Carin Cares: A Personal Application to Help Women with Urinary Incontinence
Train Their Pelvic Floor
SUBMITTED IN PARTIAL FULLFILLMENT FOR THE DEGREE OF MASTER OF SCIENCE
ISABELLA WENTINK
10268901M
ASTER
I
NFORMATION
S
TUDIES
G
AME
S
TUDIES
F
ACULTY OF
S
CIENCE
U
NIVERSITY OF
A
MSTERDAM
June 4th, 2018
1
stSupervisor
2
ndSupervisor
Dr. Frank Nack
Dr. Andre Nusselder
ISLA, UvA
ISLA, UvA
Carin Cares: A Personal App to Help Women with Urinary
Incontinence Train Their Pelvic Floor
Isabella Wentink
Gamestudies Master Thesis
Faculty of Science
University of Amsterdam
ABSTRACT
This thesis research was conducted in order to look into motivating applications that would help support women with urinary incontinence to maintain their training routines. Interviews were conducted with 10 Dutch women between the age of 45-65 with urinary incontinence to elicit their specific needs to stay motivated. This data was developed into 8 new functions for the Carin application of Lifesense-group and were tested in the form of a prototype application. The conclusion of this research showed that the target audience felt best motivated when they received constant guidance from an “expert” system that explained to them which exercises to do and how to do them accurately. They did want to be able to verify this system, and also have access to their data retrieved from a sensor that measures the leakages in their Carin underwear. The conclusion of this research showed that women would value a reliable “coach” technology application that guides them towards a full recovery, but that is constantly verifiable by data. Two new application functions were suggested to Lifesense-group to turn their Carin product into a “coach application”.
CCS Concepts
• Human-Centered applications➝Interaction design • Participatory design
Keywords
Wearable technology; application; health; urinary incontinence; Carin; exercise coach
1. INTRODUCTION
Wearable technology has become an important tool within the field of health care. It is largely used to monitor patients for the practice of physical medicine and rehabilitation (Bonato, 2005). It also turned out to be helpful in the diagnosis as well as treatment of specific diseases, such as cardiovascular diseases (Binkly, 2003). Another benefit of wearable technology is the potential it offers to track the progress of certain therapies outside the health care institutions. The largest setback however for such home practices, is the lack of motivation patients experience to do the required exercises (Kimel, 2005).
This research focuses on urinary incontinence (hereinafter referred to as “ui”) in women and the potential of wearable technology to help women who suffer from ui to exercise in order to cure their malady. Bladder control issues, such as urinary incontinence, which involves muscles contractions during laughing, coughing, playing sports, and sneezing, are pressing problems for women. In the Netherlands it is estimated that 30% of women aged averagely 56,9 suffer from involuntary urinary loss (Bemelmans et al, 2003). But eldery people, men and also young women suffer from incontinence. It was estimated that in the Netherlands alone, the costs were 256.000.000 euro in 2014
(incontinentie.net) spend on physical therapy, specialist treatments, and incontinence materials, such as pads. The problem however is that many women do not go to their doctor for diagnosis or treatment but simply stop playing sports (10% of women) and “risk” activities (20% of women) (ihealthspot.com). They simply accept their condition as a given incurable inconvenience. There are however many relatively easy ways to cure urinary conditions.
There exist many therapies to help cure most of the urinary disorders, especially stress incontinence. They include specific physical exercises to increase the stability of the muscles in the pelvic floor (Bø, 2004; Dumoulin & Hay-Smith 2010). Gynaecologist Arnold Kegel first introduced exercises to train the pelvic floor muscle (Kegel, 1948). “Kegel exercises” have become the mainstream therapy to cure stress incontinence and seek to support the uterus, bladder, small intestine and rectum. It involves instructions for contracting and relaxing the pelvic floor muscles (Bø, 1990). The pelvic floor area is a complex network of pelvic ligaments, organs, muscles and nerves to help control the bladder. A weak pelvic floor often is caused after pregnancy or during menopause when the muscles are unable to support the bladder properly. The pelvic floor area is also connected to the reproductive organs (Bø, 2004). These solutions for curing urinary incontinence offer interesting options for wearable technology, as it can track via a sensor the muscle strength in the vagina, or the leakages inside the underwear, as well as offer Kegel exercises in the form of videos via an application. Many Kegel trainers already exist, which will be discussed in the literature review section of this thesis.
For this research it was important to underscore the intimacy of the pelvic floor area, and the perhaps emotional connection women might have with their vaginas. They might not feel comfortable with technology “invading” their privacy. The area allows women to give birth and through which they receive their monthly periods, which has very complex and emotional effects. The question is how to support women to help them cure this intimate area in a respectful manner?
This paper discusses the results from structured interviews that were conducted with 10 Dutch women aged 45-65, who suffer from urinary incontinence. This human-centered approach was deemed best suitable in order to retrieve direct feedback from the users while designing the application. In the next stage it was necessary to elicit very specific feedback on what truly motivated them to exercise, for this reason a prototype app was developed to make the functions more concrete, visible and interactive and to allow the target audience to engage with the product. The research question that is addressed in this thesis is the following: how to motivate women with urinary incontinence to do their exercises using wearable technology and application functions?
The rest of this paper is structured as follows: first a literature review is provided to discuss current applications and wearable technology that seek to stimulate users to exercise. This section also includes psychological and gamification research that has been conducted on motivation and stimulation of users, as well as an overview of existing Kegel Trainer devices. Then the approach of this research is discussed, including the design of the interviews and prototype. Finally the results are shown after which a conclusion is presented with suggestions for a new application and a further work reference.
2. LITERATURE REVIEW
Wearable technology is a helpful way to cure urinary incontinence, given that so many women refuse to seek help from specialists out of shame. Wt allows them to deal with their condition in a private, personal way supported by the promise of discreteness of the technology. As was mentioned, training schedules with wt are however hard to maintain without the support of a physical therapist or doctor. Yet there are many applications that try to help their users to stay motivated.
