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1.  Experiences of Multidisciplinary Development Team Members During User-Centered Design of Telecare Products and Services: A Qualitative Study 
User-centered design (UCD) methodologies can help take the needs and requirements of potential end-users into account during the development of innovative telecare products and services. Understanding how members of multidisciplinary development teams experience the UCD process might help to gain insight into factors that members with different backgrounds consider critical during the development of telecare products and services.
The primary objective of this study was to explore how members of multidisciplinary development teams experienced the UCD process of telecare products and services. The secondary objective was to identify differences and similarities in the barriers and facilitators they experienced.
Twenty-five members of multidisciplinary development teams of four Research and Development (R&D) projects participated in this study. The R&D projects aimed to develop telecare products and services that can support self-management in elderly people or patients with chronic conditions. Seven participants were representatives of end-users (elderly persons or patients with chronic conditions), three were professional end-users (geriatrician and nurses), five were engineers, four were managers (of R&D companies or engineering teams), and six were researchers. All participants were interviewed by a researcher who was not part of their own development team. The following topics were discussed during the interviews: (1) aim of the project, (2) role of the participant, (3) experiences during the development process, (4) points of improvement, and (5) what the project meant to the participant.
Experiences of participants related to the following themes: (1) creating a development team, (2) expectations regarding responsibilities and roles, (3) translating user requirements into technical requirements, (4) technical challenges, (5) evaluation of developed products and services, and (6) valorization. Multidisciplinary team members from different backgrounds often reported similar experienced barriers (eg, different members of the development team speak a “different language”) and facilitators (eg, team members should voice expectations at the start of the project to prevent miscommunication at a later stage). However, some experienced barriers and facilitators were reported only by certain groups of participants. For example, only managers reported the experience that having different ideas about what a good business case is within one development team was a barrier, whereas only end-users emphasized the facilitating role of project management in end-user participation and the importance of continuous feedback from researchers on input of end-users.
Many similarities seem to exist between the experienced barriers and facilitators of members of multidisciplinary development teams during UCD of telecare products and services. However, differences in experiences between team members from various backgrounds exist as well. Insights into these similarities and differences can improve understanding between team members from different backgrounds, which can optimize collaboration during the development of telecare products and services.
PMCID: PMC4051739  PMID: 24840245
user-centered design; telecare; eHealth; participation; multidisciplinary team; barriers and facilitators
2.  Usability testing of a monitoring and feedback tool to stimulate physical activity 
A monitoring and feedback tool to stimulate physical activity, consisting of an activity sensor, smartphone application (app), and website for patients and their practice nurses, has been developed: the ‘It’s LiFe!’ tool. In this study the usability of the tool was evaluated by technology experts and end users (people with chronic obstructive pulmonary disease or type 2 diabetes, with ages from 40–70 years), to improve the user interfaces and content of the tool.
Patients and methods
The study had four phases: 1) a heuristic evaluation with six technology experts; 2) a usability test in a laboratory by five patients; 3) a pilot in real life wherein 20 patients used the tool for 3 months; and 4) a final lab test by five patients. In both lab tests (phases 2 and 4) qualitative data were collected through a thinking-aloud procedure and video recordings, and quantitative data through questions about task complexity, text comprehensiveness, and readability. In addition, the post-study system usability questionnaire (PSSUQ) was completed for the app and the website. In the pilot test (phase 3), all patients were interviewed three times and the Software Usability Measurement Inventory (SUMI) was completed.
After each phase, improvements were made, mainly to the layout and text. The main improvement was a refresh button for active data synchronization between activity sensor, app, and server, implemented after connectivity problems in the pilot test. The mean score on the PSSUQ for the website improved from 5.6 (standard deviation [SD] 1.3) to 6.5 (SD 0.5), and for the app from 5.4 (SD 1.5) to 6.2 (SD 1.1). Satisfaction in the pilot was not very high according to the SUMI.
The use of laboratory versus real-life tests and expert-based versus user-based tests revealed a wide range of usability issues. The usability of the It’s LiFe! tool improved considerably during the study.
