisions are made. To accomplish this task, the following research questions were addressed: 1) What do elders with mobility impairments perceive as their areas of difficulty in maintaining independence? 2) Which smart technology do elders with mobility impairments perceive as solutions (or encumbrances) in helping maintain their independence? 3) How do elders with mobility impairment make decisions in choosing which smart technology is needed or not needed? As characteristic with qualitative research description as well as discussion of the findings from the data will be inte grated throughout this chapter. This chapter includes four sections. The first section presents the demographic information of the sample. The next three sections correspond to the three research questions identified for this study. The next section examines participan ts current activity pe rformance status, thus determining the difficult areas participants had in maintaining independence. The third section focuses on categorizing the ST selected by study pa rticipants. The fourth section examines how study participants made their decisions regarding ST need. In this section themes are identified and quotes are used to provide greater understand ing of each theme. Specifically an ethnographic decision tree modeling approach was utilized in th is section to create a preliminary elder smart technology decision tree model. Description of Participants Participants ranged in age from 69 to 88 years, with a mean of 76(6.2). Sixty-three percent were female, and all were Caucasian. Fiftyfive percent completed some college, and 27%

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79 achieved at least an undergraduate degree. Demographic, health, a nd activity characteristics of the sample are summarized in Table 4-1. Thirty-six percent of participants lived alone, while 45% lived with a spouse, and 18% lived with an adult-child. Eighteen-perce nt of the sample had incomes under $15,000 per year, while 18% had incomes above $50,000 per year. Sixty-three percent of participants described their health as Good. Fifty-five percent of participants could walk greater than 100-yards, and 27% had not fa llen in the last year. Sixty-three percent of participants had less than five chronic conditi ons, and 18% utilized le ss than six assistive devices. While sample findings are not generalizable due to the qualitative nature of the study, a comparison of the study sample parameters to the national elder population parameters is described below. The study sample ratio of male (36%) to female (63%) closely resembled the national parameter of male (41%) to female (59%)(He, Sengupta, Velkoff, & DeBarros, 2005). The study sample ratio of elders who lived alone (36%) to elders who lived with someone (63%) also closely resembled the national parameter of 28% to 66% respectively (Gist & Hetzel, 2004). In terms of education the study sample had a high er level of education with 18% receiving HS diplomas, 55% attending college, and 27% achie ving a bachelors degree as compared to national parameter of 32%, 18%, and 15% resp ectively(Gist & Hetzel 2004). In terms of functional status the study sample had a much higher frequency of reported ADL difficulties with 18% of participants having difficulty with 1-2 ADLs, 55% of participants having difficulty with 3-4 ADLs, and 27% of participants havi ng difficulty with 5-7 ADLs as compared to national parameter of 6%, 4%, and 3% respectiv ely(He et al., 2005). However the study sample had a slightly lower prevalence of back problem s (27%) as compared to the national parameter of 38%(Pfizer Global Pharmaceuticals, 2007). Lastly the study sample had a much higher

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80 percentage of participants with a history of a stroke (36%) as co mpared to the national parameter of only 9%(Federal Interagency Foru m on Aging-Related Statistics, 2004). Research Question 1: What Do Elders with Mobility Impairments Perceive as Their Areas of Difficulty in Maintaining Independence? The aim of the analysis in this section was to examine participants current activity performance status, thereby determining the ar eas in which participants have difficulty maintaining independence. Docume nting the status of the participants daily activity needs is pivotal to the overall goal of th is study, which is to explore ho w elders perceive the degree to which smart technology can meet these daily activity needs. Activities of Daily Living Within the seven major categories of activi ties of daily living (1 -bathing/showering, 2bowel and bladder management, 3-dressing, 4eating, 5-functional mobility, 6-personal hygiene and grooming, and 7-toilet hygien e) assessed, the most frequen tly cited difficulties were functional mobility (100%), and bathing/showeri ng (82%). The least frequently cited difficulties were bowel and bladder management (9%) and n one of the participants had difficulty eating (Figure 4-1). Out of the 154 ADL tasks assessed (14 ADL task s assessed for each participant, refer to itemized list in Figure 3-3) participants cited having difficulty 47% of the time. These difficulties were met (via acquisition of AT, or family assi stance) for 39% of the ADL tasks, however needs were reported unmet for 8% of the tasks (Figure 4-2). Assistive technology (82%) and AT -family assistance (8%) were the most frequently cited method for resolving their ADL difficulties (Fig ure 4-3). The most comm only cited unmet-tasks were dressing (33%), getting in /out bathtub (17%), carrying it ems (17%), and climbing stairs

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81 (17%) (Figure 4-4). Assistive technology (58%) and family a ssistance (25%) were the most frequently cited assistance methods that were no t fully meeting their (unmet) need (Figure 4-5). Instrumental Activities of Daily Living Within the eight major categories of instrume ntal activities of daily living assessed (1communication device use, 2-community mob ility, 3-financial management, 4-health management and maintenance, 5-home establis hment and management, 6-meal preparation and cleanup, 7-safety procedures and emergency re sponses, and 8-shopping), the most frequently cited difficulties were home establishment and management (i.e., vacuuming, yard care) (100%), meal preparation and cleanup (63%), and community mobility (63%). The least frequently cited difficulties were shopping (9%), and financia l management (18%) (Figure 4-6). Out of the 385 IADL tasks assessed (35 task s assessed for each participantrefer to itemized list in Figure 3-4) participants cited having difficulty 19% of the time. These difficulties were met (via acquisition of AT, hiring assistan ce) for 16% of the IADL tasks, however needs were reported unmet for only 3% of the tasks (F igure 4-7). Family assistance (48%) and hiring assistance (20%) were the most frequently cited method for reso lving IADL difficulties (Figure 4-8). The most commonly cited unmet-tasks were typing on a computer (23%), writing a message when on phone (15%), preparing meals ( 15%), and cleaning uten sils (15%) (Figure 49). No assistance used (46%), AT (23%), and fam ily assistance (23%) were the most frequently cited assistance method that were not fully meeting their (unmet) need (Figure 4-10). Research Question 2: Which Smart Techno logy do Elders with Mobility Impairment Perceive as Solutions in Maintaining Their Independence? The aim of the analysis in this section focu sed on categorizing ST se lected by participants. Majority of participants (82%) cited at least one smart technol ogy device as needed. Out of the seven major component areas of smart technolog y (1-remote control-voice, 2-remote control-

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82 touchscreen, 3-household automation, 4-personal r obotic assistance, 5-monitoring technologies, 6-reminding technologies, and 7-prediction technol ogies) assessed, the most frequently cited (as needed) component areas were personal robotic assistance (73%), and prediction technologies (64%)(Figure 4-11). The least frequently cite d (as needed) component areas were household automation (18%), and remote control-touchscreen (0%). Out of the 484 technology-decisions (44 sm art technology devices assessed for each participant) participants regard ed smart technology as needed only 11% of the time, (Figure 412). Eighty-nine percent of the time participants cited technology as not needed to maintain independence. Participants fre quently cited ST as convenient or a novelty device. Of the 44 smart technology devices assessed (Table 4-2), only 16 devices (36%) were perceived as needed. Of the perceived needed devices the majority (89 %) were cited as only slightly needed. The three ST devices that were cited as being moderate ly needed were the dressing-aid, blood pressure management-aid, and the carrying aid. The two ST devices that were c ited as being strongly needed were the automatic front door, and the tr ansfer-aid. Two of the ST main category groups had all of their ST devices select ed at least one time. All the type s of personal robotic assistance devices (walking aid, bathing aid, transfer aid, dressing aid, and ca rrying aid) were selected, as well as all of the types of pred iction technologies (early detecti on: changes in activity level, memory loss, changes in walking pattern, and cha nges in eating/drinking pattern) were selected by at least one participant. When the participants were asked if their were any additional smart technology devices needed to assist in their da ily activities, seven a dditional devices (voicemessage aid, voice-typing aid, voice-dialing phone number aid on cellphone, food prep aid, utensil cleaning aid, monitor-appl iance aid, and auto-che cklist to remind when appropriate time for routine checkups) were cited (Table 4-2).

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83 To further explore perceived smart technology need, participants were grouped by health condition, housing status, number of ADL deficits, and ambula tion ability (Figure 4-13). Averaging the number of smart technology devices cited by members of in each group, revealed that participants with stroke cited more ST need than participants with ba ck problems. The stroke participants selected more devices to assist with two-handed tasks (i.e., voice message aid, typing on a computer, and food prep aration aid). Participants with additional deficits (ADL or ambulation) cited more ST need than participants with fewer deficits. Research Question 3: How do Elders with Mobility Impairments Make Decisions in Choosing Which Smart Technology is Needed? The aim of the analysis in this section was to explore how participants made their decisions regarding ST need; while constructing a prelimin ary decision tree model of how these decisions are made. The resultant elder sm art technology decision tree model is discussed in this section. Themes are identified and excerpts from the interviews are used to provide greater understanding of the participants perceptions of their ST need. Elder Smart Technology Decision Tree Model The elder smart technology decision tree mode l is presented in Figure 3-15. For these elders with mobility impairments, the model identifies that they began the process (of determining whether ST was needed) by ascertaini ng (if they were no longer performing all or part of the activity) if all or pa rt of the activity should be restarted. If the participants were content with no longer performing all or part of th e activity then the participants did not critically consider the ST device. If the participants desired to restart all or part of the activity then they would consider ST as a possible solution. If the pa rticipants were already performing the activity they would begin by ascertaining if they were satisfied with thei r current performance level. If the participants determined that they were sati sfied with their current activity performance level

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84 then they would not critically consider the ST de vice. If the participants determined that they were not satisfied with their current activity perf ormance level they would then consider ST as a possible solution to assist with their activity performance. Dissa tisfaction with current activity level was no assurance that the participants would necessarily desire ST to assist with their daily activity needs, due to the numerous other barrier criteria identifie d in the model. If any of the other barriers were a concern then the elders would not desire the ST device. Additional potential barrier decision themes that emerged when the part icipants were ascertaini ng if ST could assist with their activity performance were if the ST device was: practical, usable, easy to learn, reliable, or if it created more st ress or problems. The model also identifies important facilitator criteria that could motivate elde rs to adopt ST assistance. Th ese key decision criteria (i.e., barriers, facilitators) identified in the model are discussed in more detail in the subsequent sections. Key Barrier Themes Seven predominant barriers central to the pa rticipant ST need decision process emerged from the data (Table 4-3). The analysis rev ealed many complex sub-th emes surrounding several of the predominant barrier themes that center on the participants evaluation of the ST device itself. As illustrated in Figure 3-15 the first two predominant barrier themes initiate the ST decision process while the remaining five predomin ant barrier themes are not hierarchical. Each of the predominant barrier themes as well as thei r integrated sub-themes is presented below. Do I desire to start performing al l or part of the activity again? In the following sections excerpts from the interviews are used to provide greater understanding of the participants decision criteria. A primary ba rrier theme that emerged from the analysis of the data was that these elders wi th mobility impairments did not aspire to perform all (or part of all) 49 activities that were asse ssed. After their ability levels declined, activities

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85 that were once performed in the past were no longer entirely performed. Participants were content with not performing all or part of certain activities. A common activity that was no longer performed was bathing in a bathtub (82%). Of those partic ipants who no longer bathed in a tub, 78% did not miss the activity. An objective of ST is to provide compensation techniques to return an individual to functiona l status; however findings indicate that participants were content with not performing all or part of certain activities any longer. Th e point of being content with no longer performing all or part of certain activities is illust rated in the following quotes: Participant-5: No, I miss it [bat hing in a bathtub], ah, sometimes. Interviewer: Now, if there was a relatively inexpensive technology that helps you get up and down from the tub, would you be inte rested in a device such as that? Participant-5: I don't miss it that much. (Trans cribed Interview, pages 28, Participant 5). Interviewer: Do you get down [in your tub] a nd take a bath; do you get into the bathtub? Participant-11: I havent; I haven t gotten in a bathtub in years. Interviewer: Is that something you miss, or is it-Participant-11: No. Interviewer: Youre okay without that. Participant-11: Uh-huh. (Transcribed In terview, pages 47-48, Participant 11). A subcomponent of the barrier theme of being content stopping all or part of an activity was that participants felt it was easier to adjust th eir actions or the activity itself rather than to incorporate external assistance as a solution to the difficult task. Participants felt it was easier to modify their behavior first over incorporating external devices. Rather than incorporating an assistive device (i.e., dressing stick, sock aid, butt on hook, robotic dressing ai d) into their activity performance or asking for assistan ce (i.e., spouse, adu lt child) they would ra ther self-compensate or modify certain activities. Th is point is illustrated below, Well, you revise the way youre doing things, or you wear shoes that don t need to be tied (laughs) or whateveruhso that, I guess my feeling about this was--my overall feeling about the smart house was that it s easier to adjust a person rather than this over-the-top technology.(Transcribed Interview, pages 86, participant 8).

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86 Another subcomponent of the barr ier theme of being content with stopping all or part of an activity was that particip ants were found to be preplanning to stop or limit certain tasks. Rather than planning how they will maintain full functioning with tasks, the data analysis revealed participants were preplanning how they would be limiting future activities. Participants cited plans to stop certain parts of an activity (i.e., not having garments with buttons or zippers, not wearing socks or trousers) over planning how to fu lly perform an activity. Therefore a ST device that would allow them to wear garments with buttons and zippers would consequentially not be needed. This point is illust rated in the following quotes, Interviewer: Let's say it gets to the point where, you physically cant reach over anymore to put on your socks? Participant-4: I just wouldnt wear socks. Interviewer: What about for your trousers you would resort to using a reacher? Participant-4: No, I'd wear skirts and tops. Of which I have a cl oset full, I just like wearing pants. Interviewer: So you would be able to modify your outfit so you wouldn't have to bother with, Participants-4: I would do that, before I went with those [assistive devices] other things. Interviewer: So with skirts you woul d just have to step into them? Participant-4: Well, you can pull it over your head, or you step into it, you see its not stepping in to, now the underpants you always got to do those, just have to do that, or Interviewer: So if it came to th e underpants, you have to use some type of dressing stick? Participant-4: I suppose a person would, I have but I don't feel like that's like socks, [participant laughs] I would just adjust my clothing, I wouldn't put on shoes and socks, I would put a robe on, I mean, I would just ma ke compensations as I've always have. (Transcribed Interview, pages 20-21, participant 4). This barrier may have several other subcom ponents tied into the decision of stopping an activity, such as the length of time since stopping an activity or the pre-deficit gratification level of the activity. This barrier of being content with limiting all or part of an activity reveals a primary barrier central to the participant ST n eed decision process, if the elder consumer is content with not performing all or part of an act ivity then ST will not be needed to compensate