2.1 General Health Monitoring
A research overview of existing motivating functions was conducted by Ananthanarayan & Siek (2012) to see which “tools” are helpful to stimulate people into action. Self-monitoring technologies, for instance, motivate users as it offers digital journals to help maintain a routine by providing interactive goal setting and feedback on progress. This could be an interesting form of stimulation but it does not make the exercises themselves necessarily more enjoyable. A way to make them more fun could be to create a group dynamics. Systems that support this form of interaction allow a group of friends or peers to share information (social networks), have common health goals, or compete against each other. As a result, an individual in the group reflects more on their daily activity due to the collective experience of sharing or competing with her peers.
Another option is to create an exciting experience to make the somewhat boring exercises more engaging. Turning the exercises into a game makes the experience more aesthetically and empirically interesting, but also more fun. Gamification however is more complex than simply turning things into games.
2.2 Gamification
According to Gamification 101 (Bunchball, 2010) gamification implies a variety of behaviors, actions and control mechanisms that can be used to motivate and steer people’s behavior. To gamify an activity means to create an engaging user experience by making use of compelling, motivational and stimulating game dynamics. These dynamics include: Points, Levels, Challenges, Virtual goods and spaces, Leaderboards, Rewards, Stats, Achievement and Competition. An important aspect of gamification is persuasion. According to de la Hera (2013) persuasion in games aims to convey persuasive messages to affect the responses of others. This form of signification can consist of countless visual, linguistic, haptic or audio representations that can be infused with meaning and used in communication. Meaning is derived from the relationships between the signs, the rules of the environment and the user within a social context, in
other words it is created by specific cognitive frames. Cognitive frames can be influenced by the personal circumstances and beliefs the player has when they enter a virtual domain, but can also be generated within the frame by the use of metacommunication.
2.3 Motivation
Despite the fact that persuasion and gamification can be very helpful tools in guiding users through a process, there is a chance that the gimmick elements might falter or lose their engaging qualities after a while. The best way to motivate people, research (Chatzisarantis, Biddle, & Meek, 1997; Ryan and Deci, 2000) has shown, is when there is true intrinsic motivation involved. According to Ryan and Deci (2000) there are at least three important innate psychological needs that people require for self-motivation, they are: relatedness, competence and autonomy. Motivation, they argue, relates to energy, persistence and more generally to intention and activation. When motivation is authentic, i.e. when it is self-authored or endorsed instead of being externally controlled, it enhances the performance as well as the persistence. Key elements of intrinsic motivation are the inherent tendencies to seek out novelty and challenges, to explore, learn and to extend personal capacities. Gamification therefore is an interesting component for motivating people.
In addition, the social context in which the action is performed can enhance intrinsic motivation as well when it communicates positive performance feedback. A reward system was shown to be detrimental to intrinsic motivation, as were pressured evaluations, imposed goals and deadlines. Emphasizing choice, acknowledgment of feelings, and opportunities for self-direction on the other hand stimulated autonomy and therefore personal wellbeing and intrinsic motivation. So do contexts that characterize a feeling of security and relatedness.
Another option is to “internalize” external motivations (internalized motivation) by making them self-determined. For instance, instead of making the exercises themselves more enjoyable to stimulate intrinsic motivation, it is also possible to make use of external motivation: a possibility could be to provide medical reasons to steer behavior. Research conducted by Chatzisarantis, Biddle, & Meek (1997) has shown that indeed internalized motivation can be very effective for physical exercise as it stimulates effectiveness and enhances wellbeing.
2.4 Kegel Trainers
There exist a variety of wearable technologies to help women train their pelvic floor, for instance the Kegelsmart1 (2009), the
KGoal2 (2017), the Perifit3 (2017), and Elvie4 (2014). These
wearable technologies describe themselves as a personal trainer that allows the user to see which muscles need to be trained and shows which muscles are becoming stronger. The trainers are inserted inside the vagina in order to measure the strength of the pelvic floor muscle by squeezing the specifically designed machines. They also include gamification to make the exercises more enjoyable.
1 https://www.intimina.com/en/kegelsmart 2 https://www.minnalife.com/products/kgoal 3 https://perifit.io/
Carin5 the urinary incontinence product that was used for this
research, is different from other pelvic floor products because it does not have to be worn internally. All other Kegel trainers need to be worn internally inside the vagina in order for the sensor to measure the strength of the pelvic floor muscle by clenching and unclenching the technology. Carin’s approach is different since the focus is on measuring the leakages in the underwear, not the muscles. The sensor therefore can also track when leakages are happening (for instance during active behavior). This different approach respects the intimacy of the pelvic area, which might be a comfort to some women, especially of an older generation, who are not so accustomed to technology. Carin however also allows for a variety of exercises through videos that can be watched through their app, which unlike the other Kegel trainers is not connected to the sensor. This is a real advantage in terms of training the pelvic floor, as Kegel exercises are seen to be not always effective, and can actually also do harm to women who have a tight pelvic floor (Crawford, 2012). Other exercises, such as deep squatting or yoga exercises, can also be great supportive exercises. Given that the idea of the wearable technology is to heal and strengthen the pelvic floor, it is therefore perhaps not helpful, and potentially even harmful, to focus exclusively on clenching the pelvic floor muscles via Kegels. What is also interesting is that because of this “free range potential of exercises”, Carin has the possibility to offer unique training schedules. It can offer specific individual trainings for different type of urinary incontinences and different users, instead of a general training that needs to suit all. The current application does not include this option, but it is an interesting potential.