PMCID: PMC3962312  PMID: 24669188
accelerometry; chronic obstructive pulmonary disease; diabetes mellitus type 2; heuristic evaluation; telemonitoring; thinking aloud
3.  User-centered development and testing of a monitoring system that provides feedback regarding physical functioning to elderly people 
To involve elderly people during the development of a mobile interface of a monitoring system that provides feedback to them regarding changes in physical functioning and to test the system in a pilot study.
Methods and participants
The iterative user-centered development process consisted of the following phases: (1) selection of user representatives; (2) analysis of users and their context; (3) identification of user requirements; (4) development of the interface; and (5) evaluation of the interface in the lab. Subsequently, the monitoring and feedback system was tested in a pilot study by five patients who were recruited via a geriatric outpatient clinic. Participants used a bathroom scale to monitor weight and balance, and a mobile phone to monitor physical activity on a daily basis for six weeks. Personalized feedback was provided via the interface of the mobile phone. Usability was evaluated on a scale from 1 to 7 using a modified version of the Post-Study System Usability Questionnaire (PSSUQ); higher scores indicated better usability. Interviews were conducted to gain insight into the experiences of the participants with the system.
The developed interface uses colors, emoticons, and written and/or spoken text messages to provide daily feedback regarding (changes in) weight, balance, and physical activity. The participants rated the usability of the monitoring and feedback system with a mean score of 5.2 (standard deviation 0.90) on the modified PSSUQ. The interviews revealed that most participants liked using the system and appreciated that it signaled changes in their physical functioning. However, usability was negatively influenced by a few technical errors.
Involvement of elderly users during the development process resulted in an interface with good usability. However, the technical functioning of the monitoring system needs to be optimized before it can be used to support elderly people in their self-management.
PMCID: PMC3770345  PMID: 24039407
user-centered design; telemonitoring; physical functioning; community-dwelling elderly people; usability
4.  The added value of user involvement during the development of a feedback system regarding physical functioning for community-dwelling elderly people 
The number of frail elderly people is increasing. Unfortunately, the number of caregivers is not increasing at the same pace, which affects older people, caregivers and healthcare systems. Because of these developments, self-management is becoming more important in healthcare. To support community-dwelling elderly people in their self-management, a system was developed that monitors their physical functioning. This system provides feedback to elderly people and their caregivers regarding physical indicators of frailty. The feedback is provided to elderly people via the screen of a mobile phone. It is important that elderly people understand the content of the feedback and are able to use the mobile phone properly. If not, it is unlikely that the system can support self-management. Many interactive health technologies that have been developed do not fulfil their promises. An important reason for this is that human and other non-technology issues are not sufficiently taken into consideration during the development process.
To collaborate with elderly people during the development and evaluation of a feedback system for community-dwelling elderly people regarding physical functioning.
An iterative user-centered design that consists of five phases was used to develop and evaluate the feedback system. These five phases were: 1) Selection of users, 2) Analysis of users and their context, 3) Identification of user needs, 4) Development of a prototype, and 5) Evaluation of the prototype. Three representatives of a target group panel for elderly people were selected in phase 1. They shared their needs and preferences during three expert group meetings that took place during the development process. This resulted in the development of a prototype which was first evaluated in a heuristic evaluation. Once adjustments were made, 11 elderly people evaluated the adjusted prototype using a think aloud procedure. They rated the usability and acceptability of the developed interface on a scale from 1 till 7 using an adapted version of the Post-Study System Usability Questionnaire (PSSUQ).
A feedback system was developed that provides feedback regarding physical indicators of frailty via a touch screen mobile phone. The interface uses colours, smiley’s, and spoken/written messages to provide feedback that is easy to understand. The heuristic evaluation revealed that there were some problems with consistency and the use of user language. The think aloud evaluation showed that the 11 elderly people were able to navigate through the interface without much difficulty despite some small problems related to the lay-out of the interface. The mean score on an adapted version of the PSSUQ was 5.90 (SD 1.09) which indicates high user satisfaction and good usability.