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87 for the loss in activity performan ce. This barrier would limit the window of opportunity for ST to be needed by elders. Satisfied with current activity performance? The second primary barrier theme that emerged from the analysis was the most frequently cited barrier. Participants repeatedly cited being satisfied with their current activity performance level. No need for smart technology emerge d routinely during the study. This finding was reflected in data from research questions 1 and 2, where minimal overall reported unmet ADL (8%) and IADL (3%) need was found. Satisfaction with doing activities in th eir own way was commonly alluded to by participants. Participants had adapted their met hod of activity performance and did not express a need to make a change in their behavior. Even if the task could be simplified and performed more easily with ST. Participants did not desire technology to help complete tasks more easily. Participants who would benefit fr om a robotic carrying aid frequen tly verbalized being satisfied with their method of activity completion and not desi ring ST to assist. This point is illustrated by participant-2 who had balance difficulties, utilize d a 4-wheeled walker for long distances, and had difficulty carrying items with both ha nds (contractured right-hand) below, Interviewer: What if he [robotic carrying aid] was able to grasp and carry items for you? What if he was able to grasp your basket that you use to carry items? Participant-2: I can carry the basket in my right hand; my left hand has to hold the cane. And I couldn't find a lot of use for him [robotic carrying aid]. Just to transfer a few books in and out of a room he would be totally wo rthless. I take my groceries out of the wagon, and put them on the counter.I think he woul d be too much trouble than he is worth. (Transcribed Interview, page 39, Participant 2). Participants also commonly alluded to being satisfied with tasks taking more time than usual. If it took an extended amount of time to complete an activity (i.e., answering the door, turning on/off lights, walking acros s a room) participants were ok with it. Participants did not desire technology to help complete tasks faster This point is illustrated by the quotes below,

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88 Participant-5 who takes considerable time with he r single-point cane (utilizes a 4-point cane at night) to ambulate across a room, Interviewer: Just getting around your home does take considerable time? Participant-5: Yeah, Interviewer: But giving you t echnology, it wouldn't be needed? Participant-5: Yeah, Interviewer: To save you time? Participant-5: yeah, yeah, Interviewer: Or do you feel that, Participant: Time, I ha ve plenty of it, Interviewer: So you have plenty of time, you don't feel that, if you can only do things faster, you would be able to do more things each day? Participant-5: no, Interviewer: So you are okay with the bala nce of time and how long each activity you do takes? Participant: Yeah. Participant-3 had a history of multiple stroke s, limited left-hand functioning, could perform transfers only, and received dial ysis three-times a week, stated, Thatd [household automation] be nice, but things take a litt le bit of time right now and I can do it, so there's no need for it. I am in a lot better shape, than a lot of people that go out to that [dialysis] clinic. And a lot better attitude, a lot of them are so damn depressed; I try to keep a positive attitude. (Transcrib ed Interview, page 43, participant 3). While household automation technology would have al lowed participant-3 to more speedily turn on/off his lights and open/close his blinds he verba lized that he felt he co uld sufficiently perform the tasks (in his powered wheelchai r). He cited things take a littl e bit of time right now and he can do it, so theres no need for it, expressing that he is cont ent with how long it takes him to complete these activities. Participants commonly alluded to being satisfied with thei r endurance level in performing tasks. If they could only walk household dist ances or only walk up a few steps at a time participants were generally satis fied with it. Participants did not have a strong desire for technology to improve their endura nce level. For instance the majo rity of sample (82%) required AT to ambulate, however only 18% of participants cited a slight need for the ST walking aid.

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89 Even though participant-9 would benefit the most due to low endurance and difficulty walking household distances, he did not f eel a strong need for desiring the robotic walking aid. Although the walking aid would allow pa rticipant-9 to potentially cons erve his energy, and ambulate longer distances, he only felt the walking aid would be convenient but not necessary. This point is illustrated in the below quotes, Participant-9 able to ambul ate household distances only. Interviewer: Lets say it [walki ng aid] did work, just like your lift chair worked. Lets say this thing worked and all the bugs were work ed out of it and this thing would free up your handsyou wouldnt have to hold onto a walker any moreand they can say, Well, you can use this and you wouldnt have to hold onto anything. What are your thoughts on that? Participant-9: It would bebe lovely. Interviewer: Would it be a necessit y, or would it be just convenient? Participant-9: Convenient. (Transcribed Interview, pages 79, participant 9). Participant-2 who has a history of a stroke, ba lance difficulties, utilizes a cane in home and a 4-wheeled walker for long distances, and has difficulty carrying items with both hands (contractured right-hand) cited that he consider ed the walking aid only appropriate for those who had a spinal cord injury. Participant-2 who had trouble walking up steep ramps, up/down stairs without railing, and had problems carrying items while having to hold onto cane wouldnt bother with [walking aid]. Even wh en the walking aid was presented as easy as a pair of slacks to don/doff the participant did not feel any need for the ST device. This point is illustrated in the below quotes, Interviewer: And now getting back to the robotic exoskeleton device, what are your thoughts on this? [pointing to the exoskeleton on the diagram] Participant-2: I, um, that's what I'm ta lking about I, I didn't see anybody, would this device be able to help someone walk down steps? Interviewer: Yes. Participant-2: I guess if a guy really had a lot of problems with his legs, it might be a good thing. I don't know, I would have to see a, the definite Interviewer: you would like to see it?

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90 Participant-2: no, I wouldn't want to see it, I would have to see the definite, it would have to be a person that would want to use this really bad. Who didn't walk very well, I don't walk very well, but rather than going to th e trouble of putting this thing on, I would just use the stairs. Interviewer: so if this thing were to help you walk further, would be worth while to put it on? It would not only help you walk up a nd down stairs but it would help you walk further. It would be similar to putting on a pair of pants so once you got ready you would just put these on like a pair of pa nts and you just go about your day. Participant-2: I, um, today in my condition I wouldn't bother with it. Interviewer: is that because it would be too much trouble? Participant-2: too much trouble to put on. Interviewer: would you be concerned a bout becoming dependent on this device? Participant-2: that's not a concern. It is just too much trouble to put on. Now in all fairness if somebody was in a condition like Mr. Superman, who had spinal cord injury, I suppose it might be a good thing. (Transcribed Interview, pages 37, participant 2). This barrier of being satisfied with their current activity performance level may have a subcomponent of length of time since onset of disa bility. Participants wh o have already adapted and established a daily routine for a long period of time may have become content with their activity performance level. Changing to a new as sistance routine may be viewed as more arduous after having already modified or limited an activit y. The analysis revealed that all participants were at least one or more years from initial onset of their chief condition. Therefore the participants may have become accustomed to thei r established daily routine for a long period of time. If ST was offered within the first few week s of a loss of ability th en potentially ST need would be greater, as the elder consumer may not have grown accustomed to their modified routine. This barrier of being satisf ied with their current activity performance level reveals a primary barrier central to the participant ST n eed decision process. If the elder consumers are satisfied, then ST will not be needed to only replace their existing activity performance method that they feel is being perfor med sufficiently. This barrier wo uld limit the window of opportunity for ST to be needed by elders. Future resear chers could further expl ore the issues surrounding

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91 this barrier theme, which may have many more subcomponent tied into it (i.e., accepting of performance level, resisting cha nge, established control issues). Is ST a practical solution? The third predominant barrier theme that emer ged from the analysis centered on the issue of whether ST devices were a practical solution. All participants in this study indicated at one point concern that ST devices were not practical for their needs. When de scribing ST participants expressed that it was too costly, excessive, or had no gain. Pa rticipants did not view ST as a practical solution to their daily activity needs Any gain to having ST device (sub theme): Forty-five percent of participan ts expressed that certain ST devices were not practical for their needs because they did not see any gains from the device. For example, participant-7 cited that she (or her family or friends) would know if she was losing her memory, or if her walking patterns changed. Therefore she did not need a ST device to tell her what she already knew. The point that ST is perceived as not being practical for their needs because no gain was seen with the device is illustrated in the following quote, I dont need this [prediction technologies], I m eanI dont need all those things cause I--I knowand people around me will noticeuhthat Im losing my memory and myIm not walking, I know that. (Transcribed Interview, page 84, participant 7). Cost prohibitive (sub theme): Ninety-one percent of particip ants expressed that certain ST devices were not practical because the technology would be too costly for their needs. Participants expressed that they only spent money on the necessities and that the mi nimal gain from technology was not worth the cost. For example even when the cost of retr ofitting and home installa tion of a fall monitoring system was taken out of the equation, participant3 did not feel a need to spend $30 a month for a

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92 fall monitoring system. He felt that $30 a month w ould be too costly only to monitor him for falls when his daughter was out of the home. This point is illustrat ed by the below quote, Participant-3: You know how much itd [fall monitoring system] costs? Interviewer: Let's say $30 a month, Participant-3: Who's goi ng to pay to put it in? Interviewer: Lets say it comes with the house, let's say this is five years from now, and houses are being built with these technology devi ces preinstalled and can be available for activation. Participant-3: I know how it works, but I figured I couldn't afford it, and have it installed. Interviewer: Let's say its there in your home just has to be activated. Participant-3: I really don' t know, it might be worth the $30, but if I got me and my daughter living together what th e hell do I need it for. (Tra nscribed Interview, pages 49-50, participant-3). Participant-7 initially expresse d a desire to use a cell phone ho wever changed her mind when she stated that she does not like to spend money on anything except n ecessities. She did not feel the added safety benefit of having a cell phone in her car was worth the expense. This point is illustrated below, Yeah; well (sighs), if I had one [cell phone], and somebody showed me how to use it, I probably would use it, but uh, I dontall that expensethe reason I can live on nothing, which you know I do, uh is because I dont spend any money on anything except absolute necessitiesand all that stuff takescost s moneyIm a-a product of the Depression, thats what I am (laughs)never gotten ove r it! (Transcribed Interview, page 27, participant 7). Excessive technology (sub theme): Sixty-four percent of particip ants expressed that certain ST devices were not practical because they were too excessive for their needs. Participants frequently cited voice controlled, home automation, monitoring, reminding technol ogies as excessive. A few participants expressed that the only population that voice controlled and home automation technologies would be good for were paraplegics or quadriplegi cs. This point is illustrated in the below quotes, I don't need anything except for the remote control that I have for my TV. There isn't anything else that I would need to have done [to my home]. There is nothing there, I don't

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93 need a voice control thermostat or lights or blinds....I don't see, in my case anyway, any value in that [voice recognition]....I can't foresee that at all in my future unless I became a quadriplegic, that's who this would benefit, maybe a paraplegic. (Transcribed Interview, pages 33-34, participant 4). Some of the new technologies that I have see n, as in the smart house, are so far-fetched, I wouldnt waste my time onem....The uhopening and closing window shades, I think, is far-fetched. (Transcribed Interv iew, page 38, participant 9). Participants often cited that a simpler and less excessive solution could be developed that would be more practical for their needs. For example participants often expressed a simpler solution would be to have a human assi st over acquiring excessive tec hnology. Stating that when their needs became extensive they would need a human (personal caregiver) and it would be easier to have a human do the task (as opposed to the ST). This point is illustrated in the following quote, Well, I guess this was my thought somewhat, too, when I called the smart house pie-inthe-sky, that I think somebody needs so much he lp would probably be better off in a place wherea group home, or something of the sort where people are able toto have various kinds of assistance, rather than having it fr om their house. I think some of those house things would be uhmore of a luxury or a convenience but not something for a real impairment. (laughs) (Transcribed Interview, page 76, participant 8). This barrier of perceiving ST as not being a practical solution for their needs is central to the participant ST need decision process. If the elder consumer does not perceive ST devices as practical solutions to their needs then ST will not be needed to a ssist with their daily activities. Can I physically use the ST device? The fourth predominant barrier theme that emerged from the analysis was the least frequently cited (predominant) barrier. Twenty-sev en percent of participan ts reported concerns of potentially not being able to adequately utilize the ST devices For instance participants with limited use of an upper extremity expressed concerns of not bei ng able to use touch screen devices as it requires the use of both hands. Concerns of not having adequate hand dexterity to don an exoskeleton walking aid were conveyed as well. Participants with visual impairment verbalized frequent problems utilizing ATM mach ines; therefore participants with visual

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94 impairment would have difficulty utilizing the ST touchscreen devices. This barrier, being concerned that they would not be able to phys ically use the ST devi ce, is central to the participant ST need decision proces s. If the elder consumer percei ves that they can not physically use the device then ST will not be desired. Is the ST easy to learn and use? The fifth predominant barrier theme that emerged from the analysis centers on the ease in which the participants perceive ST as being utilized. Sixty-four pe rcent of participants indicated concerns with both, how they were going to initia lly learn how to use the ST devices, and if their daily interactions with ST would be too complicated. Par ticipants expressed previous experiences with not wanting to buy a new washer and dryer because they did not want to learn how to work the newer appliance. Therefore the id ea of having to learn how to interact with a whole new (smart) home was overwhelming. This barri er is illustrated in the following quotes, Interviewer: And why would you say you woul dnt want to live in the smart house? Participant 9: Itd take too long to learn how to use it. (Transcribed Interview, pages 36-37, participant 9). Well, I dont like it when I get a new washing m achine or dryer cause I dont want to have to learn the machine again. UhI dont have a lot of patience. I have less patience now that Ive found out Ive got Pa rkinsons (laughs) th an I ever did. I think Id kill myself before I have to live like that [in a sm art house]. (laughs) I think it would be one frustration after another, fo r me. (Transcribed Interview, pages 36-37, participant 11). This barrier of being concerne d with the ease in which the ST devices would be to learn how to use and how complicated th e daily interaction would be is central to the participant ST need decision process. If the elder consumer per ceives that the process of learning how to use the ST device or their daily interaction level as complicated then ST will not be desired. Will using the ST create more stress/problems? The sixth predominant barrier theme presente d as the most complex theme with six subthemes revealed during the analysis. This prim ary barrier theme centered on the concern that

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95 utilizing the ST device would cause additional problems and stress. Fifty-five percent of participants expressed concerns that additiona l problems may accompany th e utilization of ST. Any perceived value gained from utilizing the ST device would potentially be negated by the associated perceived new probl em. Participants expressed th at technology could potentially: cause physical dependency, bring unwanted stig ma, replace needed human contact, and annoy and stress the participants with an overload of information. These potential new problems are discussed below. Misinterpretation of information (sub theme): Eighteen percent of participants expressed th at there may be more stress and problems created by the utilization of ST devices because the information output from the ST device may be misinterpreted. Participants expressed that they may become more anxious, and potentially would assume the worst-case scenario when give n so much information regarding their health. This point is reflected in the below quote, It [prediction technologies] sounds like a real stress inducer to me [p articipant laughs], this sounds like a potentially really troubleso me, because of, it says okay, it gives you a symptom but it does not really interpret and the recipients immediate response is the worst-case scenario, I have tremors oh my god I have Parkinson's now. (Transcribed Interview, page 31, participant 1). Information overload (sub theme): Twenty-seven percent of participants expres sed that there would be more stress and problems created by the utilization of ST de vices because they may become irritated by technology telling or reminding them to do things Participants expressed that having an inanimate object constantly telling them some thing would become annoying. This point is illustrated by the below quote, I know all these things [pre diction technologies] when it happens, uhI dont know the advantageif you got sick enough that you didnt know these things, I dont the advantage of some inanimate object telling you. II I dont respond favorab ly to this.I dont