There is however also a problem with Carin’s distanced tracking system. It cannot offer any definite assurance that the users are performing their exercises correctly. Because the other Kegel trainers are inserted into the vagina, there is no possibility for the user to do the exercises in a “wrong” way. In addition, via the application that these trainers provide, the user receives immediate feedback on how and when to clench, the system then instantly measures how strong the pelvic floor is and this can be a great stimulation and encouragement. Carin can never provide such accurate guidance, nor such immediate feedback on the progress. Executing the workout in the correct way is absolutely necessary in order to truly strengthen and heal the pelvic floor. Doing the exercises right is therefore not only an important motivator but also crucial to the success of Carin, as Lifesense-group claims they can help cure women within 2 months. It is vital for the application to provide information in other ways to ensure a form of guidance and support for their clients.
2.5 Health Applications
There already exist applications that offer a “personal trainer” type of experience that seeks to assure that users are getting their right training, such as for instance the Nike+ Kinect6 (2012) and
Freeletics7 (2014). Freeletics offers a personalised training regime
to help their users reach their goal (for instance to get stronger, or lose weight). They can create their own account on the application and can choose from a variety of different types of exercises. The videos provide information on how to execute the exercises correctly (by showing an explanatory video of a few seconds that explains the right posture). If the user finds the exercises too 5 https://carinwear.com/nl/
6 https://news.nike.com/news/introducing-nike-kinect-training 7 https://www.freeletics.com/en
intense, an easier version can be chosen in order to ensure that the user is still able to complete their training. Freeletics makes use of a lot of gamification, the exercises are timed and on the user’s personal profile page they can post their scores. There is also a “feed” section in which users can “follow” other users and keep track of and compare their training scores with each other. There is even a leaderboard that shows the person who did the workout the fastest.
The Nike+ Kinect edition for the Xbox is also an interesting solution to the problem of motivating people to do their exercises as well as ensuring they are doing the movements accurately. Nike uses the Kinect to see how the user moves their body by scanning their body and displaying it on a tv screen. Because of the kinect the program can provide real-time feedback on whether the user is doing the exercises in the right way, and identify areas for improvement and creates a personalized workout plan that is tailored to the specific requirements of each user. It can also provide very detailed information on the buildup of muscle development, weight loss and other body related issues. It is a very safe and controlled form of workout, the problem however is that the special Kinect camera and Xbox are required to carry out the training.
Nike also developed an application Nike+8 that can be viewed on a
mobile device. It consists of a network of services and information specifically designed to accommodate the needs of the Nike consumers. It consists of a sensor that can be worn inside a runner’s shoe that syncs with an e-health application through a wireless base station and that tracks the pace as well as the distance of the workout. It keeps track of all types of activities performed by the runner: walking (counting the steps), climbing stairs (number of floors), and sleeping (hours of sleep). It also provides personal training advice and uses “persuasive methods”, game mechanics such as adding challenges and leaderboards, to make the work out more appealing. In addition it connects the user to the online community on the Nike+ website and allows people to share their goals or compete in challenges with each other. This well designed gamification turned a simple tracking system used for common workouts, and turned it into a multifunctional daily experience that is also effective as advertising medium.
An application that provides personal information and is related to women’s health is Clue9. Clue was designed to help women keep
track of their menstrual cycle and everything that is connected to their period. It calculates and predicts a user's period, fertile window, and premenstrual syndrome, and is also able to inform users when they are most or least likely to become pregnant. In addition it gives users the chance to track more than 30 health categories, including sex, sleep, pain, exercise, hair, skin, digestion, emotions and energy. Clue is tailored to the unique experience of the user, as of course all women experience their own unique cycle. A tailored approach is very interesting it can provide unique training schedules for different types of urinary incontinence.
2.6 Social Websites
Another feature that could also potentially help motivating women, is the aspect of relatedness that according to the research by Ryan and Deci (2012) was deemed so important. The success 8 https://www.nike.com/nl/nl_nl/c/nike-plus
of social websites such as Facebook10 proof that sharing
information or pictures with friends or others can greatly stimulate people to use an application. Whether it supports women to do their exercises is the question. A health application needs to ensure the privacy of its users. Given the taboo of urinary incontinence it is hardly likely that users would want to share their “ui status” with friends, but nevertheless the option of sharing information should perhaps be made available, information in the form of articles or stories. Giving users the option to share information regarding urinary incontinence with other people who also suffer from ui could be beneficial and help reduce the taboo.
3. RESEARCH QUESTION + CONTEXT
Taking into account these psychological and theoretical inquiries in how to motivate people, this research focused on how women with urinary incontinence can be supported to do their exercises. The specific question that needed to be answered was how to motivate women with urinary incontinence to do their exercises using wearable technology and application functions? The research was conducted in collaboration with the company called LifeSense-Group11 that developed the product Carin. Carinconsists of a sensor that can be installed externally in specifically designed underwear and that helps women keep track of any possible leakages by use of an application for a mobile phone. In addition, the application contains training videos with exercises explained by an instructor. The current Carin application does not contain any form of gamification. Only once a week the underwear and sensor have to be worn: a “measuring day” during which the system application on the mobile phone keeps track of the leakages. Every day the user needs to do the exercises. The system works as follows: the app contains 7 weeks of training schedules, each week contains approximately 4 videos. Each video contains a short explanation and example on how to do the movements. The user can choose which video they would like to do, then watch the intro and do the exercise for 10 minutes.
4.0 APPROACH
4.1 Requirement Analysis
In order to answer the research question on how to use application functions and a sensor to motivate women with urinary incontinence to do their exercises, it was necessary to receive input from the women themselves on what motivates them. Structured interviews with closed-ended answers were used to elicit specific information from the target audience. The answers were used to determine what features the Carin application should include in order to motivate women with urinary incontinence to exercise.
