Abstract
Between June 2021 and March 2023, the Centre for Innovation and Research in Aging (CIRA) evaluated the effectiveness of the 2RaceWithMe exergaming product from Centivizer Inc in two New Brunswick long term care homes. 2RaceWithMe provides physical activity, through seated exercise, for older adults. In 2RaceWithMe, exercise is motivated by the requirement that residents needs to keep pedaling in order to view scenic videos from around the world. The objective of this paper is to report on some of the qualitative results obtained in the CIRA study, and to assess some of the barriers and facilitators to the use of an exergaming product like 2RaceWithMe in long term care.
Introduction
According to the U.S. Centers for Disease Control and Prevention (CDC, 2024): “Regular physical activity is vital for healthy aging. It can help delay, prevent, or manage many costly chronic diseases faced by adults 50 years or older.” However, many older people may not be motivated to get sufficient exercise. Fortunately, exercise can be made more enjoyable using exergaming, a combination of exercise and videogames (Yim & Graham, 2007). Pedaling exercise has been a focus of several exergames. For instance, PaperDude was a Virtual Reality cycling based exergame system inspired by the arcade game Paperboy (Bolton et al., 2014). Chignell et al. (2020) showed a scenario with pedaling around a course presented on video, where an element of social interaction (and possible competition) was added by having a second person pedal around the same course.
The 2RaceWithMe (2RWM) technology, combines a “biking” activity with travel around the world using augmented reality (Hall et al., 2021; Jbilou et al., 2021). At the start of the project, 2RaceWithMe contained 100 videos with most of the videos shot outside Canada. By the time the project finished in March 2024 there were close to 500 videos, with roughly half of them being shot inside Canada. This was partly in response to users who wanted to see more places that they were familiar with.
When using 2RaceWithMe, the long-term care residents are seated in a chair, or their wheelchair. 2RaceWithMe users pedal with the hand or foot pedals or both, to exercise and watch the travel videos. If the user stops pedaling then the video stops playing until the person starts pedaling again.
There are numerous examples of well-meaning technologies being introduced into long term care, but not being accepted in that setting, often because of unintended increases in staff workload that they create. For instance, social robots were introduced into long term care with the intent of helping staff by providing distraction, entertainment, or promoting social interaction with people with dementia. Early studies reported positive effects for older people with dementia (PwD), such as decreased agitation, reduced loneliness, and increased opportunities for social engagement (Abbott et al., 2019; Broadbent et al., 2009). However, those studies did not consider the impact of social robots on staff (Yamato et al., 2023). Subsequent research that considered impacts on staff showed that the benefits that social robots provided were outweighed by increased workload for caregivers (Persson et al., 2022). The robots have been found to increase staff workload because they introduce additional tasks and responsibilities, such as learning to operate them, concerns about potential malfunctions, and worries about maintaining hygiene, which add to the already demanding schedules of caregivers in long term care (Hung et al., 2019).
In view of the problems that have previously been found in implementing technology in long term care we wanted to evaluate not only whether residents would enjoy using 2RaceWithMe and get exercise at the same time, but also whether staff would find the technology acceptable and whether the two long term care homes in the study would be willing to have sustained use of 2RaceWithMe after completion of the research project.
Research Questions
The following research questions were addressed in the study:
RQ1. How much exercise would residents get using the system (in terms of frequency of use, duration of use, amount of pedaling?)
RQ2. How interesting are scenic videos as an accompaniment to exercise? Will participants tend to watch videos all the way through, or will they watch only a small portion before either switching to other videos or stopping exercise?
RQ3. To what extent would staff and residents in long-term care centers be interested in continuing to use the equipment after the end of the research project?
RQ4. What modifications should be made to the design of 2RaceWithMe to improve its usability and effectiveness?
The desired outcome of the project was to answer these research questions and evaluate whether or not sustained use of 2RaceWithMe as a beneficial exergaming intervention for increasing the amount of exercise gained by long-term care residents.
Method
A total of 32 older adults were enrolled in the project, ten at York Care Centre in Fredericton and 22 at Faubourg du Mascaret in Moncton. The participants ranged in age from 55 to 99 years, including 21 females and 11 males. Ten participants resided in a long-term care unit, 15 in an independent living unit and seven in a semi-independent living unit.
A quasi-experimental design was used for this study. Both quantitative and qualitative data was collected pre/post intervention. Sample data included:
Personal and health information, physical and cognitive status, social engagement, and well-being.
Observations and feedback from participants.
2RWM device data (i.e., number of pedal revolutions and videos viewed).
Technology Acceptance Model (TAM) ratings, as implemented in the version of the Technology Acceptance Questionnaire that we developed (see Appendix).
We adopted an action research approach where the 2RaceWithMe system was improved over time in response to feedback provided by the residents and staff at the long-term care centers. Our logic for doing action research in this way is that technology enabled activities are never a fixed intervention, since the technologies can always be improved through design interventions. Thus, in addition to collecting data on amount of use, usage, and sustainability, we also documented design changes that were made in response to user and staff feedback.
Results
As noted above, the study used an active research approach. This jettisoned rigorous analysis of data from controlled experiments in favor of analyses of barriers and facilitators to the use of our software, and qualitative assessments of who enjoyed using the equipment and why.
Benefits of using 2RWM included:
An enjoyable way to exercise and increase physical activity (reflected in device data and anecdotal feedback).
Enhanced well-being as highlighted by direct feedback from participants.
Increased social engagement and enjoyment as highlighted by participants’ and family members’ feedback.
Increased level of comfort using technology as per responses to the technology the knowledge and skills gained by participants included the following:
Increased physical activity.
New learning and knowledge regarding key facts about numerous cities/towns/countries around the world.
Increased social engagement with other participants, the project team, students, and volunteers during use of the 2RWM.
Reminiscing and sharing experiences and information about local, national, and international destinations where they lived or visited.
The following were found to be key facilitators that enabled participation:
Support from family members and/or Power of Attorneys.
Support of activity coordinators, rehab team members, unit coordinators, and staff.
Support and assistance from the research team, volunteers, and students to help residents actively use the 2RWM.
Support from department leads, notably, the manager of therapeutic recreation and volunteer services.
Support from the senior leadership teams.
Information on barriers to use of 2RaceWithMe encountered during the product are provided in Table 1.
Barriers to the Use of 2RaceWithMe and Their Mitigation.
Conclusions
The methodology used in this study, and the results obtained, highlight how human factors engineers can participate in design-oriented research in the field of technology in aging.
Our experience also highlights the need for iterative design of technological products, post-implementation to improve the chances of sustainable use after their initial research evaluation, field testing, or market introduction.
Footnotes
Appendix
Acknowledgements
We would to thank the staff and residents at York Care Centre and at Faubourg du Mascaret for participating in the project. We would also like to think the AGE-WELL National Centre of Excellence and the University of Toronto (Connaught Foundation) for supporting the development of 2RaceWithMe.
Declaration of Conflicting Interests
The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Mark Chignell is the President of the University of Toronto spinoff company, Centivizer Inc., that makes and sells 2RaceWithMe. In view of this potential conflict of interest Mark took no part in the collection and analysis of the data reported in this paper.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by the Healthy Seniors Pilot Project, a funding agreement between the Government of New Brunswick and the Public Health Agency of Canada jointly led by the Government of New Brunswick’s Department of Social Development and the Department of Health through the Seniors and Healthy Aging Secretariat. Development of 2RaceWithMe was funded by the AGE-WELL NCE.