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96 know that I would appreciate an inanimate obj ect telling me, Hey, youre not walking so good today (laughs). (Transcribed In terview, page 79, participant 10). Fear of dependency (sub theme): Twenty-seven percent of participants expresse d that there would be more problems created by the utilization of ST devices because they have a fear of becoming dependent on the technology. One participant reported a fear of dependency, not on t echnology, but rather fear of dependency on having a personal assistant come in to help him bathe. His fear was that the less he physically does himself the weaker he will ge t and the more dependent he will become on the personal assistant. However the majority of participants who voiced fears of becoming dependent cited technology rather than human a ssistance as a concern. Pa rticipants expressed concerns such as having to use a wheelchair b ecause they did not do enough for themselves. Or as, one participant stated, she would have to strap her lift chair on her back and take it with her everywhere if she became dependent on her lift ch air. The following quotes illustrate fear of becoming dependent on technology, Yeah; somebody thinkssomebody figures that out and thinks it up theyre smart, but some of the things arent needed.I dont know I think that we have too much helpI see my granddaughters, for instance, and theyre both a little overtheyre both overweight cause they d ont do enoughthey dont do enough, you know? And, I think we need to keep doing things for ourselvesI justthats why thisall this stuff kind of turns me off, to tell you the truth.I mean, a wheelchairyou could do some things for yourself, and Im not sure you dont end up in a wheelchair cause you dont do things for yourself, you know, I mean(laugh s). (Transcribed Interview, page 68, participant 7). Because I know that Im not walking to get my exercise right now; and I know that pretty soon, I wont be able to do anything [due to pr ogression of Parkinsons Disease]. If I use that damn lift chair to get out of the chair all the time, Id have to strap it on my back and take it with me. And Im not going to rest rict myself like that. But I feel like mymy legs need the struggle th at I go through to get out of that ch air the way I get out of it. But I dontI have never yet let it lift me up; I let it recline me. (Transcr ibed Interview, page 39, participant 11). One caveat is that the analysis also revealed that a majority of participants (73%) were adamant about not being concerned about beco ming dependent on technology. They verbalized

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97 that they would basically be aware of becoming dependent on technology, however did not have a fear of it. Clarifying further if they were to start relying on technology (i.e., wheelchair) then they would automatically know that they should be sure to do exercises to keep up their strength. Potential stigma (sub theme): The analysis revealed one part icipant that expressed a perceived stigma to technology. This participant was one of the fe w who would have benefited th e most from the exoskeleton. Participant-3 utilized a powered wheelchair, coul d only perform transfers, fell 6-8 times in the last 12-months (due to his knees giving out), howev er he cited a strong stigma to needing the ST device. Specifically participant-3 felt the exos keleton device was weird and he was concerned that people may think he was totally paralyzed wh en he was wearing it. This point is illustrated by the following quote, You're going to ride in a car and go uptow n and let everybody see you like that. It [robotic walking aid] looks yucky, I don't know, it looks like you're co mpletely paralyzed or something, and that things got you going. That's what I would say. I don't like the looks of it, I feel weird putting that damn thing on. (Transcribed Interview, page 44, participant 3). Privacy concerns (sub theme): Eighteen-percent of participants expressed th at there would be more stress and problems created because they would potentia lly have privacy concerns if they installed the ST device. Participants cited that they would not like ha ving cameras monitoring their every move. This point is illustrated below, I wouldnt pay for that kind of [monitoring] agency. I could see myself paying for a person to be a companion, but thatthat comp anion also would not have her eyes on me every instant of the time, uhshe would be there, butit would also be auh normal relationshipnow, I wouldI would not go fo r the camera system underwell, I dont want to say under any circumstances. (Trans cribed Interview, page 72, participant 8). One caveat was that when technology was pr esented in the form of monitoring with cameras and sensors, privacy became a concern, however when technology was presented in the

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98 form of robotics and dressing ai ds the opposite effect occurred. Privacy was perceived as being enhanced by technology as partic ipants did not want to have a human helping them with sensitive activities (i.e., dressi ng tasks). Participants stated th at having a person help you dress may be too personal and a robot dressi ng aid would preserve some privacy. Loss of human contact (sub theme): Twenty-seven percent of participants expresse d that there would be more problems created by the utilization of ST devices because a fe w of the devices would limit human contact. Participants expressed a need for human contact because it provided a human element of caring that a technological device was without. While participants expressed concerns of additional problems (i.e., trust) when having a hired care person in their home, these concerns where trumped by the potential of losing human c ontact. This point is illustrated below, I dont think I would like it [robot ic assistance]. I would rather have human help or at prepresent, I dont need it. I can get up and down myself, but if I needed help, I think I would rather have human help than this .When you have someone come in your home and work, you dont immediately trustem to help you get in and out of the bathtub. But, after they have become your friend and help ed you in other areas, then I think you would, uhyou have to learn to trustemit doesn t come automatica lly, likea robotyou dont care whether it trusts you or not (laughs)it just does it s job. The humanwith a-with a human being, the human element come s into it. and the fact that my husband helped me get dressed when I was sicktha tthat warms your heart. (Transcribed Interview, page 68, participant 10). This barrier centering on the concern that u tilizing ST would cause additional problems and stress is central to the partic ipant ST need decision process. If the elder consumer perceives that the utilization of ST would cause more stre ss and problems then any perceived value gained from utilizing the ST device would be negated. Ther efore ST will not be desired. As this primary barrier theme was the most complex, further expl oration of the issues surrounding the type of stress associated with type of problem would be beneficial. Th e study analysis process did not clearly differentiate between stress and problems that would be created.

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99 Is the ST reliable? The seventh predominant barrier theme that emerged from the analysis centered on the issue of perceived reliability of ST devices. Seventy-three percent of participants indicated concern that ST devices were not reliable. Participants with previous experience interacting with voice-recognition software expressed concerns th at the technology was still not advanced enough for reliable use. Participants frequently expr essed concerns that ST would frequently break. When evaluating ST need the participants frequen tly compared ST reliability with that of having a human caregiver. For example participants woul d cite that you do not have to worry about a human not understanding what you say. The concerns with ST reliability are illustrated by the following quotes, The reasonwell, if, you knowif you have a good person that is reliable (laughs) technology is not. (Transcribed Inte rview, page 77, participant 8). Right, because you wouldn't have those dirty, cord s, I started to say that you wouldn't have to worry about them [voice controlled bli nds] breaking, but the piece of machine is going to break first, (participant laughs). (Trans cribed Interview, page 38, participant 4). This barrier centeri ng on the issue of percei ved reliability of ST devices is central to the participant ST need decision process. If the el der consumer perceives the device as unreliable then the ST device will not be desired. Key Facilitator Themes Seven predominant facilitators central to the participant ST need decision process emerged from the data (Table 4-4). Facilitator themes we re categorized by the type of assistance provided to the participant. For example assist with an ac tivity currently unable to perform was classified as providing physical assistance, enhance ability to monitor hea lth was classified as providing cognitive assistance, and incr ease sense of autonomy was cla ssified as providing psychosocial assistance. Elders with mobility impairments expr essed more physical assistance facilitators (i.e.,

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100 assisting with tasks that are difficult or are un able to be performed) than cognitive assistance facilitators (i.e., assisting with monitoring personal health stat us) or psychosocial assistance facilitators (i.e., decreasing imposition, increasing sense of autonomy) f acilitators. Facilitator themes generally provided multiple types of assi stance (physical, cognitive, or psychosocial) and as illustrated in Figure 3-15 they are not hierarchical in the elder ST need decision process. Each of these facilitator themes is discussed in detail below. Decrease imposition on family/friends (psychosocial) A primary facilitator theme that emerged from the analysis of the data centered on the issue of decreasing imposition on fa mily/friends. Fifty-five percen t of participants expressed a desire for ST to assist in lessening the burden of live-in family memb ers (i.e., spouse, adultchild). Citing that at times family members would be burdened by having to stop doing what they were doing in order to assist the participan t with a (dressing) task. Participants expressed that it would be more convenient for ST to a ssist with their activity needs than imposing on their families. This point is il lustrated by the following quotes, Dressing I don't really have a problem I ju st call my daughter, and she comes and helps me. She does a tremendous amount of stuff for me.it [robotic dressing aid] may be nice, does it button things? I mean that's one of the hardest th ings I can't do is button things. Because I use to have one of them bu tton hooks, but you know how long that thing takes?.... I just leave my shirts buttoned, and pull them over my head like a T-shirt. I can do it, but it's a tough job. If it would help, he ll yeah.well so far I do not need it [robotic dressing aid], but it would sure be nice if I ha d it. I mean I don't know what kind of attitude to give you, but that's the way I feel about it.Oh I am not comfortable, because it [donning slacks] is awful difficult, and someti mes she [daughter] is doing something else and gets all ticked off. You know how that is so. I don't like to have to depend on my family because they got th eir own lives and everything. (Transcribed Interview, page 4546, participant 3). The [dressing aid] robots not as good-looking as she [spouse] is, but probably would be moreprobably be more convenient. Justjust so she wouldnt beone of the things she wouldnt have to do. (Transcribed In terview, page 51, participant 9).

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101 Yeah I would get the robot, over my husba nd.I don't want to interrupt him [spouse], because it's always more convenient to call a robot over a person. (Transcribed Interview, page 51, participant 5). Findings also indicate that th e facilitator theme of desiring to decrease burden of family extends beyond live-in spouses and adult-child ren. Participants in the study who did not currently live with any adult children indicated they felt that their children have lives of their own and they did not want to burden them. A few participants indicated th at they would rather hire someone to assist with their needs rather than burdening a family member. This point is illustrated in the following quote, Yes; I would like to have somebody because I dont know if I would need something, you know. But, otherwise, they [neighbors in bui lding] have told me that, You do have a son. Well, thank goodness, I do, but I dont lik e the idea that I have to depend on my kids, and I dont want them to feel that they are obligated to have to run every time that I need something, you know, I dont like that dependent feeling. It makes me uneasy, to say the least. I wouldnt mind having to pay somebody to, I dont know, whatever it is--But, uhOr the maintenance people, whatever but the maintenance people arehes actually doing double the amount of work that he would be, that person should be having to do, you know what I mean? They should rea lly have two people for maintenance, but they just have this one, and hes really ove r-worked. And, so, I really would hesitate to call him, knowing that hes doing more than hi s share. (Transcribed Interview, page 16, participant 6). Uh-huh. I think thats [remaining in own home] key to my happiness andand what I want for my daughter and her husband also. I dont want them to have to give up their lives to worry about me. I have a long-t erm care policy, but its(laughs) theyre never long enough term, you know? (Transcribed In terview, page 16, participant 6). A subcomponent of the faci litator theme desiring to decrease imposition on family members, that was revealed was those particip ants who have previous experience with care giving may be wary of burdening their family members. For example participant-10 expressed concerns of potentially losing her very good relationship with her children by burdening them with her activity needs. Participant-10 cited th e experience of losing th e great relationship she had with her angel mother, when she had to start caring for her mother who became very

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102 distrustful while the participant was her caregive r. An example of this is illustrated by a quote from participant-10 below, Thats the main thing. We have a very good relationship with both of our [children]they like us; were friends; they enjoy being with us; we go out to eat fo r every birthday and every anniversary and every opportunity we get; we just were out last Saturday nights why I keep pointing at this (gestures)uhafter my experience with my mother, II just dont think it would work; and I would not risk our relationship for that, uhif I couldnt afford to hire somebody, one of ourwe have some insurance policies that, when the CD rates went down, we bought.but one of the polic ies has a thing that if I get where I cant live alone and I need help, that I can borrow money from that to go into a nursing home. I would go into a nursing home before I would st ay with my children. Now, the only way I could afford it would be either sell the hous e or somehow qualify for Medicaid. UhI think you can keep your house and qualify for Me dicaid, and I could probably qualify for Medicaid money wise, uhif they let me keep the house. If I had to sell the house, of course, Id have that money. So, that would not be my first choice. like I said, when we came here (laughs) from a very ha ppy life of traveling in an RV to take care of my angel mother, who had always been the world s greatestmymy friends all called her Momshe was just--she was just Mom but thethe disease made her very uh contraryvery suspicious. (Transcribed Interview, page 23, participant 10). This facilitator theme centering on the issue of decreasing imposition on family/friends is central to the participant ST need decision process. If the elder consumer perceives the ST device as potentially relieving a family members burden then ST device may be desired. Increase sense of autonomy (psychosocial) The second primary facilitator theme that emerge d from the analysis of the data centered on the issue of incr easing the participants se nse of autonomy. Eighteen percent of participants expressed a desire for ST to assist in providi ng more autonomy. For exam ple a few participants chose technology over hiring a car egiver due to perceiving that technology would provide a greater sense of autonomy. Also part icipants expressed that they w ould feel more in control of a robot than a hired caregiver. This poin t is illustrated by the following quotes, Interviewer: You can either have this robot stay with you and help you dress and do your morning routine, or have an agency care assistant come in and help you? Participant-6: I probably would prefer the robot. Interviewer: And that would be because? Privacy?

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103 Participant-6: Um (long pause), possibly. I probably would feel that I was still independent. Interviewer: Because you would be having the robot do something for you? Rather than relying on? Participant-6: On a human being, yes. Interviewer: Now, with the human being, you would have control of the human being; you know, you would pay them and stuffbut, that w ouldnt necessarily be as much control as having the robot and telli ng the robot what to do? Participant-6: Right. Interviewer: Because you can tell the robot to put on your sock a lot easier than telling a person to put on your sock. Participant-6: Well. Interviewer: Depending on the relati onship you had with that caregiver? Participant-6: Yeah. (Transcribed In terview, pages 73-74, participant 6). This facilitator theme centering on the issue of increasing sense of autonomy is central to the participant ST need decision process. If the elder consumer perceives the ST device as potentially increasing their sense of aut onomy then the ST device may be desired. Assist with a difficult activity (physical/c ognitive assistance) The third primary facilitator theme that emerged from the analysis of the data was the most frequently cited facilitator. This theme centered on the issue of assisting with activities that were currently difficult to perform. Eighty-two percent of participants expresse d a desire for ST to assist in providing assistance (i.e., physical, co gnitive) with activities that they were having difficulty performing. Participants frequently c ited a desire for ST to assist with physical activities such as dressing or preparing meals, and with cognitiv e activities such as medication management or remembering to perform daily exercises. A few participants who had difficulty with two-handed tasks frequently expressed a need for ST to assist with food pr eparation activities. For example, participant-1 cited he no longer utilized his stove or oven but rather only utilized his microwave to prepare his meals. He stated that prepackaged meals were all that he could ma ke and that a ST device that would assist with preparing food would be readily accepted. Also, pa rticipants who had diff iculty getting in and