4.2 Requirements
4.2.1 Participants
10 Dutch women, aged between 45-65 years old who suffer from urinary incontinence were recruited. Verification for pool: urinary incontinence is most common in women who are pregnant, or who are going through menopause (healthline.com). Most wearable technologies for urinary incontinence, such as the Elvie,
10 https://www.facebook.com/
11 http://lifesense-group.com/
focus specifically on women during and after their pregnancy. However, due to the invasive method that such Kegel trainers offer, it is possible that elderly women do not feel comfortable with their solution. The option of Carin would potentially be interesting to this group of women, as the technology can simply be worn inside the underwear. In addition, it is more likely that women in this age group suffer from ui, and they are also more likely to have the time (after retirement, having no small children etc.) to do the exercises and perhaps even have a bigger incentive to improve their condition as it can worsen with age. In order to research this potential market for Lifesense-group, as well as help create a non-invasive solution for elderly women who suffer from urinary incontinence, the target audience was based on women around the ages of 45-65.
4.2.2 Setting
The interviews were conducted with all participants in their own homes. This was very important in order to make them feel comfortable to talk about their illness but also to try and envision the product of Carin (which includes the underwear, sensor and app) within their own home. If the interviews had taken place in a public space, such as a cafe or the office of Lifesense-group (where other employees would be present), they probably would not have felt comfortable talking about their condition, especially given the taboo of urinary incontinence. It was necessary to make the participants feel at ease in order to answer the questions truthfully. Conducting the interviews at their own house also helped them to envision whether they would feel comfortable doing the exercises at their home. Furthermore, it was also necessary to do the interviews away from Lifesense-group in order to make it safe for the participants to express any potential critical remarks about the product Carin.
4.2.3 Design of interviews
On the basis of the literature research questions were developed that sought to determine the specific needs of the target audience. The questions focused on 5 domains: autonomy (the option to choose the exercise videos), relatedness/security (option to share with others, or read about other’s experiences as well a feeling of security, i.e. medical support), competence (option to receive tailored feedback and progress information), gamification (possibility to turn the exercises into a game experience) and internalized motivation (offering medical reasons). The complete questionnaire is presented in the Appendix,1).
4.2.4 Procedure
The participants were asked to answer each question with either: 1) “yes - I would be motivated to exercise because of this feature” 2) “no- this feature would not motivate me to exercise”.
4.2.5 Findings
Table 1. Test 1: Interviews on Motivating Features
4.2.6 Discussion
Analyzing the data it became clear that all expressed the desire to do the Carin exercises daily from the comforts of their home. Half of the women wanted to do these exercises by use of a fixed schema, designed by a trustworthy “expert” that they could simply follow each day. Whereas the other half expressed the need to have multiple options and a desire to decide for themselves when and which type of exercises they would like to do. They preferred an overview of videos that they themselves could assembly and play whenever they liked. All women wanted the exercises to be shown in a “regular” fitness video style that would allow them to simply copy the movements of the trainer, instead of a gamified experience. This also makes sense, given that curing urinary incontinence depends entirely on doing the exercises correctly, it is therefore necessary to receive information on how to execute them properly. Creating a game experience would make the exercises potentially more enjoyable, but it would not be able to verify whether the user is executing the training correctly. There is no way for the technology to measure the pelvic floor muscle, and so the women preferred to see and hear a coach, and to simply copy the movements as they are watching the videos. They wanted to be guided by an instructor for the full 10 minute workout, in order to be absolutely sure that they are following the instructions accurately. (The current version of Carin only provides a short introduction). 80% stated that they needed direct feedback after doing their exercises to stay motivated. More than half of the women said they would want to share their Carin experiences with their friends. Whereas almost all women (90%) expressed the desire to have a statistical sensor overview that would measure their improvement, as they mentioned this to be an important form of reward and stimulation. In order to try and find additional stimulants to help motivate women, I wanted to include additional information about the issue relating to urinary incontinence, and thereby stimulate internalized motivation. 90% expressed the desire to receive professional medical information about the pelvic floor area, stress
incontinence and an explanation on why it is important to do the trainings. 70% of the women expressed they would like to have the option to write their personal experiences or read about other women who are dealing with similar issues. The latter on the condition that it really fitted their own situation/age group. They would not like to read about women who are pregnant for instance, because they have very different hormonal issues and motivations. They would like to receive information that is very carefully tailored to their own situation: menopause, hormonal balances, urine incontinence, and medical information about why it is necessary to do the exercises). Another 70% of the women said that in addition they would also want to receive alternative information such as Ayurvedic diet information that is said to also help cure urinary incontinence. 80% of the target audience wanted to receive customized, personal and friendly daily reminders to do their exercises, as a sort of personal trainer to help them stay motivated.
From the first test it became clear that women around the ages of 45-65 wanted to feel personally engaged and to have a positive, stimulating support application with verifiable data that would help them do the exercises but which was tailored to their personal needs.
4.3 Stakeholder
The findings of the first tests were shown to the stakeholder and during a team meeting with the marketing director, business developer and app developer, the possible options for concepts were discussed to redesign the application. The stakeholder made it clear that all the current functions of the app should stay as they are, but that it would be interesting and technically possible to create personalized feedback systems, as well as a “news option” to read about personal and medical stories. From this brainstorm session it became clear that Carin had the potential to perform diagnoses of the specific urinary incontinence condition of the user, this offered interesting potential for turning Carin into a real health application. In addition, Carin could potentially provide medical analyses of the data in order to offer the data in an understandable way to the user. The current application merely displays the data on the leakages, without any meta-communication to translate this data in an understandable way. It also only offers feedback after the user has used the product for 2 weeks. The women who were interviewed by Lifesense-group previously had stated that they needed direct feedback and motivation to maintain the exercises or otherwise they would not continue the training regime. The stakeholder said that further “personalization” would be technically possible and that a Lotus flower should be implemented in an interactive design as a new logo for Carin.