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104 out of their front door expressed a need for physical assistance in the form of an automatic door. The need for ST to provide physical assistance w ith difficult tasks is ill ustrated in the quotes below, Nah most of this [reminding technology] is stu ff Im so conscious of anyways that I really don't need any of this. Now on the other ha nd for the food recommendations, if it could just fix the food that would be great [participant laughs]. I know what I should be eating but I, I would like more salads but fixing them is not the easiest. (Transcribed Interview, page 30, participant 1). Yes I would like that [automatic front door] because I could buzz in and out with my scooter, I would be interested in that. Oh boy.The door would be nice because I would be able to zoom in and out with my scoot er, because now I have to get up and prop the door. (Transcribed Interview, page 33, participant 1). A few participants who had difficulty with their medication routine frequently expressed a need for ST to assist with reminding them wh en it was time to take their medications. For example participant-6 normally had a routine (i .e., keeping her medication bottle inverted) in place to remember if she took her medications. However on the days that she would do certain activities (i.e., paying bills) on her kitchen table she would move her pill bottles and subsequently forget to take her evening medications. Participants who had difficulty remembering to always perform exercises expr essed a desire to have technology assist in reminding them to perform daily exercises. For example participant-9 who sometimes had his wife remind him to exercise, wanted more assistance as he felt that he was too often forgetting to exercise. The need for ST to provide cognitive as sistance with difficult tasks is illustrated in the quotes below, Well, not actually necessary, but it probably is getting to that point because I occasionally have forgotten to take this [gestures to medication bottle].Yes, I think that would be almost a necessity because I do occasionally fo rget to take the medications at night, you know. In the morning, I just auto matically do that the first thing, see; I do that even before I get dressed, soto make sure that Im ta king them, you know; but, occasionally, I forget to take this one here (gesturi ng) that I take only once a w eek, and, every now and then, Ill forget about that, even though I usually put it li ke this (gesturing) so that I dont forget it; and yet, in the evening, Ill take this here a nd Ill put it away like this here (gesturing) in

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105 order to have a space over here to do some thing else, uh, pay the bi lls or something, you know,--And, then I forget to put this back he re so that I would re member, and then Ill forget-(Transcribed Intervie w, page 67, participant 6). [Reminding technologies physical exercise] Well, I hate to say this because it opens the door for her [spouse]but I need help being reminded to do more physical [exercises]. (Transcribed Interview, page 85, participant 9). A subcomponent of the facilitato r theme assisting with activitie s that are currently difficult to perform, that was revealed was that partic ipants had certain expectations of how long an activity should take. While some participants were comfortable (as cited in earlier examples) with activities taking a long duration of time, othe r participants cited a ne ed to lessen the time required to complete certain activities. Difficult activities that take l onger than a participant expects potentially may be an area for ST a ssistance. For example participant-7 expressed a desire for ST to assist with donning her support st ocking due to the fact that it takes her a long time to put them on. Tasks that are difficult but are quickly performed ma y not necessarily need ST to assist, however if a task is difficult and takes too long (per participants expectations) then ST potentially may be desired. This point is illustrated in the below quote by participant-7, Interviewer: So, if there were a device that could help you put on your support stockings or hose, youd be open to that idea? Participant-7: Yeah, right. Interviewer: Would it be necessa ry, convenient, or not needed, as far as that technology is concerned? Participant-7: Well, Id say, necessaryI gue ss, except that, since I dont use it now, its obviously not necessary cause I get along without now (laughs)but, it could be necessary, yeahif it was available. Interviewer: So, youre not able to put on the stockings yourself at this point--? Participant-7: Yeah, I putem on; but its time-consuming and not easy-Interviewer: So the reason that shifted to nece ssary is because its something that youre able to do, but youre not able to do it at the speed Participant-7: Yeah Interviewer: Or at the comfort level that you want, so thats why it became necessary--? Participant-7: Y eah, yeahexactly This facilitator theme centering on the issue of as sisting with an activity that is difficult to perform is central to the participant ST need d ecision process. If the el der consumer perceives

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106 the ST as assisting with activities that ar e physically or cognitively di fficult to perform then ST device may be desired. Assist with an activity currently unable to perform (physical assistance) The fourth primary facilitator theme that emerge d from the analysis of the data centered on the issue of assisting with activities that were currently unable to be performed. Fifty-five percent of participants expressed a desire for ST to assist in providing physical assistance with activities that they were no longer able to perform. The findings i ndicated that participants were the most open to solutions to tasks that they were no longer able to perform (as long as they desired to restart the activity). This facilitato r theme was the most easily identifiable theme as these activities were not being met by their pres ent resources (AT, family, hired assistance). Participants were quicker to accept the idea of ST assisting them with these tasks. For example participant-3 who no longer could carry items due to his poor coordination and decreased range of motion in his left hand desired ST to assi st with carrying items for him. This point is illustrated by the following quotes, That [robotic carrying aid] would be good too, you see I can't really carry anything, this arm really can't hold crap.Even though I try to carry things with it but I just drop it. It would be very nice, it would take a load off or her. Like I said she washes all the clothes and dries all the clothes. (Transcribed Interview, page 23, participant 3). Yeahthatd [climbing stair aid] be kind of ni ce, if itif itif it really helped and Iit didnt, you know, my back didnt kill me when I used itthat would be nice to be able to walk noId like that. (Transcribed Interview, page 72, participant 7). This facilitator theme centering on the issue of as sisting with an activity that is unable to be performed is central to the participant ST ne ed decision process. If elder consumers perceive that ST devices can assist with activities that th ey are physically unable to perform then the ST device may be desired.

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107 Replace existing technology to perform acti vity more safely (physical or cognitive) The fifth primary facilitator theme that emerge d from the analysis of the data centered on the issue of replacing existing t echnology in order to perform an activity more safely. Forty-five percent of participants expressed a desire for ST to assist in providing assist ance (i.e., physical, cognitive) with activities that they felt needed to be performed more safely. Participants frequently cited a desire for ST to assist with p hysical activities such as carrying items or turning on/off bedroom lights, and with cognitive act ivities such as appliance monitoring. A few participants who had difficulty with two-handed tasks frequently expressed a need for ST to assist with carrying activities. For exam ple, participant-1 cited that he felt as though he was walking on the edge of disaster because he would either have to ambulate without his cane or utilize his affected extremity to carry an item while walking. Either method was not ideal as it took him considerable attempts to transfer from a seated position to a standing position and once ambulating his balance and coordination were both poor. This point is illustrated by the following quotes, Physical assistance: Well I tell you something that would be useful would be a big carri er, a wired controlled carrier, for instance a dolly in which I can put things on it and then control it with a like a remote-controlled car and having carry things back to my bedroom. A radio controlled cart.Yeah it would definitely be a very pr actical utilitarian de vice; you can carry your laundry basket on it or trash basket or whatever. You know when I'm walking Im trying to carry something I have my cane in the left hand and have to carry something in my right hand, so I'm usually walking on the edge of disaster. (Transcribed Interview, page 24, participant 1). YeahI wouldI would probably go for that [ voice control lighting], pa rticularly at night would be convenient, you know, if Im sitting ou t here reading, and turn this light off, thenI dont want to walk to the bedroom in th e dark, so I either have to have a flashlight or have a light already on in thereand, uh, sothat wouldthat would be a convenient thing to have, uhyou know, wewe functi on very well this wayuhmy husband doesntuhlights dont annoy him, and a flashi ng light will immediately awaken me, so weveweve learned to (laughs)how to adjust for this, so if Im in bed, he will use a little flashlight so he doesnt turn on the light and awaken me, and that kind of thingso,

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108 if weif there were some other kinds of ways to uh cope with lighting, that would uh be a useful thing--(Transcribed Inte rview, page 42, participant 8). Cognitive assistance: A few participants who had difficulty remember ing to turn off their stovetop expressed a need for ST to assist in notifying them or automatically shutting off the stovetop appliance. For example participant-8 who had a gas stovetop in her previous home e xpressed that it was difficult to notice if she (or her husband) left the electric stove top on. This point is illustrated by participant-8s quote below, Uh huhI would like that [stoveto p monitoring].Yeahsomebodyyou know, somebodys been having something on low heat, and youll walk awayuhmy spouse has that problem more than I do (l aughs), butuhweveweve each done it sometimesand therethere again, itsits prin cipally cause we were always used to gas [burners], and then, you know, youits o ffyou know its off or on (laughs)and-and with this little [electric] grill, youyou dont necessarilyuhthat also could be better controlled by uha smarter stove (la ughs) (Transcribed Interview, page 47, participant 8). This facilitator theme centering on the issue of replacing existing t echnology in order to perform an activity more safely is central to the pa rticipant ST need decision process. If the elder consumer perceives the ST as assisting with activ ities that are being perf ormed unsafely then the ST device may be desired. Add a safety net (physical/psychosocial) The sixth primary facilitator theme that emerge d from the analysis of the data centered on the issue of providing a safety net. Eighteen percent of participants expressed a desire for ST to assist in monitoring for falls. This facilitator was not frequently cited by participants as the majority of participants lived with someone (i.e., spouse, adult-child) and th ey felt that the live-in person acted as their safety net. However a few pa rticipants expressed a desire for ST to assist with monitoring them for falls. For example Part icipant-1 felt ST would be ideal for monitoring him for falls while his adult-son was gone weeks at a time. Also participant-6 lived alone and

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109 cited a need for a fall monitoring system due to he r fear of falling while in her apartment. This point is illustrated by the following quotes, Yeah it would be useful especially when my son is on the road, and he gets concerned when I try to do things too fast he is concer ned about me falling. I have fallen a few times, but it has been a quite a while since I've falle n. (Transcribed Intervie w, page 28, participant 1). Participant-6: I have felt that way up til now yes. But, lately Ive been wondering if I shouldntas long as I have a litt le bit more money than I did have in the past, that maybe I should get that--Interviewer: Pendant---the emergency response system? Participant-6: Yes. So, out of all of these, nothings really necessa ry, whereas the only one thats necessary is the fa ll [monitoring system]-Participant-6: Yeah-Interviewer: and, at this pres ent time, it may be necessary--? Participant-6: Right. (Transcribed Interview, page 65, participant 6). This facilitator theme centering on the issue of providing a safety ne t is central to the participant ST need decision pr ocess. If the elder consumer perceives the ST device as effectively providing a safety net (i.e., monitoring for falls) then the ST device may be desired. Enhance ability to monitor health (cognitive) The seventh primary facilitator theme that emerged from the analysis of the data centered on the issue of enhancing cognitive ability to monitor health st atus. Seventy-three percent of participants expressed a desire for ST to assi st them with monitori ng their health condition. Participants frequently cited a desire to mo re objectively measure their health status. For example participant-1 felt that his subjective impressions may be inaccurate and he may not become aware that his abilities we re declining. Also participant-2 expressed a strong desire for an objective system that would remind him when he needed to get a checkup. This point is illustrated by the following quotes, Well, tremors if I, if I starting to get the shakes every once in a while, I would go see the doctor, I have a problem, but I never had before, if I get out of bed, and I get up really fast, there are times that I get a littl e dizzy, so I called the provider and I said this happens to me, and she said believe it or not it happens to me too, and I am only a third as old as you

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110 are, that's perfectly normal, I sa id well okay, then I won't concer n myself with it, but, that's the important thing, you got to find, there s hould be a checklist, th at you, you, like you get a driver's manual, when you buy a new car you open the glove compartment there is always a driver's manual and it. And they say this is the thing you look for, the tire pressure, you know, there should be a manual, a nd I think that would be more helpful than anything. (Transcribed Intervie w, page 45, participant 2). For me, oh boy. I suppose, yes, because sometimes our subjective perceptions aren't as objective assessment of what we think we are doing, yeah yeah yeah I agree, this [prediction technologies] could be enlighteni ng because sometimes what we think we are doing is not really what we ar e doing.I suppose that would be useful, if I started to get lazy, and then I would see the graph and say oh my goodness. I'm just saying it would seem to be more beneficial, because I think that activity could change without being aware of it. You could start getting lazier and lazier, and think that things are just fine. (Transcribed Interview, page 32, participant 1). Summary The results suggest that the general perception of the sample was that the majority of their ADL and IADL needs were being met. Participan ts perceived very litt le unmet ADL and IADL needs. In addition the results suggest that the ge neral perception of the sample was that ST was perceived as not needed in order to maintain their independence. Participants frequently perceived ST as a novelty or a convenience de vice but not needed for their independence. The results suggest that when ST was perceive d as needed, robotic a ssistance technologies may easily match many of the ADL and IADL un met needs cited by study participants. Robotic assistance technology (i.e., dressi ng aid, carrying aid, food prep ai d) was found to be the most frequently desired ST component area. In addi tion the results also s uggest that prediction technologies may be perceived by study participants as adding so mething to their abilities. Specifically prediction technology may be perceived as going beyond compensation for a loss in activity performance. Prediction technologies ma y have been perceived by participants as providing an additional ability (beyond co mpensation) to monitor their health. The results also suggest that there are multiple key barriers and facilitators involved when elders with MIs make decisions in choosing whic h ST is needed or not needed. A predominant

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111 barrier to ST need that was identified in the fi ndings was that study participants were found to be satisfied with their current activity performance. Study participants were content with performing their activities in their own adap ted styles. The results suggest th at if the study participant was satisfied with their activity performance status, th en ST will not be needed to only replace their existing activity performance method that they feel is being performed sufficiently. Another predominant barrier to ST need that was identified in the findings was that study participants had concerns that utilizing ST would create more stress and problems. For example participants expressed that th ey may become more anxious, and potentially would assume the worst-case scenario when given so much in formation regarding their health. The results suggest that if the study particip ant perceives that th e utilization of ST would cause more stress and problems then any perceived value gained from utilizing the ST device would be negated. Therefore ST will not be desired. A predominant facilitator to ST need decisi on process that was identified in the findings was that study participants desi red to decrease imposition on family and friends. Participants frequently cited that at times family member s would be burdened by having to stop doing what they were doing in order to assist the participan t with a task. Participants desired to lessen the burden of their live-in family members. The result s suggest that if the st udy participant perceives the ST device as potentially relieving a family members burden then ST device may be desired. Another predominant facilitator to ST need decision process that was identified was that study participants desired ST to replace existing technology in order to perform their activities more safely. For example participants reported a n eed for ST to assist in carrying items, turning on/off lights, and monitoring appliances. The re sults suggest that if the study participant

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112 perceives the ST as assisting w ith activities that are being perf ormed unsafely then the ST device may be desired. Finally the resulting preliminary decision tree model suggests that the elder smart technology need decision process is complex. Th e model illustrates that there are numerous decision criteria surrounding the elder ST need decision process. The results suggest a decision process that is not linear, but more of a multidirectional process.

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113 Table 4-1. Demographic, health, an d activity status information N=11 Frequency (%) N=11 Frequency (%) Age Mean = 75.8 (SD= 6.2) Overall Health Condition Described as 65-69 3 (27%) Excellent 70-74 2 (18%) Good 7 (63%) 75-79 3 (27%) Fair 3 (27%) 80-84 2 (18%) Poor 1 (9%) 85+ 1 (9%)No. of Chronic Conditions Sex 0-1 1 (9%) Male 4 (36%) 2-3 2 (18%) Female 7 (63%) 4-6 7 (63%) Race 7+ 1 (9%) Caucasian 11 (100%)No. of ADL Difficulties Education 1-2 2 (18%) High School 2 (18%) 3-4 6 (55%) College No Degree 6 (55%) 5-7 3 (27%) College Degree 3 (27%)No. of IADL Difficulties Living Arrangements 1-2 3 (27%) Live Alone 4 (36%) 3-4 4 (36%) Live with Spouse 5 (45%) 5-8 4 (36%) Live with Adult-Child 2 (18%)No. of Falls-last 12 months Annual Income none 3 (27%) Less than $15,000 2 (18%) 1-3 6 (55%) $15,000-$29,999 3 (27%) 4-6 1 (9%) $30,000-$49,999 4 (36%) 7-9 1 (9%) $50,000 or more 2 (18%)Typical Walking Distance No. Assistive Devices Utilized >100 yards (>300 ft) 6 (55%) 1-5 2 (18%) House & Yard Only 3 (27%) 6-10 6 (55%) Household Only 1 (9%) 11-15 2 (18%) Transfers Only 1 (9%) 16+ 1 (9%)

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114 Figure 4-1. Participants with defici ts in activities of daily living.

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115 Figure 4-2. Report of ADL task s with/without difficulty and whether need was met/unmet for the sample. A total of 154 instances ADL ta sks were assessed (that is 14 ADL tasks x 11 participants = 154 instances).

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116 Figure 4-3. Report of how ADL-difficulty needs ar e being met. This is out of a total of 60 instances were ADL tasks were reported as difficult whilst needs were met for the sample.

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117 Figure 4-4. Report of unmet ADL-di fficulty needs. This is out of a total of 12 instances were ADL tasks were reported as difficult wh ilst needs were unmet for the sample.

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118 Figure 4-5. Perceived unmet ADL assistance areas that participan ts cited could be replaced or improved to resolve unmet need. This is out of a total of 12 inst ances were ADL tasks were reported as difficult whilst needs were unmet for the sample.

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119 Figure 4-6. Participants with deficits in instrumental activities of daily living.

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120 Figure 4-7. Report of IADL task s with/without difficulty and whet her need is met/unmet for the sample. A total of 385 instances IADL task s were assessed (that is 35 IADL tasks x 11 participants = 385 instances).

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121 Figure 4-8. Report of how IADL-difficulty needs are being met. This is out of a total of 60 instances were IADL tasks were reported as difficult whilst needs were met for the sample.

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122 Figure 4-9. Report of unmet IADL-difficulty needs. This is out of a total of 13 instances were IADL tasks were reported as difficult wh ilst needs were unmet for the sample.

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123 Figure 4-10. Perceived un met IADL assistance areas that partic ipants cited could be replaced or improved to resolve unmet need. This is out of a total of 13 instances were IADL tasks were reported as difficult whilst needs were unmet for the sample.

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124 Figure 4-11. Percentage of sample that ci ted a major smart technology component area need.

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125 Figure 4-12. Percentage of need cited by sa mple regarding smart technology applications. A total of 484 instances of smart technol ogy devices were assessed (that is 44 ST devices x 11 particip ants = 484 instances).

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126 Table 4-2. Itemization of smart technology cited as needed by participants Smart Technology Assessed Selected Selected Remote Control-Voice (10) Personal Robotic Assistance (7) VoiceThermostat 0 Walking Aid 2 VoiceTV set 0 Bathing Aid 2 VoiceSecurity System 0 Transfer Aid 2 VoiceBlinds 0 Dressing Aid 7 VoiceWasher + Dryer 0 Carrying Aid 3 VoiceMicrowave Oven 0 *Food Prep Aid 3 VoiceLights 2 *Utensil Cleaning Aid 1 *VoiceMessage Aid 2Monitoring Technologies(9) *VoiceTyping Aid 3 MonitorMedication Management 0 *VoiceDialing #s on Cellphone 2 MonitorBlood Pressure 0 Remote Control-Touch (6) MonitorWeight 1 TouchThermostat 0 MonitorVisits to the Bathroom 0 TouchTV set 0 MonitorFall Detection 2 TouchSecurity System 0 MonitorCooking Patterns 0 TouchWasher and Dryer 0 MonitorWalking Patterns 0 TouchMicrowave Oven 0 MonitorSleep Patterns 0 TouchLights 0 *MonitorAppliances left on 2 Household Automation (8) Reminding Technologies (6) 1 AutoThermostat 0 Health condition management 0 AutoTV set 0 Mental Exercise 0 AutoSecurity System 0 Important event reminder 0 AutoBlinds 0 Medication Reminding 3 AutoWasher + Dryer 0 Food Recommendation 0 AutoMicrowave Oven 0 Physical exercise 1 AutoLights 0 *Autochecklist remind when appropriate time for routine checkups 1 AutoFront Door 2 Prediction Technologies (4) Early detection changes in activity level 7 Early detection of memory loss 4 Early detection changes in walking patterns 4 Early detection of changes in eating/ drinking patterns 4 Note: *Smart technology suggestions made by participants that were not included in initial form.

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127 Figure 4-13. Comparison of average smart technology device need cited per group.

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128 Table 4-3. Key need barrier themes Theme (potential barrier) Number of participants who cited theme (%) Do I desire to start perf orming all or part of the activity again? 11 (100%) Satisfied with current activity performance? 11 (100%) Is ST a practical solution? 11 (100%) Any gain to having ST device 5 (45%) Cost Prohibitive 10 (91%) Excessive technology 7 (64%) Can I physically use the ST device? 3 (27%) Is the ST easy to learn and use? 7 (64%) Will using the ST create more stress/problems? 6 (55%) Misinterpretation of info 2 (18%) Information overload 3 (27%) Fear of dependency 3 (27%) Potential stigma 1 (9%) Privacy concerns 2 (18%) Loss of human contact 3 (27%) Is the ST reliable? 8 (73%)

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129 Table 4-4. Key facilitator themes Theme (potential facilitators) Number of participants who cited theme (%) Decrease imposition on family/friends 6 (55%) Increase sense of autonomy 2 (18%) Assist with a difficult activity 9 (82%) Assist with an activity currently unable to perform 6 (55%) Replace existing technology to perform activity more safely 5 (45%) Add a safety net 2 (18%) Enhance ability to monitor health 8 (73%)

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130 CHAPTER 5 CONCLUSIONS AND RECOMMENDATIONS Introduction Comparatively little research has been conducted regarding the smart technology needs of the elder population despite th e proliferation of smart tec hnology prototypes (Baillie, 2003; Mihailidis, Cockburn, & Longley, 2005). A majori ty of studies involve evaluating smart technology already in the prototype stages. There were few qualita tive studies that specifically addressed this gap in the literat ure on elder ST needs analysis, wh ich would help in determining what prototypes to create and test (Baillie, 2003; Mihailidis et al., 2005) Qualitative studies are needed to provide insights to assist develope rs in the design of products (Mariampolski, 2006). The purpose of this study was to explore the perceived ST needs of elders with mobility impairments while constructing a preliminary de cision tree model of how these decisions are made. The resultant decision tree model was deve loped from data collected from in-depth interviews and participant obser vations (Figure 3-15). This m odel conceptually outlines the criteria surrounding how elders with mobility impai rments make decisions in choosing which ST device are needed. This decision mo del adds to the elder ST needs literature and potentially will help future designers create appropriately matche d technological devices th at will assist in the care of aging baby boomers with mobility impairments. Major Findings The results of this study expa nded and clarified many of the previous ST themes reported in the literature (Figure 2-2). Pr evious ST themes (i.e., fear of dependency, privacy concerns) are illustrated in the decision tree model along with newl y identified barriers and facilitators in the ST need decision process. Only one ST theme (perce ived abilities) reported in the literature is not illustrated in the decision tr ee model. Although interviews with participants lasted from 2.5-4

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131 hours, the design of the study (which assessed 44 ST devices) did not allow for complete exploration of each ST concept that emerged. For example a few participants would express that they did not need a fall monitoring system or a personal emergency response system (PERS) and that they knew how to properly fa ll or that if they fell they fe lt that they would not be knocked unconscious. This researcher did not further explore th is perceived ability. Future researchers could further explore the issues surrounding th is barrier theme, which may have many subcomponents tied into it (i.e., pride, denial, calculated risk, independence). The results of the study suggest that elder participants con tinually assess th e cost-benefit ratio prior to determining if a ST device is need ed or not needed. Elder participants would weigh the cost aspect against the benefit aspect to determine if the ST device was desired. Barrier themes (i.e., reliability, loss of human contact) that were c ited by the participant were the cost aspect and the facilitator themes (i.e., increase sense of autonomy, enha nce ability to monitor health) were the benefit aspect. For example participants w ould assess the cost -benefit ratio of whether the need to decrease the imposition of a family member (benefit) was greater than the potential of becoming dependent on the ST devi ce (cost). Future researchers could further explore the threshold needed in order for each ST device to be perceived as needed. Barrier Themes Do I desire to start performing al l or part of the activity again? This study has several important findings that have implicati ons for designers needing to create appropriately matched el der friendly technological devi ces. Elder participants were content with stopping all or part of an activity. Therefore to create more appropriately matched technological devices designers should conduct studies to confir m all or part of the specific activity being addressed is in fact perceived as being missed. Elder consumers may be content

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132 with limiting or no longer performing certain tasks, therefore products that address these activity limitations may not be readily adopted. Satisfied with current activity performance? Elder participants were primarily satisfied with their current activity performance. Elder participants were conten t with limiting and/or taking longer to complete activities. To create more appropriately matched tec hnological devices designers shoul d be wary of developing ST devices based solely on whether the device can do a task faster, more efficiently, and/or for a longer duration. Elder participants were found to be content with performing activities in their own adapted style. As identified in the model if a participant is satisfied with his/her current activity performance level then he/she may decide that ST is not needed. Is ST a practical solution? A distinct feature of the study was to assess all 44 ST devices rega rdless of impairment level. Participants were asked about each of the ST devices, specifically if the device could assist in their daily activities. For example even if pa rticipants did not have difficulty operating their TV remote control, they were still asked if a voice recognition remote control would be desired, and similarly if a medication reminding system would be desired without having any difficulty managing medications. This would e xplain some types of barrier th emes that were revealed in the findings, such as perception of no gain from the ST device. For instance, if a participant did not have an impairment that the specific ST device addressed then they may not easily see any gain to adopting the ST device. To create more appropriately matched technolog ical devices designers should be wary of developing ST devices that may be perceived by elder consumers as too costly for their needs. Elder participants were often concerned with the costs associated w ith utilizing ST. Elder participants cited being content with making minor adaptations in their behavior rather than

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133 desiring ST to assist with a diffi cult task. Elder participants expre ssed that they only spent money on necessities; therefore if a partic ipant viewed a device as only slightly needed and the cost was perceived as high, then he/she may decide that the ST device is too costly for his/her needs. Can I physically use the ST device? Is the ST easy to learn and use? To create more appropriately matched technolog ical devices designers should be wary of developing ST devices that utilize a touchscreen as the primary interface. When given the option elder participants preferred voice recogn ition technology over touc hscreen technology. Touchscreen interfaces were perceived as cumb ersome to learn and use. To create more appropriately matched technologica l devices designers should be aw are of how far removed from existing technology a ST device may be perceive d by the elder consumer. Elder participants expressed concerns of having to learn a comp letely new system. Possibly incorporating ST components into an existing technology design may be more readily adopted. Will using the smart technology de vice create more stress/problems? Elder participants had concerns of problems a nd stresses associated with utilizing ST. To create more appropriately matched technological devices designers should be aware of the level of information generated by the device. Elder pa rticipants perceived t echnology as potentially overwhelming them with constant reminders or personal health information. To create more appropriately matched technologi cal devices designers should be cognizant of the amount of human contact being replaced by the ST. The need for ST was often trumped by the desire of the elder participants to have human interaction. Is the ST reliable? Elder participants were found to be concerne d with the reliability of the technology. ST was often perceived as not being advanced enough to be reliable. To create more appropriately matched technological devices desi gners should be alert to the fa ct that elder consumers often

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134 compare ST reliability with the reliability perfor mance of humans. As identified in the model if a participant is concerned about the reliability of the device then th ey may decide that ST is not needed. Facilitator Themes The model identifies numerous facilitator cr iteria (i.e., decrease imposition, increase autonomy) surrounding the elder ST need decision process (Figure 3-15). These facilitator criteria are important additions to the elder ST needs literature as they outline potential motivators to adopting ST assistance. Previous li terature simply utilized terminology such as favorable, open to the idea, convenient, willingness to accept or have in home when describing elder ST decision criteria (Demir is et al., 2004; Johnson, Davenport, & Mann, 2007; Mihailidis et al., 2005). This deci sion criteria knowledge will he lp designers creat e appropriately matched technological devices that potentially de creases imposition on family/friends, increases sense of autonomy, assists with difficult activitie s, assists with unsafe activities, and enhances the monitoring of health. Decrease imposition on family/friends To create more appropriately matched technol ogical devices designe rs could incorporate features in the ST device that focus on decreasi ng the level of assistance participants receive from family. Specifically elder participants freque ntly expressed a desire for ST to assist in decreasing imposition on family caring for them. In corporating ST features that are able to decrease imposition on family members may increase the desirability of the ST device. Increase sense of autonomy Elder participants desired ST that assisted with increasing their sense of autonomy. Elder participants felt more in control of a robot than with a hired care giver, therefore ST devices that replaced certain caregiver tasks may increase the participants sense of autonomy. To create

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135 more appropriately matched tec hnological devices designers coul d focus on ST devices (such as a robotic dressing aid, transfer aid, or bathing aid) that would decr ease the participants reliance on others, thus increasing their sense of autonom y. As identified in the model if a participant perceives the ST device as poten tially increasing his/her sense of autonomy then ST device may be desired. Assist with a difficult activity/Assist with an activity currently unable to perform Generally the findings indicate that ST is perceived as a poor s ubstitute for elder participants own skills, especially when they are satisfied with their current activity performance status. However when elder participan ts cited an unmet need (i.e., unsatisfied with activity performance) then ST wa s increasingly seen more as a pot ential solution. To create more appropriately matched technologi cal devices designers could fo cus on ST devices that would address any frequently cited unmet activity need (i.e., dressing tasks, carry ing items, or preparing meals). Replace existing technology to perform activity more safely To create more appropriately matched technol ogical devices designe rs could focus on ST devices that would allow activit ies to be performed more sa fely. It was found that elder participants desired ST to replace existing t echnology (i.e., ambulatory device, stove safety device) in order to perform ac tivities more safely. Developers could focus on designing ST devices (i.e., robotic carrying ai d, smart stove) that would help m eet these unmet activity needs. Add a safety net To create more appropriately matched technol ogical devices designe rs could focus on ST devices that provide elder particip ants with safety nets. Specifical ly elder participants felt a need for a fall monitoring system to act as a backup inca se they were to fall and be unable to call for assistance. Incorporating a safety net feature ma y increase the desirabil ity of the ST device.