4.4 Requirements 2.0
4.4.1 Design of Interview
The domains that had received the most “yes” (50% or above) from test 1 were turned into application functions that sought to include the necessary motivating qualities that had been discussed and rated by the women. This resulted in the development of eight different “motivating functions” that were turned into an application prototype in order to be tested. It was necessary to turn the information into working prototype functions in order to be able to test the functions more specifically. The first interviews
Exercise
Flex
Trainer
Game
Feedback
Share
0
5
10
15
0
5
5
10
2
4
No
Yes
Sensor
Medical
Story
Diets
Daily Not
0
5
10
15
1
1
3
3
2
No
Yes
had focused on what “generally” motivated the participants; turning this general information into specific motivating functions, allowed the target audience to be more specific in what they required from Carin. They now tested with a visible, active application that the participants could use and feel for themselves. New interviews were conducted in order to elicit very specifically what the target audience, as a representation of senior women with urinary incontinence, need from an application in order to be motivated to exercise.
4.4.2 Concept Design Prototype
Figure 1. App Map.
1) Exercise Progress System: Flower + Light: 80% of the target audience stated that they would need to receive stimulating feedback messages after their exercise in order to be motivated to do their exercises. The EPS was designed to stimulate the user by giving feedback on their exercise through the symbolism of a flower as a representation of their improvement. It functions as an interactive external representation of the pelvic floor, using the “flower” symbol that Lifesense-group asked to use. The flower is connected to whether the user executes their exercises correctly, and blossoms accordingly. The function was however not designed as gamification; it is not meant to “punish” women when they do not perform their exercise, but merely as a reflection of the state of their pelvic floor, and as a daily positive feedback image. The flower is the principal part of the application: whenever the user opens the app the state of their flower is immediately shown. The app becomes a personal, intuitive, interactive visual representation of the user’s pelvic floor that seeks to connect women in a positive way to their vagina. Function Flower: the Lotus flower blossoms/closes according to the daily exercises that are done by the user. After a user finishes an exercise video they are asked to answer whether they had any trouble with the exercises or whether they were able to finish the entire training. If they press the button that they finished the training, they will receive a message that says that their flower is growing and they can go to the progress screen to see the state of their flower. The flower has 3 states, visualized in Figure 2.
Figure 2a: The 3 states of the flower.
After two days of exercises the second stage of the flower is reached, after 4 days the flower has reached stage 3 and is fully blossomed. After that, the flower needs to be maintained, otherwise it will start to close again (it will go back to stage 2), after 4 days of not training the flower will be stage 1 again, the user will receive a message that notifies the user that their flower is closed. This is not meant as a punishment, but as a reflection of their pelvic floor condition. A “fact”, not a game.
Light: To create even more visual stimulation, the state of the flower is also connected to the shade of the interface of the app. When the flower starts to blossom, the app too, in its entirety, will start to illuminate. When a user fails to exercise, their flower starts to close, and the interface of Carin will start to darken as well. (See Figure 2a).
After the exercise, the user has the option to give feedback on how the exercise went (figure 2b) if the exercise went well, the user receives a positive message that explains that the flowers is blossoming one step further (figure 2c). If the exercises went “bad”, the user receives an overview with possible reasons connected to the medical support system, part of the MFS (#3), see figure 6c and 6d.
Figure 3a and 3b.
2) Sensor Progress System: 90% stated that receiving statistical data was deemed an important element that induces motivation as it provides reliable feedback on the progress of the ui. To make this function more visual, the opening screen, apart from the flower, also includes a progress bar that connects to the sensor (see Figure 2a. The bar that surrounds the flower). In addition, because notifications were deemed important to stay motivated, the progress bar is connected to a message system: after every 25% of improvement, the user will receive a positive message to congratulate them on their progress to recovery. Because each user will have their own pace of recovery this system allows for a unique experience of every user, based on their unique data from the sensor. The message includes information about their current status with regards to ui as well as plays a little music to draw attention to having reached part of the progress. Half way through the progress the user receives a gift from Carin to reward their progress as well as to help them stimulate to continue to reach the
full 100% but also to maintain a connection between the company Lifesense-group and their users. The gift is an umbrella, because they are on their way to stay dry. In addition the color of the progress bar changes according to the percentage of their recovery, from dark (0%) to light (100%).
The SPS also provides statistical information on the data from the sensor (see Figure 3a). Furthermore, a medical report offering an explanatory interpretation of the data from the sensor is made after every measurement day, i.e. every week (see Figure 3b). This information is further explained in the Personal Health Report (see Figure 4c). The first two times the user uses the sensor, the SPS makes a diagnosis of their unique condition.
Figure 4a, 4b, 4c.
3) Medical Feedback System: Carin needs to ensure that the exercises are done in a safe way to help women maintain their training, and to ensure that they are executing the training movements correctly in order to cure. Receiving medical information on urinary incontinence and its necessary exercises, such as Kegel’s, was tested with 90% affirmation. This function was therefore designed to provide the user with all kinds of medical support to ensure a smooth recovery:
i) Access to the Personal Health Report. This is the explanatory interpretation of the data retrieved by the sensor and reflects the progress of the personal urinary incontinence condition of the user (Figure 4c.).
ii) General Information on urinary incontinence. A selection of professional medical texts should be provided by Carin with verifiable sources, see Figure 5a.
iii) Medical Exercise Information regarding the correct usage of the exercises in order for the women to understand why (Kegel) exercises are necessary and how to do them properly (See Figure
5b). This function corresponds to the fact that 50% of the women
wanted to receive structured trainings by a medical expert. Before the exercise video, the user receives a message that provides medical information on how to perform the correct movements. After every exercise video the user has the chance to resort to a medical system if they had trouble with the exercises. This system should be able to answer their questions, and recommend them to consult a doctor when in need. (See Figure 5d).
iv) Immediate Feedback. After the exercises there is immediate feedback by asking how the exercises went, and if they went “ok”, a positive message is send that is connected to the EPS, i.e. the flower and the illumination of the interface. If they were unable to complete the training, they can explain “why” (Figure 5c). This part will have no effect on the closing of the flower, as it is not the user’s choice to end their training.