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136 Enhance ability to monitor health It was found that elder participants frequently desired ST to assist with their ability to monitor their health. This frequently expressed need may have been due to fact that this category of ST device goes beyond compensation of a task As elder participants were generally found satisfied with their current activity performance le vel, they did not express a need for assistance with tasks that they we re already comfortable with. This specific prediction technology went beyond compensation and may have been perceived as adding something to the participants abilities, specifically providing an additional abi lity to monitor their health. Therefore to create more appropriately matched techno logical devices designers may fo cus on ST devices that would be perceived as enhancing their abilities. Futu re researchers could furt her explore the issues surrounding this facilitator theme, which may have many subcomponents tied into it (i.e., satisfaction level with their healthcare ma nagement, number of chronic conditions). Limitations Several limitations exist in this study. The firs t limitation in this study is generalizability of the findings. The findings can not be generalized to the elder mobility impaired population due to the purposive sampling method, small sample size, and lack of ethnic di versity (all Caucasian participants) in this study. The findings can not be generalized to the population due to the fact that all participants had 12 months to adapt to th eir impairment (all were at least 1 year status post onset of decline). A cohort of elders with a more recent decline in mo bility impairment may provide a more unique reception to ST providing assistance. Generalizability of findings to all ST devices may be limited due to the fact that the majority of ST devices (i.e., remote contro l voice/touchscreen, household automation, personal robotic assistance) assessed in this study provide d compensatory interventions. Participants were satisfied with their current activity performance le vel, therefore evaluating primarily ST that only

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137 provided compensation assistance fo r tasks that they were already comfortable with may have been incomplete. An additional limitation may involve research er bias. Having a background in occupational therapy where the objective is to return clients to full functional status may have influenced the progression of questions during the interviews. For example ma ny of the questions centered on exploring how to enable the pa rticipants to achieve full func tioning. This may have limited the number of questions that explor ed how participants were satisfied with limiting their activity performance level. Another limitation of the study is its concep tual nature. At times participants would express a desire to physically see or utilize the ST device in orde r to be able to make a more informed decision regarding whether they would us e the device. Without being able to fully test the ST devices, participants may have been ab le to only provide perfunc tory answers. If the participants were confronted with the actual ST device their perceptions may vary from those reported during their interviews. An additional limitation of this study is the study design. Although interviews lasted from 2.5-4 hours, the large quantity of activities (49) and ST (44) assessed, limited the researchers ability to completely explore each concept that emerged. Future researchers could further explore the issues surrounding each barr ier/facilitator theme that was revealed by this study. Implications As advances are made with underlying ST we can expect commercial smart home ventures to significantly move into the mainstream popul ation. As a rule commercial products are not created solely for the benefit of their users, th ey are created by companies whose target is to make money (Kuniavsky, 2003). Ther efore designers may design smart technology that benefits primarily the technology-enthusiast or younger c ohorts, as has been shown in the past with

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138 communication and business technologies (Eriks son & Timpka, 2002). Therefore an important role of university-based research is to ensure that ST also be developed with the elder consumer in mind and provide the most support for older peopl e with disabilities. The results of this study have added to the literature that describes the elder consumer needs regarding ST. This knowledge will help designers crea te appropriately matched technol ogical devices that will assist in the care of aging baby boomers with mobility impairments. Future Research The qualitative nature of this study served to create an initial overall conceptual ethnographic decision tree model. This composite elder ST decision tr ee model illustrates the decision criteria involved in dete rmining elder ST need. This study carried out the initial stages of the first of two phases in ethnographic deci sion tree modeling, result ing in a preliminary ethnographic decision model of the elder ST decision process. Utilizing the composite decision tree model created from this study, future studies can further explore each of the individual 44 ST devices that were assessed. Decision trees can be built for each of the 44 ST devices. During phase two of the ethnographic decision tree modeli ng process these individua l decision trees can be formally tested for their pr edictive accuracy on a separate group of elder consumers from the same population. Knowing the elder consumers ST decision making process could provide future direction for developers and policymakers. The overall conceptual ethnographi c decision tree model can also provide a basis for future qualitative studies to further e xplore the issues surrounding each barrier/facilitator theme that was revealed. These end-user concepts and decision criteria identified could also provide the needed conceptual framework for future quant itative studies. Understanding concepts and categories utilized by the end-user can improve upon the validity of future quantitative studies (i.e., survey design) where the terms and categ ories have to be known in advance (Blomberg,

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139 Burrell, & Guest, 2003). Therefore a quantitative survey design study could be fruitful and would assist with generalizing the findings. Specifically, a study focusing on a younger cohort (<50 years of age) would be beneficial in establishing if a younger population would be eager to regain as much function and efficiency as possible. Possibly this younger cohort would exhibit a stronger ST need, as they would be willing to accept any ST in order to accomplish more throughout the day. Finally a study focusing specifically on elders who have recently been admitted to an assisted living facility or nursing home (or thei r caregivers) could be be neficial. These cohorts may be able to provide further insights into what ST would be needed to slow decline and delay the onset of transitioning to an ALF or nursing home. Conclusions The construction of a preliminary decision tree model adds to the literature on elder ST needs analysis. The awareness of multiple barrie rs and facilitators to the ST need decision process potentially will help futu re designers create appropriately matched technological devices. As illustrated in the findings of this study the elder ST need decision process is complex and multifaceted. Unmet activity needs are potentially e ffective ST gateways as these needs are not being met. Satisfaction with current activity perf ormance level is potentially a major barrier for ST to be adopted. The findings of this research suggest that compensatory ST interventions may not be readily accepted by elders with MIs. Pote ntially ST devices that could be presented as preventing further decline, retr aining physical abilities, or rest oring cognitive functioning, may be found to be more readily accepted.

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140 APPENDIX A INITIAL INTERVIEW GUIDE Confidential Study Pa rticipant Number: _________ Interview Date: ____________ Start Time _______ Completion Time: _______ DEMOGRAPHIC INFORMATION: 1. Age: [ > 90yo will be utilized in future to de-identify data ] 2. Gender: 1. Male 2. Female 3. Race: 1. Black 4. Asian 2. White 5. Native American 3. Hispanic 6. Ot her________________ _______________________ 4. Level of Completed Education: 1. Less than 12th Grade 5. Bachelors degree 2. High School Graduate 6. Masters degree 3. Some college, no degree 7. Doctorate/Medical degree 4. Vocational, tech, or business school degree 5. Marital Status: 1. Married 4. Single 2. Widowed 5. Ot her ___________________ ___________________ 3. Divorced 6. Living Arrangement: 1. Live alone 2. Live with someone (Please Circle) -Spouse -Adult Child -Parent -Other Family Member -Friend -Roommate 3. Occasionally have family/friend stay overnight in home to help with care 4. Other ________________________ __________________ ____________

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141 7. Description of Home: 1. A single-family detached home 2. A multi-unit buildin g (apartment, either lo w-rise or high-rise) 3. A mobile home 4. A semi-detached home (townhouse or duplex) 5. Other ________________ __________________ ____________________ 8. How much income do you (and your husband/wife) have a year? Yearly A 0-$10,000 B $10,000$20,000 C $20,000$30,000 D $30,000$40,000 E $40,000$50,000 F $50,000$60,000 G $60,000$70,000 H $70,000$80,000 I $80,000$90,000 J $90,000$100,000 K >$100,000 9. How many people altogether live on this income (that is, it provides at least half of their inco me)? __________________

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142 HEALTH AND ACTIVITY INFORMATION: 1. What best describes your overall health condition? 1. Excellent 4. Poor 2. Good 5. Ot her__________________________ _______________ 3. Fair 2. Description of Health Condition: Type of Condition Has Condition (Description) Speech or Communication Difficulties Poor Hearing Memory Difficulties Low Vision RIGHT EYE Low Vision LEFT EYE Function of RIGHT Hand Full/Partial Paralysis Not Fully Open/Close Pain Arthritis Function of RIGHT Upper Arm Full/Partial Paralysis Not Raise over Shoulder Pain Arthritis Function of LEFT Hand Full/Partial Paralysis Not Fully Open/Close Pain Arthritis Function of LEFT Upper Arm Full/Partial Paralysis Not Raise over Shoulder Pain Arthritis Function of RIGHT Leg Full/Partial Paralysis Pain Arthritis Function of LEFT Leg Full/Partial Paralysis Pain Arthritis

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143 Type of Condition Has Condition (Description) ***Other (Heart dz, diabetes, COPD, HTN, dizziness, etc.): Other: 3. Description of Fine Moto r Assistive Device Used: 1. None 5. Button Hook 2. Built up Handle on Utens ils 6. Plate Food Guard 3. Universal Cuff Utensils 7. Writing Aid 4. Other___________ __________________ ______________ 4. Description of Mobility Assistive Device Used: (Please indicate primary mobility AD utilized indoor/outdoor) 1. None 5. Wheelchair____________________ 2. Cane________________ 6. Scooter_______________________ 3. Walker_______________ 7. Powered Wheelchair_____________ 4. Other___________ __________________ ____________ 5. Description of Typical Walking Distance (can be with use of cane/walker): 1. No difficulty 4. Household Distances Only 2. Slow Gait Only 5. Transfers Only 3. House and Yard Only 6. Description of Falling History -Over the Past Year: 1. None 4. Three-Five 2. One 5. >Five 3. Two 6. Other __________________________ __________ 7. Do you find yourself limiting your act ivities because of a fear of falling? 1. Yes 3. Other __________________________ ____________________ 2. No 8. Description of Visual Assistive Device Used: 1. None 2. Glasses ________________________ __________________ ___________ 3. Magnifier ________________________ _____________________ ________ __________________ ________________________ ______________________ 4. Bioptic Telescope System (auto near and far focusing) ________________

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144 __________________ ________________________ ______________________ 5. Closed Circuit Television Systems CCTV (video camera used to capture image of reading material and magnify it on a monitor) ______________ ________________________ _____________________ ___________________ 6. Screen Reader Software (software system that converts text to speech) ___ ________________________ __________________ ______________________ 7. Blind Cane _____________________ __________________ _____________ __________________ ________________________ ______________________ 9. Description of Visual Impairment: (With Better Eye can be with Glasses) 1. No Impairment 2. Unable to Read Prescription Bottle Directions 3. Unable to Read Newspaper Text 4. Unable to Drive Due to Loss of Vision 5. Unable to Read Facial Expressions 6. Frequently Bump into Objects in an Unfamiliar Environment 10. Description of Security around Home: 1. Gated Community 2. Home Security System 3. Personal Emergency Response System 4. Dog 5. Other ___________ __________________ _________________________ 11. Description of Resident Safety Check System: 1. None 2. Live-in spouse/family/roommate bu ilt in multiple daily check system 3. Personal Emergency Response System 4. Daily phone call/visit from family/friend/agency to check in 5. Weekly phone call/visit from family/friend/agency to check in 6. Monthly phone call/visit from family/friend/agency to check in 7. Other ____________________ ________________________ __________ 12. Description of Availability Assistance from Outside Home: 1. None 2. Local family/friends available to assist when needed 3. Out of town family/friends available to assist when needed 4. Assisted Living Facility 5. Continuing Care Retirement Community

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145 13. How would you define the word independence? 1. Do everything by self without use of assistive devices (cane, walker, button hook) 2. Do everything by self can use assistive devices (cane, walker, button hook) 3. Do everything by self Can use high-tech assistive devices (automatic front door, floor sa fety monitoring) 3. Can accept assistance from spouse or family member 4. Can accept assistance from neighbor 5. Can accept having an agency personal attendant 6. Will accept anything to remain in home. Comfort level remains steady as long as stay in home.

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146 AGING IN PLACE INFORMATION: 1. Do you own or rent y our place of residence? 1. Own 2. Rent 3. Other _______ _____________________ _____________________________ 2. How long have you lived in your current residence? 1. Less than 5 years 4. 21-30 years 2. 6-10 years 5. 31-40 years 3. 11-20 years 6. Over 41 years 3. Do you plan to continue to live in y our current residence for the next 10 years? 1. Yes __________________ _______________________ 2. No ____________ __________________ ____________ a. Plan to move into sm aller home (easier to maintain) b. Plan to move in with family/friend c. Plan to move into ALF or CCRC 3. Dont Know ____________________ _______________ 4. What best describes your reacti on to the following statement? Id really like to live in my current residence for as long as possible 1. Strongly Agr ee 4. Strongly Disagree 2. Somewhat Agree 5. Dont Know 3. Somewhat Disagree 5. You are living alone and you discover you require some assistance to continue living in your home, wher e would you seek assistance to remain living at home? (Rank) _____ Family Assist _____ Friends Assist _____ Hire Personal Care Assistance _____ Purchase Technology to Assist (PERS, robotic vacuum) _____ Dont Know 6. If it was not safe (d/t fa lling, constantly forgetti ng medication) to live alone in your home do you think you would continue to choose to live there? 1. Yes 2. No 7. Name three things that you feel may cause you to have to move out of your home (whether to an ALF, NH, family or friends)? 1. Fall 4. SOB 2. Vision loss 5. Ot her ____________________ ___________________ 3. Arthritis

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147 TECHNOLOGY ATTITUDES/EXPERIENCE INFORMATION: 1. Which statement would you agree with more strongly (e.g., high definition TV, robotic vacuum, automatic front door)? 1. I like to try out new technology 2. I do not like to try new technology 2. Which statement would you ag ree with more strongly? 1. Technology helps me connect with other people 2. Technology makes me feel detached from other people 3. I feel neutral about technology 3. Do you have a computer at home? 1. Yes 2. No 4. Do you have a web-camera at home? 1. Yes 2. No 5. How would you describe your familiarity with computers ? 1. Very familiar 3. Somewhat unfamiliar 2. Somewhat familiar 4. Not familiar 6. How would you describe your frequency of computer use ? 1. Daily 4. Rarely Use 2. Few times a week 5. Never Use 3. Few times a month 7. Do you have high-speed internet access? 1. Yes 2. No 8. How would you describe your familiarity with the internet ? 1. Very familiar 3. Somewhat unfamiliar 2. Somewhat familiar 4. Not familiar 9. How would you describe your co mfort level with the internet ? 1. Comfortable 3. Somewhat uncomfortable 2. Somewhat Comfortable 4. Uncomfortable 10. Do you have a cell phone ? 1. Yes 2. No

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148 11. How would you describe your familiarity with cell phones ? 1. Very familiar 3. Somewhat unfamiliar 2. Somewhat familiar 4. Not familiar 12. How would you describe your frequency of cell phone use ? 1. Daily 4. For Emergencies Only 2. Few times a week 5. Never Use 3. Few times a month 13. Do you have a Personal Emergency Response System (PERS) at Home? 1. Yes 2. No 14. How often do you wear your PERS system ? 1. All the time 4. When feeling sick 2. During the daytime 5. Leave PERS (pendant, bracelet) by bed 3. During the nighttime 6. Never use 15. What is your experience with smart technology? 1. No experience 2. Have seen it on TV or in Newspaper 3. Been on a tour of the lo cal smart house in Gainesville 4. Have participated in Focus Groups on smart house technology in Gainesville

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149 APPENDIX B CURRENT ACTIVITY PERFORMANCE GUIDE

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150 CURRENT ACTIVITY PERFORMANCE GUIDE : Confidential Study Pa rticipant Number: _________ Interview Date: ____________ Start Time _______ Completion Time: _______ Remote Control (RC), Automation (A) Monitoring (M), Prompting /Reminding(P) Current Activity Performance Evaluation Legend: C=current status P=preferred solution I=informal care (family, spouse) F=formal care (paid caregiver) *Last column will be completed during in-depth interview (phase 2) where thorough exploration of elders perceptions of ST occurs. Does Not Do or Have in Home No Difficulties Performing Takes Considerable Time Onl y Has Pain but able to Successfull y Perform without AD Successfully Performs (with AD) Modified Independence Successfully Performs with Slight (25%) Caregiver/ Family Assistance Impossible to Perform without Moderate (50%) Assistance Impossible to Perform without Total (100%) Assistance No Assistance Available Not a Priority (not needed) No Assistance Available Is a Priority (missed a lot) *Open to the Idea and Would Use ST if available ADLs (taking care of ones own body) (A) Example: Cooking Popcorn P CI X (A) Physically Bathing/ Show ering self (A) Turning on Shower/Sink Faucets (A) Adjusting Water Temperature of Shower/Sink (A) Grooming (brushing teeth, co mbing hair, etc) (A) Bowel and Bladder M anagement (intentional control bowel/bladder)