Figure 5a, 5b, 5c, 5d.
4) Daily Notifications: To ensure a committed attitude towards the exercises that are necessary to cure urinary incontinence, 80% stated that they would like to receive daily messages to remind them to exercise. A sort of alarm function. Given that not all women liked the idea of daily messages, it is necessary to include the option to switch this function off. (See Figure 6a). Every day the user will receive a personal message from the Carin Coach that reminds them to do their work out. They can either press “yes” - which will immediately bring them to the exercise screen; or “no”, in which case the message disappears and their flower immediately starts to close one step; or “not yet”, which is a snooze function that asks the user to reschedule the notification. (See Figure 6b).
Figure 6a and 6b.
5) Personal Doctor/Trainer: 50% of the women wanted a personal trainer with medical knowledge that tells them which exercises to do. According to Lifesense-group it is possible to provide tailored training schedules on the basis of a diagnosis of the unique ui type of the user. As was mentioned in #2, the SPS should not only be able to show the sensor data, but also be able to interpret the data and provide an understandable interpretation in the form of a diagnosis. On the basis of this diagnosis, this PDT function should advise specific exercises that support the unique urinary incontinence condition of the user, as was mentioned in the literary study: Kegel exercises are not always suitable. Every day the personal doctor/coach suggests specific exercises based on the weekly health report, Figure 7b. The user simply has to follow the instructions in the video and has the option to look into their personal health report (Figure 4c) to read the medical verification for their training. After the exercise the user has the option to give feedback, which is connected to the EPS, and MEI support if the user had any trouble. (NB It is important to emphasize that the PDT was not designed as substitute for a real doctor's diagnosis, but as a complementary function that allows the user more insight into their personal condition).
6) Flexible Trainer: To ensure that the user is stimulated to do her exercises, 50% of the women stated that they wanted to have the option to choose the exercises themselves (flexible training overview figure 7a). The user can choose which exercise video
they would like to do. This function is not connected to the SPS and PDT, but is simply an extra “fast” option to always have the possibility of doing (extra) exercises, to have an overview of all the possible exercises, or to train a specific area in the body that the user wants to pay extra attention to. The “Flexible Trainer” is also accompanied by a medical preview message that explains how to do every exercise video in the correct way (Figure 7b), but is not connected to the PDT as these videos are not suggested on the basis of the health condition of the user, but on their personal motivation. And, just like after the exercise videos of the PDT, the user has the option to give feedback on how the exercise went, which is connected to the EPS, and to receive medical support if necessary.
Figure 7a and 7b.
7) Exercise Journal: Given that 100% of the target audience wanted daily exercises and 90% liked the idea of an overview report of the sensor, I developed the idea of an Exercise Journal to combine the two. This function also seeks to include the personal element of making a personal story, which was received with 70% affirmation, by allowing the user to write personal comments after every exercise to keep track of a journal. This part could be shared with others in the Carin Community, #8.
The journal keeps track of all the personal information (figure
8a):
1. Overview of the exercises that have been done and whether they were done successfully (based on the feedback).
2. Summary of their sensor progress of all the weeks that have been measured.
3. Summary of all the personal health reports,
4. Personal comments. After every exercise the user can write comments about how the exercises went (figure
8b).
Figure 8a and 8b.
8) “Carin Community” (News Feed with Sharing Options): This feature was developed to stimulate a more personal engagement between the women and their pelvic floor. Instead of the sterile sensor and medical input, this function seeks to show alternative methods to help women heal their pelvic floor. 70% of the women stated they would be interested in receiving dieting information, as well as read personal experiences of other women that might supportive. The option to share information, which was tested with 60%, is included in this section. The user has the option to write down their own story (potentially based on their EJ) and send it to Carin. The company Lifesense-group makes a selection of all the information (diets, the personal stories and alternative methods for healing the pelvic floor) and stores them in a database. According to the unique ui type of the user they receive (from this database) articles, stories and advice in the “carin community” function. The interviews made clear that the women only wanted to receive tailored information suited to their own personal ui condition. In order to secure the privacy of the user, this is the only part of the app that includes a “sharing option”. The articles can be freely shared, also with women who do not own Carin in order to help tackle the taboo of urinary incontinence. This sharing element can also create “mouth to mouth” advertising for Carin.
Figure 9. Carin Community function.
4.5 Evaluation of Prototype
The first interviews had focused on what “generally” motivated the participants. This general information was turned into the 8 motivating functions that could be tested with the participants. They now could interact with a visible, active application instead of hypothetical features. The second round of interviews was conducted in order to elicit very specifically what the target audience thought of the functions that were developed on the basis of their previous input, whether the functions indeed were successful in motivating them to exercise.
The prototype was shown to the same 10 participants, followed by another structured interview with close ended answers (see Appendix 2). The participants were asked to rate each function separately by a number ranging from:
- “0 - this function would not motivate me at all to exercise”, to - “10 - this function would perfectly motivate me to exercise”. The averages of all the separate functions were analyzed and compared. On the basis of the highest rating a conclusion was formed on the research question: how to motivate women with urinary incontinence to do their daily exercises using wearable
technology and an application? The results were suggested to Lifesense-group to innovate their Carin application.
4.5.2 Findings
Table 2. Test 2: Ratings of Motivating Features
Exercise Progress System 6,7
Sensor Progress System 8,5
Medical Feedback System 8,3
Daily Notifications 7,8
Personal Doctor Trainer 8,5
Flexible Trainer 6,7
Exercise Journal 7,2
Carin Community 7,3
(Overview of the averages of the individual functions).