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151Remote Control (RC), Automation (A) Monitoring (M), Prompting /Reminding(P) Current Activity Performance Evaluation Legend: C=current status P=preferred solution I=informal care (family, spouse) F=formal care (paid caregiver) *Last column will be completed during in-depth interview (phase 2) where thorough exploration of elders perceptions of ST occurs. Does Not Do or Have in Home No Difficulties Performing Takes Considerable Time Onl y Has Pain but able to Successfull y Perform without AD Successfully Performs (with AD) Modified Independence Successfully Performs with Slight (25%) Caregiver/ Family Assistance Impossible to Perform without Moderate (50%) Assistance Impossible to Perform without Total (100%) Assistance No Assistance Available Not a Priority (not needed) No Assistance Available Is a Priority (missed a lot) *Open to the Idea and Would Use ST if available (A) Functional Mobility: (A) Getting in/out of Bed (A) Getting in/out of Shower (A) Getting in/out of Tub (A) Transferring on/off Toilet (A) Carrying Items around the House (A) LB -Dressing (including shoes) (A) UB -Dressing (A) Eating IADLs (oriented toward interacting with the environment) (RC) Turning on/off Lights in Home (RC) Opening/closing Blinds in Home (RC) Unlocking/Locking Front Door (RC) Opening/closing Front Door (RC) Answering the Doorbell in Time

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152Remote Control (RC), Automation (A) Monitoring (M), Prompting /Reminding(P) Current Activity Performance Evaluation Legend: C=current status P=preferred solution I=informal care (family, spouse) F=formal care (paid caregiver) *Last column will be completed during in-depth interview (phase 2) where thorough exploration of elders perceptions of ST occurs. Does Not Do or Have in Home No Difficulties Performing Takes Considerable Time Onl y Has Pain but able to Successfull y Perform without AD Successfully Performs (with AD) Modified Independence Successfully Performs with Slight (25%) Caregiver/ Family Assistance Impossible to Perform without Moderate (50%) Assistance Impossible to Perform without Total (100%) Assistance No Assistance Available Not a Priority (not needed) No Assistance Available Is a Priority (missed a lot) *Open to the Idea and Would Use ST if available (A) Meal Preparation and Cleanup: (P) Planning/Preparing Meals (A) Using a Microwave to Reheat Items (A) Using a Microwave to Cook a Prepackaged Frozen Meal (A) Cleaning up Food and Utensils (M) Remembering to Turn Off Stove Top/Oven Communication Device Use: Cell phone Telephone Computer Shopping: (M) Preparing Grocery Shopping List Purchasing Items at a Store Community mobility:

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153Remote Control (RC), Automation (A) Monitoring (M), Prompting /Reminding(P) Current Activity Performance Evaluation Legend: C=current status P=preferred solution I=informal care (family, spouse) F=formal care (paid caregiver) *Last column will be completed during in-depth interview (phase 2) where thorough exploration of elders perceptions of ST occurs. Does Not Do or Have in Home No Difficulties Performing Takes Considerable Time Onl y Has Pain but able to Successfull y Perform without AD Successfully Performs (with AD) Modified Independence Successfully Performs with Slight (25%) Caregiver/ Family Assistance Impossible to Perform without Moderate (50%) Assistance Impossible to Perform without Total (100%) Assistance No Assistance Available Not a Priority (not needed) No Assistance Available Is a Priority (missed a lot) *Open to the Idea and Would Use ST if available Driving Using Public Trans. -taxi, bus Financial Management Home establishment management (home, yard, garden, appliances, vehicles): (RC) Adjusting the Thermostat in Home (M) Checking the mail (M) Preventing Food from Expiring Before Use (M) Keeping Track of Food in Kitchen (A) Doing Laundry (A) Vacuuming (P) Remembering Appliance Maintenance (A) Mowing the Yard

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154Remote Control (RC), Automation (A) Monitoring (M), Prompting /Reminding(P) Current Activity Performance Evaluation Legend: C=current status P=preferred solution I=informal care (family, spouse) F=formal care (paid caregiver) *Last column will be completed during in-depth interview (phase 2) where thorough exploration of elders perceptions of ST occurs. Does Not Do or Have in Home No Difficulties Performing Takes Considerable Time Onl y Has Pain but able to Successfull y Perform without AD Successfully Performs (with AD) Modified Independence Successfully Performs with Slight (25%) Caregiver/ Family Assistance Impossible to Perform without Moderate (50%) Assistance Impossible to Perform without Total (100%) Assistance No Assistance Available Not a Priority (not needed) No Assistance Available Is a Priority (missed a lot) *Open to the Idea and Would Use ST if available Safety Procedures and Emergency Responses (knowing and performing preventive procedures to maintain a safe environment as well as recognizing sudden, unexpected hazardous situations): (RC) Seeing who is at the front door (RC) Closing all doors/windows in home (RC) Locking all the doors/windows in home (RC) Setting the Home Security Alarm (P) Remembering to check in with designated family/friend (daily/weekly/monthly) (M) Remembering to turn off all appliances (M) Knowing which stove top burner is on/off Health Management/Maintenance (developing, managing, maintaining routines for health and wellness promotion):

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155Remote Control (RC), Automation (A) Monitoring (M), Prompting /Reminding(P) Current Activity Performance Evaluation Legend: C=current status P=preferred solution I=informal care (family, spouse) F=formal care (paid caregiver) *Last column will be completed during in-depth interview (phase 2) where thorough exploration of elders perceptions of ST occurs. Does Not Do or Have in Home No Difficulties Performing Takes Considerable Time Onl y Has Pain but able to Successfull y Perform without AD Successfully Performs (with AD) Modified Independence Successfully Performs with Slight (25%) Caregiver/ Family Assistance Impossible to Perform without Moderate (50%) Assistance Impossible to Perform without Total (100%) Assistance No Assistance Available Not a Priority (not needed) No Assistance Available Is a Priority (missed a lot) *Open to the Idea and Would Use ST if available (M) Monitoring Vital Signs (Blood Pressure, Temp, Respiration Rate) (M) Monitoring Sleep Patterns (M) Tracking the Frequency of Trips to the Bathroom at Night (P) Physical Fitness Activity/Routines (P) Mental Fitness Activity/Routines (P) Maintaining Well Balanced Nutritional Meal Choices (P) Decreasing Health Risk Behaviors (P) Medication Management/Routines (P) Remembering MD Appointments LEISURE ACTIVITIES: Viewing TV (RC) Changing the Channel (RC) Changing the Volume SOCIAL PARTICIPATION:

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156Remote Control (RC), Automation (A) Monitoring (M), Prompting /Reminding(P) Current Activity Performance Evaluation Legend: C=current status P=preferred solution I=informal care (family, spouse) F=formal care (paid caregiver) *Last column will be completed during in-depth interview (phase 2) where thorough exploration of elders perceptions of ST occurs. Does Not Do or Have in Home No Difficulties Performing Takes Considerable Time Onl y Has Pain but able to Successfull y Perform without AD Successfully Performs (with AD) Modified Independence Successfully Performs with Slight (25%) Caregiver/ Family Assistance Impossible to Perform without Moderate (50%) Assistance Impossible to Perform without Total (100%) Assistance No Assistance Available Not a Priority (not needed) No Assistance Available Is a Priority (missed a lot) *Open to the Idea and Would Use ST if available Family/Peer/Friend: (P) Remembering Birthdays (P) Remembering Important Community Events

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157 APPENDIX C IN-DEPTH INTERVIEW GUIDE Confidential Study Pa rticipant Number: _________ Interview Date: ____________ Start Time _______ Completion Time: _______ In-depth Interview Questions : [Eight visual display boards will be utilized to introduce smart technology and help subjects visualize the differences between automating, monitoring, prompting/reminding, predicting, and remote controlling technologies in smart home design.] What are your initial thought s about smart home technology ? Prompt Questions: How do you feel about smart home technology? Do you feel it will help save you time, allow you to conserve energy, you connect with people, or make you feel detached, frustrate you, be too expens ive)? What role do you see technology having in your future? What are your thoughts on having a house that can be operated by a remote (voice or touch screen) control? Prompt Questions: Would having remote control abilities in your home enhance your daily activities ? Is there a task that you are no longer able to perform in your home that a voice control device would be able to assist? (blinds, lights, thermostat, security) Do you currently have difficulty getting around your home to (answer the door, phone, turn on/off lights etc.)? Do you feel unsafe or rushed when getting around in your home? Would you prefer voice interf ace or touch screen interface? What are your thoughts on having a house that is more automated (smartwave, TV/Stereo, vacuum)? Prompt Questions: Do you currently have any tasks in y our home automated (lights, sprinkler system, security system, water heater, and thermostat)? What if your front door could be automated? Microwave that was automated? Robot that would help you dress? Robot that woul d help you bathe? Robot that would help you get in and out of the bath tub? How about windows and doors that were automated? Automated lawn mower? Personal robot that would help bri ng things to you or open things?

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158 What are your thoughts on having a house that is able to monitor you ? Prompt Questions: Do you currently have any monitoring devices in your home (security system, PERS, BP machine, blood glucose machine)? What are your thoughts on having a house that could monitor for falls? What about a house that could monitor your sleep patterns? Or check to see how many times you have been getting up to use the bathroom? Medication use? Monitor your blood sugar (via commode)? Monitor what you were eating? Monitor the items in the refrigerator and let you know if something was about to expire? Monitor if you left your stove or oven on? Monitor for water leaks? Monitor if someone is at the door? Monitored how much you were exercising? Monitor all your doors and windows? Monitor if your mail has arrived? What are your thoughts on having a house that is able to prompt you ? Prompt Questions: Do you currently have any problems reme mbering to do things while at home? What methods do you currently employ (post-it notes, spouse/family do the reminding, have a check system)? Do you have problems remembering you put something in the microwave, oven, on stove top, in W/D? Do you frequently have to th row out expired food items? Do you feel you are able to do all the things that you want to do in a day? Is their anything that you wish you had more time to do? How do you feel you are managing your health? What type of role would you say you pl ay in maintaining your health (passive, active, dont know)? Do you feel having a house that would remind you when to take medications could benefit? What about diet choices? What if a house were to schedule ex ercise appointments with you each day? Or if it were to remind you of someones birthday or automatically let you know it has been a month since you talked to a particular friend? What are your thoughts on having a house that is able to make predictions and suggestions ? Prompt Questions: Do you feel that you would not want to have to interact with your house, would rather have your house make suggestions fo r you? (let you know when a favorite TV program is about to start, let y ou know of storm that is approaching).

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159 What about a house that learns what bat h water temp. you like and sets it for you? Or learns when you use hot water duri ng the week and turns on/off your water heater automatically. What if you did not have to manual turn on/off your lights the house knows when you are in the room and what lighting you need? What do you think about a house that could monitor your walking pattern and if it changes in negative way make predictions? Or a house that can monitor if your hands shaking is changing (when you use your mouse, remote control) and lets you know? Do you foresee yourself having smart technology installed in your home in the future? Prompt Questions: If so, what would it be for (physically helping, reminding you, monitoring your health)? If not, what are the barriers (no need, too expensive, too hard to learn)?

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160 APPENDIX D SMART TECHNOLOGY DE VELOPMENT FRAMEWORK Figure D-1. Smart technology development framework.

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161 APPENDIX E SMART HOME TECHNOLOGY VIS UAL INFORMATION BOARDS

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162 Smart HomeHome capable of intelligently supporting residents in their daily activities.Such as: Voice activated lights and blinds Automated front door Monitoring support (fall detection, sleep patterns) Reminders to take medications Early detection of health conditions Figure E-1. Smart home desc ription display board.

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163 November 8, 2006 November 8, 2006 24 24 Remote Control Remote Control (voice recognition) (voice recognition) Figure E-2. Remote control voi ce recognition display board.

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164 November 8, 2006 November 8, 2006 25 25Remote Control Remote Control ( ( touchscreen touchscreen ) ) Figure E-3. Remote control to uchscreen display board.

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165 November 8, 2006 November 8, 2006 26 26Household Automation/Monitoring Household Automation/Monitoring Figure E-4. Household automati on/monitoring display board.

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166 Figure E-5. Personal robotic assistance display board.

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167 November 8, 2006 November 8, 2006 28 28Monitoring Technologies Monitoring Technologies Figure E-6. Monitoring tec hnologies display board.

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168 Prompting/Reminding Technologies Figure E-7. Prompting/reminding t echnologies display board.

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169 November 8, 2006 November 8, 2006 30 30Prediction Technologies Prediction Technologies Figure E-8. Prediction technol ogies display board.