4.4.5 Discussion
As the findings section makes clear, the women regarded the sensor progress system and the personal doctor/trainer most and equally important, 8,5. This shows that what motivates women most is a target focused approach towards recovery, in which they want to be supported by an “expert” (a medical expert and trainer specialist, the PDT), as well as reliable data obtained by the sensor to ensure that they really are making progress. It is however important to note that the women all expressed the need for the absolute assurance that their privacy was protected and that the medical information consisted of sources that they could verify. They were skeptical about the potential of an application to imitate a doctor’s analysis but nevertheless stated that they were very intrigued by the idea. They all stated that if the doctor function really worked, they would value it greatly. None of the women would see the app as a substitute for a doctor however, but as a supportive help system.
Interestingly, in the first test 50% of the women wanted to have the option to choose the training videos themselves, the “flexible trainer” function. But in the second test this option received about the lowest score, a 6.7. The personal trainer was now voted most important, no longer equally valued to the “flexible trainer”. The women stated that they would feel more assured that the PDT function would guide and help them recover. It shows that they preferred to rely on specialist guidance, and not on their personal feelings. The system of PDT allows no personal choice, but delineates training schedules by a system (that would have to be implemented) and which would function on the basis of an algorithm, based on the personal health report. The test showed that this technological control system was preferred.
Preliminary conclusion: from the second test it became very clear that what stimulates women to train most, is a supportive technological system that tells them exactly what, and which can be verified by a reliable tracking system.
5.0 DISCUSSION
Due to the time limitation of the internship, (which was three months in which the entire research needed to be conducted) there was no time to test the prototype app with the target audience for the full duration of the process that is necessary to cure, i.e. 2 months. Ideally the prototype would have been tested with all 10 women for 2 months to see whether the functions really help them to stay motivated, unfortunately due to time restraints this was not possible. The testing of the prototype was therefore restricted to interviews of approximately an hour in which the user could interact with the prototype app as well as give feedback. This does not give a good indication on whether the motivators are successful in the long term. Yet despite the fact that the prototype was not tested for the recovery period, the research does provide an important insight on features that women expect from Kegel Trainers. This research therefore provides important information on how to help senior women with urinary incontinence get started to help them cure their condition. The results from the test give an indication on factors that are important to this target audience and therefore need to be included when designing a health exercise application for them.
Another discussion point refers to the target audience that was selected for this research. It would also have been interesting to focus on women who had already used Carin and therefore could very specifically answer what features they disliked or liked to have in the new version in order to stay motivated. This type of research was however not possible because only one of the women who had tested Carin was willing to cooperate with further research, after extensive attempts to contact them all. This research therefore focused on a “fresh” pool of women with urinary incontinence who had no experience with Carin. The interview questions therefore focused more generally on exercise motivations, instead of very specific questions about the current Carin application and any possible changes. In hindsight it is perhaps better that this research has focused more generally on what motivates women with urinary incontinence, thereby making the research valuable, not only to Lifesense-group.
It is however important to reflect on the small number of the test population. Again due to time limitations there was no possibility to extend this number beyond 10 women. Ideally a large pool of 50 women to test the product with would be necessary to give a more reliable indication of what generally motivates women with urinary incontinence best. Also the fact that the target audience consisted only of Dutch women implies that the results do not have to relate to women with urinary incontinence in other parts of the world. This is important to remark, as Lifesense-group is also looking for markets in Australia, the United States, Japan and other European countries. Women in these countries might need very different types of motivation and support.
As a last remark, if there had been more time it would have been preferred to work together with an artist to help design the prototype functions. I had to create the prototype myself, and it therefore lacks a professional quality. With a more carefully designed prototype, the functions would potentially have resulted in very slightly different answers, as well as would have given Lifesense-group an indication of what type of design would appeal to the target audience. Nevertheless the prototype was able to convey its functions and this was most important for my research. Further research would have to be conducted to see which design suits the target audience best.
6.0 CONCLUSION
The conclusion of my research is that Dutch senior women with urinary incontinence do not lack internal motivation, but that they need a support system that provides them with information that they themselves do not have. The app needs to be supportive to their goal: a full recovery from their urinary incontinence condition. They are very target oriented and need constant reassurance on receiving expert information on why and how they need to exercise, as well as a sensor that tracks their leakages to see if are making progress.
What was surprising was the fact that the wearable technology turned out to be an important motivator for the target audience. It had not been expected that this reliance on a measuring tool would be so successful, when leakages and progress of the pelvic floor can of course also easily be felt by women themselves. The fact that they preferred to rely on technology to monitor this intimate area was somewhat surprising to me. Given the intimate area, it would be expected that women would simply want to have an exciting gamified experience to help them through the somewhat boring exercises, or that they might prefer to have a more personal and social experience. But what the tests showed, both of them very clearly, was that the target audience was very driven to do the exercises “right” and external assurance that their pelvic floor is healing. They want the constant instructions and guidance of an “expert”, yet are skeptical and want to have the option to check the expert, using the sensor data to see whether the coach really works. A somewhat surprising result, as it was expected that the women would have a very intimate connection with their vagina and that they would not like the idea of being depended on an external source, especially not on an app and a sensor. But despite the fact that they had some concerns about the safety of the technology for their health, all were very willing to rely exclusively on the technology to help them cure, more than on social, personal or gamified functions.
Given these results, it is recommended to innovate the current Carin application into this “expert” support system. At the moment the app mostly functions as a display of the data from the sensor, there is no meta-communication that explains the data to the user, nor is there any supportive medical information regarding the user’s personal condition or to support them during the exercises. On the basis of this research, it would be advised to remodel Carin into a “personal coach”, not as a substitute for a real medical expert, but as a support system to guide women with urinary incontinence in a private but reliable way. The PDT, as well as the SPS I designed for the prototype could be used by Lifesense-group as a way to implement this specific meta-communication and to ensure that their clients receive the valuable feedback they require. Further research however is of course necessary to see if this approach suits their customers on the long run. The company did however receive from my research an almost guarantee, that if their application would consists of this innovative, tailored technology all the women stated that they would buy Carin. Without these functions none of them wanted to buy their product.
The results and recommendations for Carin were presented to Lifesense-group who were very pleased with the result. The research had supported their method of an external solution by use of their unique sensor, and had also verified their indication for developing Carin further by using the sensor data for other
purposes, such as performing diagnoses. They were very happy with the prototype functions that had been developed, and offered me the chance to work on them further to help develop a new version of Carin.
7.0 ACKNOWLEDGMENTS
My thanks go out to Lifesense-group for their warm welcome into their company and for allowing me the opportunity to perform my research within a wide range of options. The freedom made it not only a pleasure to work on this project, but also allowed me to try out exciting new possibilities for application features. Special thanks also to my thesis supervisor Frank Nack, who despite my late application still saw himself fit to greatly help me with the design of my research. And also special thanks to my second reader, Andre Nusselder, who had helped me on thesis number one, before it was thrown overboard, but was still willing to help me navigate towards thesis 2 successfully. Lots of thanks to both their help!
8.0 REFERENCES
[1] Ananthanarayan, S., & Siek, K. A. (2012). Persuasive wearable technology design for health and wellness. In Pervasive Computing Technologies for Healthcare (PervasiveHealth), 2012 6th International Conference on (pp. 236-240). IEEE.
[2] Bemelmans, B. L. H., Vandoninck, V., Donkers, L. H. C., Robertson, C., Boyle, P., & Kiemeney, L. A. L. M. (2003). Prevalentie van ongewild urineverlies bij vrouwen is afhankelijk van de gebruikte definitie. Huisarts en wetenschap, 46(3), 817-820.
[3] Binkley, P. F. (2003). Predicting the potential of wearable technology. IEEE engineering in medicine and biology magazine, 22(3), 23-27.
[4] Bø, K. Hagen, R. H., Kvarstein, B., Jørgensen, J., Larsen, S., & Burgio, K. L. (1990). Pelvic floor muscle exercise for the treatment of female stress urinary incontinence: III. Effects of two different degrees of pelvic floor muscle exercises. Neurourology and Urodynamics, 9(5), 489-502.
[5] ---. (2004). Pelvic floor muscle training is effective in treatment of female stress urinary incontinence, but how does it work?. International Urogynecology Journal, 15(2), 76-84.
[6] Bonato, P. (2005). Advances in wearable technology and applications in physical medicine and rehabilitation. Journal of neuroengineering and rehabilitation, 2(1), 2.
[7] Bunchball, I. (2010). Gamification 101: An introduction to the use of game dynamics to influence behavior. White paper, 9.
[8] Crawford, Nicole. (2012). Stop doing Kegels: Real Pelvic Floor Advice for Women. Retrieved May 29, 2018, from
http://breakingmuscle.com/fitness/stop-doing-kegels
[9] De la Hera, T. (2013). A Conceptual Model for the Study of Persuasive Games. Paper presented at the International DiGRA Conference in Atlanta.
[10] Dumoulin, C., & Hay-Smith, J. (2010). Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev, 1(1).
[11] IHealthSpot | Medical Website Design and Digital
Marketing Agency. (n.d.). Stress Incontinence | Websites for Doctors | iHealthSpot. Retrieved May 29, 2018, from https://www.ihealthspot.com/.
[12] Incontinentie.net. (n.d.). Retrieved May, 29, 2018, from https://www.incontinentie.net/php/urlc.php
[13] Kegel, A. H. (1948). Progressive resistance exercise in the functional restoration of the perineal muscles. American Journal of Obstetrics & Gynecology, 56(2), 238-248. [14] Kimel, J. C. (2005). Thera-network: A wearable computing network to motivate exercise in patients undergoing physical therapy. In Distributed Computing Systems Workshops, 2005. 25th IEEE International Conference on (pp. 491-495). IEEE.
[15] Rathore, M., Agrawal, S., Nayak, P. K., Sinha, M., Sharma, D. K., & Mitra, S. (2014). Exploring the significance of" Mudra and Bandha" in pelvic floor dysfunction. Yoga Mimamsa, 46(3), 59.
9.0 Appendix
1) Test 1
Question 1: Would receiving (new) exercise videos every day, which you can do at home instead of a gym or at a physical therapist, stimulate you to start exercising? (autonomy) Question 2: Would the options to choose the exercise video
yourself stimulate you to exercise? (autonomy) Question 3: Would the option to have a “specialist” trainer
select/recommend the right exercise video for you stimulate you to exercise? (relatedness/security)
Question 4: Would a gamified experience stimulate you to exercise instead of “normal” fitness style? Figure 11? Question 5: Would receiving tailored feedback on your exercises
in the form of personal messages stimulate you to exercise? (Competence)
Question 6: Would the option to share your exercises or story with others stimulate you into exercising? (Relatedness)
Question 7: Would receiving data from a sensor that tracks the leakages, your personal recovery, in the Carin underwear stimulate you to exercise? (Internalized motivation). Question 8: Would receiving tailored medical feedback on the
exercises and why you need to do them stimulate you to exercise? (Internalized motivation)
Question 9: Would reading about personal stories of other women who suffer from urinary incontinence stimulate you to exercise? (Relatedness)
Question 10: Would reading about additional methods, such as diets or yoga poses, to heal your pelvic floor in addition to the Kegel and other exercises stimulate you to exercise? (Internalized motivation)
Question 11: Would daily notifications to do your exercises stimulate you to exercise? (Internalized motivation)
2) Test 2
Question 1: Please rate the Exercise Program System from 1-10: Question 2: Please rate the Sensor Progress System from 1-10: Question 3: Please rate the Medical Feedback System from 1-10: Question 4: Please rate the Daily Notifications from 1-10: Question 5: Please rate the Personal Doctor Trainer from 1-10: Question 6: Please rate the Flexible Trainer from 1-10: Question 7: Please rate the Exercise Journal from 1-10: Question 8: Please rate the Carin Community from 1-10:
Figure 11.