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170 APPENDIX F PARTICIPANT OBSERVATION GRID GUIDE

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171 PARTICIPANT OBSERV ATION GRID GUIDE Confidential Study Pa rticipant Number: _________ Interview Date: ____________ Start Time _______ Completion Time: _______ Observation Description 1. Who is present in the house? a) Friends/family/pets 2. What are their roles? a) Participant caring for others? 3. How do the people behave toward one anothe r? a) Who makes the decisions for whom? b) What nonverbal communication do they use? 4. How does participant move in home? a) Furniture walking, alternating between cane and walk er, frequently bumps into furniture. 5. How has the space in the home been allocated ? a) Clear pathways vs. aesthetics b) Majority of time spent in which room c) Are co mmonly used items centered around a favorite chair? d) Safety concerns overridden for aesthetics (smoke alarms, fire extinguisher)

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172 Observation Description 6. How has the AT been integrated ? a) Walker scooter, cane, grab bars, in prominent lo cations (safety is priority?) b) A lot of environmental modifications? c) Any homegrown modifications? 7. How has the technology been integrated ? a) Multiple or separate computer room(s)? b) Highly used Tivo, PDA, cell phone

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173 LIST OF REFERENCES Allen, B. (1996). An integrated approach to sm art house technology for people with disabilities. Medical Engineeri ng & Physics, 18 (3), 203-206. Alonso-Zaldivar, R. (2005). Seniors uncomfortable with Medicare web site Retrieved July 14, 2006, from http://www.baltimoresun.com/ Anderson, G. (2001). Making use of user research Retrieved July 20, 2006, from http://www.cooper.com/newsletter s/2001_09/making_use_of_user_research.htm Ante, S., & Edwards, C. (2006). The science of desire Retrieved September 11, 2006, from http://www.businessweek.com/index.html Assistive Technology Act, 105 U.S.C, Public Law 105-394, Section 3 (1998). Association for Computing Machinery. (2006). ACM digital library Retrieved July 29, 2006, from http://www.acm.org/ Baillie, L., Benyon, D., Macaulay, C., Petersen, M. G. (2003). Investigating design issues in household environments. Cognition, Technology & Work, 5 (1), 33-43. Banerjee, S., Steenkeste, F., Cout urier, P., Debray, M., & Franc o, A. (2003). Telesurveillance of elderly patients by use of passive in fra-red sensors in a 'smart' room. Journal of Telemedicine and Telecare, 9 (1), 23-29. Basler, B. (2006). How part D plays in the heartland Retrieved July 14, 2006, from http://www.aarp.org/bulletin/me dicare/medicare_partd.html Becker, S. A. (2004). A study of web usability for older adults seeking on line health resources. ACM Transactions on Computer-Human Interaction, 11 (4), 387-406. Berner, R. (2006). The ethnography of marketing Retrieved September 11, 2006, from http://businessweek.com/ Blomberg, J., Burrell, M., & Guest, G. (2003). An ethnographic approach to design. In J. Jacko & A. Sears (Eds.), The human-computer interaction handbook: Fundamentals, evolving technologies and emerging applications (pp. 964-984). New Jersey: Lawrence Erlbaum Associates, Inc. Blueroof Technologies. (2006). Smart technologies for smart living Retrieved July 14, 2006, from http://www.bluerooftechnologies.com/ Books24x7. (2006). Referenceware by Books24x7 Retrieved July 29, 2006, from http://corporate.books24x7.com/home2.asp

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174 Bradner, S. (2005). The kids were right, school is a prison Retrieved July 24, 2006, from http://www.networkworld.com/c olumnists/2005/022105bradner.html Caldwell, D. G., Tsagarakis, N., Artrit, P., Cande rle, J., Davis, S., & Medrano-Cerda, G. A. (2001, July). Biomimetic and smart technology principles of humanoid design. Paper presented at the International Conference on Advanced Intelligent Mechatronics, Como, Italy. Carnegie Mellon University. (2004). Nursebot project: Robotic a ssistants for the elderly Retrieved May 13, 2004, from http://www-2.cs.cmu.edu/~nursebot/web/scope.html Carnegie Mellon University. (2005). Carnegie Mellon, Pitt to demonstr ate technologies that help the elderly at center for aging services technologies exhibition in Washington Retrieved July 14, 2006, from http://www.cmu.edu/PR/releases05/051212_aging.html Centers for Medicare & Me dicaid Services. (2006). Medicare part D prescription drug coverage Retrieved July 14, 2006, from http://www.medicare.gov/pdphome.asp CINAHL Information Systems. (2006). Cumulative index to nursing & allied health literature Retrieved July 29, 2006, from http://www.ovid.com/site/produ cts/ovidguide/nursing.htm CiteSeer. (2006). Scientific literature digital library Retrieved July 29, 2006, from http://citeseer.ist.psu.edu/ Cook, A. M., & Hussey, S. M. (1995). Assistive technologies: Pr inciples and practice (1st ed.). St. Louis: Mosby. Cook, A. M., & Hussey, S. M. (2002). Assistive technologies: Pr inciples and practice (2nd ed.). St. Louis: Mosby. Creswell, J. (1998). Qualitative inquiry and research design: Choosing among five traditions Thousand Oaks: Sage Publications, Inc. Davenport, R., Mann, W., & Helal, S. (2005, May). Defining an elder friend ly cell phone design: A focus group format. Poster presented at the Rehabi litation Research Day, Gainesville, Florida. Dekker, S., Nyce, J. M., & Hoffman, R. R. ( 2003). From contextual inquiry to designable futures: What do we need to get there? IEEE Intelligent Systems, 18 (2), 74-77. Demiris, G., Rantz, M., Aud, M., Marek, K., Tyre r, H., Skubic, M., et al. (2004). Older adults' attitudes towards and perceptions of "smart home" technologies: A pilot study. Medical Informatics & The Internet in Medicine, 29 (2), 87-94. Dewsbury, G. (2001). The social and psychological aspects of smart home technology within the care sector Retrieved October 2, 2006, from http://www.smartthinking.ukideas.com/

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175 Duke Med News. (2003). Monkeys consciously control a ro bot arm using only brain signals; Appear to "assimilate" arm as if it were their own Retrieved September 7, 2004, from http://www.dukemednews.org/news Duke Med News. (2004). Human studies show feasibilit y of brain-machine interfaces Retrieved September 7, 2004, from http://www.dukemednews.org/news Duke University. (2006). About the Duke smarthouse Retrieved June 23, 2006, from http://www.smarthouse.duke.edu/index.php Dyer, L. (2006). Entrepreneurs wire buildings with smart technology Retrieved July 24, 2006, from http://www.hamptonroads.com/ Eastern Virginia Medical School. (2006). Students relieve stress for local seniors struggling with drug enrollment Retrieved July 14, 2006, from http://www.evms.edu/about/news/200604-24-medicare-enrollment.html Electrolux. (2005). The world's first IT apartments Retrieved June 28, 2006, from http://www.e2-home.com/ Elite Care. (2006). Extended family residences: An alternative to assisted living Retrieved June 25, 2006, from http://www.elite-care.com/index.html Eriksson, H., & Timpka, T. (2002). The potential of smart homes for injury prevention among the elderly. Injury Control and Safety Promotion, 9 (2), 127-131. Federal Interagency Forum on Agin g-Related Statistics. (2004). Older Americans 2004: Key indicators of well-being Washington, DC. Fetterman, D. (1998a). Ethnography. In L. Bickman & D. Rog (Eds.), Handbook of applied social research methods (pp. 473-504). Thousand Oa ks: Sage Publications. Fetterman, D. (1998b). Ethnography: Step by step (2nd ed. Vol. 17). Thousand Oaks: Sage Publications. Fleck, P. (2002). Five insights for improving product development cycle success Retrieved July 5, 2006, from http://www.cooper.com/newsle tters/2002_04/five_insights.htm Freudenthal, A., & Mook, H. J. (2003). The evalua tion of an innovative in telligent thermostat interface: Universal usability and age differences. Cognition, Technology & Work, 5 5566. FutureLife. (2006). Welcome to futurelife.ch Retrieved June 28, 2006, from http://www.futurelife.ch/

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176 Georgia Institute of Technology. (2006). The aware home at Georgia Institute of Technology Retrieved June 23, 2006, from http://www-static.cc.gatech.edu/fce/ahri/ Gibbs, M. (2005). Smart technology, dumb people Retrieved July 24, 2006, from http://www.networkworld.com/c olumnists/2005/030705backspin.html Giesecke, S., Hull, J., Schmidt, S., Strese, H., Weib, C., & Baumgarten, D. (2005). Ambient assisted living: Work package one Retrieved October 2, 2006, from http://www.aal169.org/Published/CRgermany.pdf Gist, Y., & Hetzel, L. (2004). We the people: Aging in the United States Washington, DC: U.S. Census Bureau. Gladwin, C. (1989). Ethnographic decision tree modeling (Vol. 19). Newbury Park: Sage Publications. Goddard, N., Kemp, R., & Lane, R. (1997). An overview of smart technology. Packaging Technology and Science, 10 129-143. Guest, G., Bunce, A., & Johnson, L. (2006). How many interviews are enough? An experiment with data saturation and variablility. Field Methods, 18 (1), 59-82. Haigh, K. (2002, July). Automation as caregiver: A su rvey of issues and technologies. Paper presented at the Eighteenth National Conf erence on Artificial Intelligence, Alberta, Canada. He, W., Sengupta, M., Velkoff, V., & DeBarros, K. (2005). 65+ in the United States:2005 Washington DC: U.S. Census Bureau. Honeywell. (2006). Independent lifestyle assistant Retrieved June 28, 2006, from http://www.htc.honeywell.com/proj ects/ilsa/about_introduction.html IEEE Publications Online. (2006). Information driv ing innovation Retrieved July 29, 2006, from http://www.ieee.org/produc ts/onlinepubs/index.html inHaus. (2006). Innovation center intelligent house Retrieved June 25, 2006, from http://www.inhaus-zentrum.de/en/index.htm ISI Web of Knowledge. (2006). One source for high quality cont ent and the tools to access, analyze, and manage research information Retrieved July 29, 2006, from http://scientific.thom son.com/products/wos/ Johnson, J., Davenport, R., & Mann, W. (2007) Consumer feedback on smart home applications. Topics in Geriatric Rehabilitation, 23 (1), 60-72.

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177 Kanellos, M. (2004). Invasion of the robots: From medicine to military, machines finally arrive Retrieved July 20, 2004, from http://marketwatch-cnet.com.com/2009-1040_35171948.html Kaplan, B., Farzanfar, R., & Friedman, R. (2003) Personal relationships with an intelligent interactive telephone health behavior advi sor system: A multimethod study using surveys and ethnographic interviews. International Journal of Medical Informatics, 71 33-41. Kawamoto, H., Lee, S., Kanbe, S., & Sankai, Y. (2003, October). Power assist method for HAL3 using EMG-based feedback controller. Paper presented at the Systems, Man and Cybernetics, 2003 International C onference on IEEE, Washington, D.C. Kim, S., Kim, M., Park, S., Jin, Y., & Choi, W. (2004, August). Gate reminder: A design case of a smart reminder. Paper presented at the Designing Interactive Systems (DIS), Cambridge, Massachusetts. Kobb, R., Hoffman, N., Lodge, R., & Kline, S. (2003). Enhancing elde r chronic care through technology and care coordinati on: Report from a pilot. Telemedicine Journal and eHealth, 9 (2), 189-195. Kuniavsky, M. (2003). Observing the user experience: A pr actioner's guide to user research New York: Morgan Kaufman Publishers. Lawson, S. (2003). IBM builds a smarter house: Residents will be able to control their homes via the internet Retrieved July 22, 2006, from http://www.pcworld.com/ Lee, C., & Liao, C. (2003, October). A study of the product usabili ty for elderly Taiwanese people. Paper presented at the 6th Asian De sign International Conference, Tsukuba, Japan. Libin, A., & Libin, E. (2003). Older persons' perception of and communication with a companion robot. Paper presented at the 2003 Inte rnational Conference on Aging, Disability and Independence, Washington, D.C. Loudon, G. (2005). Market research alone is not good enough Retrieved September 11, 2006, from http://lightminds.co.uk/index.htm Mann, W., Helal, S., Davenport, R., Justiss, M. Tomita, M., & Kemp, B. (2004). Use of cell phones by elders with impairments: Overall appraisal, satisfaction, and suggestions. Technology and Disability, 16 49-87. Mann, W. C., Hurren, D., Tomita, M., & Charvat, B. (1995). The relationship of functional independence to assistive device use of elderly persons living at home. The Journal of Applied Gerontology, 14 (2), 225-247.

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178 Mariampolski, H. (2006). Ethnography for marketers: A guide to consumer immersion Thousand Oaks: Sage Publications, Inc. Martin, J. L., Murphy, E., Crowe, J. A., & Norris, B. J. (2006). Capturing user requirements in medical device development: The role of ergonomics. Physiological Measurement, 27 (8), R49-R62. Massachusetts Institute of Technology. (2006). House_n Retrieved June 24, 2006, from http://architecture.m it.edu/house_n/index.html McCormick, J. (2005). Promoting safety with smart technology Retrieved July 24, 2006, from http://www.detnews.com/apps/pbcs.dll/frontpage McMillan, J., & Schumacher, S. (1997). Research in education: A conceptual introduction (4th ed.). New York: Addison-Wesley Educational Publishers Inc. Medical Automation Research Center. (2006). MARC Retrieved June 25, 2006, from http://marc.med.virginia.edu/index.php Mihailidis, A., Cockburn, A., & Longley, C. (2005, June). The acceptability of home monitoring technology by baby boomers and older adults. Paper presented at the 28th Annual RESNA International Conference on Technol ogy and Disability, Atlanta, Georgia. Mozer, M. (2005). Lessons from an adaptiv e house. In D. Cook & R. Das (Eds.), Smart environments: technologies, protocols, and applications (pp. 273-294). Hoboken: Wiley & Sons. Mozer, M. (2006). The adaptive house Retrieved June 28, 2006, from http://www.cs.colorado.edu/~mozer/house/ Muller, M., Wildman, D., & White, E. (1993). Ta xonomy of PD practices: A brief practitioner's guide. Communications of the ACM, 36 (4), 24-28. Mynatt, E. D., Melenhorst, A., Fisk, A., & Roge rs, W. (2004). Aware technologies for aging in place: Understanding user needs and attitudes. Pervasive Computing, IEEE, 3 (2), 36-41. National Library of Medicine and the National Institutes of Health. (2006). PubMed Retrieved July 29, 2006, from http://www.ncbi.nlm.nih.gov/entr ez/query.fcgi?DB=pubmed NetLibrary. (2006). e-Book collection Retrieved July 29, 2006, from http://www.netlibrary.com/ Ohta, S., Nakamoto, H., Shinagawa, Y., & Tanika wa, T. (2002). A health monitoring system for elderly people living alone. Journal of Telemedicine and Telecare, 8 (3), 151-156. Omron. (2001). "Is this a real cat?" A robot ca t you can bond with like a real pet Retrieved September 19, 2004, from http://www.necoro.com/newsrelease/index.html

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180 University of Texas at Arlington. (2006). Managing an adaptive versatile home Retrieved June 28, 2006, from http://mavhome.uta.edu/ Valigra, L. (2004). Looking technology in the eye: Resear chers designing robots with more human characteristics Retrieved May 12, 2004, from http://www.csmonitor.com/2004/0205/p17s02-stct.html Village at Tinker Creek. (2006). Come home to your neighborhood Retrieved Aug 1, 2006, from http://www.villageattinkercreek.com/index.html Wada, K., Shibata, T., Saito, T., & Tanie, K. (2002, May). Robot assisted activity for elderly people and nurses at a day service center. Paper presented at the International Conference on Robotics & Automation, Washington, DC. Wada, K., Shibata, T., Saito, T., & Tanie, K. (2003, July). Psychological, phy siological and social effects to elderly people by robot assisted activity at a health service facility for the aged. Paper presented at the Internationa l Conference on Advanced Intelligent Mechatronics, Kobe, Japan. Woods, D., & Dekker, S. (2000). An ticipating the effects of tec hnological change: A new era of dynamics for human factors. Theoretical Issues in Ergonomics Science, 1 (3), 272-282. Worden, K., Bullough, W., & Haywood, J. (2003). Smart technologies London: World Scientific Publishing Co. World Health Organization. (2001). International classification of functioning, disability and health: ICF Geneva: WHO. Youngstrom, M., Brayman, S., Anthony, P., Brinson, M., Brownrigg, S., Clark, G., et al. (2002). Occupational therapy practice fram ework: Domain and process. The American Journal of Occupational Therapy, 56 (6), 609-639. Zurier, S. (2003). Virginia builder deploys web-based syst em that manages everyday tasks in the home. Retrieved June 27, 2006, from http://www.residen tinteractive.com/

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181 BIOGRAPHICAL SKETCH Rick D. Davenport entered the University of Floridas Rehabilitation Science Doctoral Program in August of 2002. The past 5 years of work as a research assistan t in the Rehabilitation Engineering Research Center on Technology for Successful Aging has set the foundation for Ricks dissertation area in smart home techno logy. Having shared authorship on four peerreviewed articles, authored a book chapter, and led a conference workshop Ricks interests lie primarily in designing el der friendly technology.


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