The involvement of end-users significantly influenced the lay-out of the interface that was developed. This resulted in an interface that was accepted by the target group. Evaluation of the prototype revealed that the usability of the interface was good. The feedback system will only succeed in supporting self-management when elderly people are able to use the interface and understand the feedback. The input of elderly people during the development process contributed to this.
PMCID: PMC3571197
user-centered design; elderly people; self management; physical functioning, usability
5.  Predicting ADL disability in community-dwelling elderly people using physical frailty indicators: a systematic review 
BMC Geriatrics  2011;11:33.
Disability in Activities of Daily Living (ADL) is an adverse outcome of frailty that places a burden on frail elderly people, care providers and the care system. Knowing which physical frailty indicators predict ADL disability is useful in identifying elderly people who might benefit from an intervention that prevents disability or increases functioning in daily life. The objective of this study was to systematically review the literature on the predictive value of physical frailty indicators on ADL disability in community-dwelling elderly people.
A systematic search was performed in 3 databases (PubMed, CINAHL, EMBASE) from January 1975 until April 2010. Prospective, longitudinal studies that assessed the predictive value of individual physical frailty indicators on ADL disability in community-dwelling elderly people aged 65 years and older were eligible for inclusion. Articles were reviewed by two independent reviewers who also assessed the quality of the included studies.
After initial screening of 3081 titles, 360 abstracts were scrutinized, leaving 64 full text articles for final review. Eventually, 28 studies were included in the review. The methodological quality of these studies was rated by both reviewers on a scale from 0 to 27. All included studies were of high quality with a mean quality score of 22.5 (SD 1.6). Findings indicated that individual physical frailty indicators, such as weight loss, gait speed, grip strength, physical activity, balance, and lower extremity function are predictors of future ADL disability in community-dwelling elderly people.
This review shows that physical frailty indicators can predict ADL disability in community-dwelling elderly people. Slow gait speed and low physical activity/exercise seem to be the most powerful predictors followed by weight loss, lower extremity function, balance, muscle strength, and other indicators. These findings should be interpreted with caution because the data of the different studies could not be pooled due to large variations in operationalization of the indicators and ADL disability across the included studies. Nevertheless, our study suggests that monitoring physical frailty indicators in community-dwelling elderly people might be useful to identify elderly people who could benefit from disability prevention programs.
PMCID: PMC3142492  PMID: 21722355
6.  The reduction of disability in community-dwelling frail older people: design of a two-arm cluster randomized controlled trial 
BMC Public Health  2010;10:511.
Frailty among older people is related to an increased risk of adverse health outcomes such as acute and chronic diseases, disability and mortality. Although many intervention studies for frail older people have been reported, only a few have shown positive effects regarding disability prevention. This article presents the design of a two-arm cluster randomized controlled trial on the effectiveness, cost-effectiveness and feasibility of a primary care intervention that combines the most promising elements of disability prevention in community-dwelling frail older people.
In this study twelve general practitioner practices were randomly allocated to the intervention group (6 practices) or to the control group (6 practices). Three thousand four hundred ninety-eight screening questionnaires including the Groningen Frailty Indicator (GFI) were sent out to identify frail older people. Based on their GFI score (≥5), 360 participants will be included in the study. The intervention will receive an interdisciplinary primary care intervention. After a comprehensive assessment by a practice nurse and additional assessments by other professionals, if needed, an individual action plan will be defined. The action plan is related to a flexible toolbox of interventions, which will be conducted by an interdisciplinary team. Effects of the intervention, both for the frail older people and their informal caregivers, will be measured after 6, 12 and 24 months using postal questionnaires and telephone interviews. Data for the process evaluation and economic evaluation will be gathered continuously over a 24-month period.
The proposed study will provide information about the usefulness of an interdisciplinary primary care intervention. The postal screening procedure was conducted in two cycles between December 2009 and April 2010 and turned out to be a feasible method. The response rate was 79.7%. According to GFI scores 29.3% of the respondents can be considered as frail (GFI ≥ 5). Nearly half of them (48.1%) were willing to participate. The baseline measurements started in January 2010. In February 2010 the first older people were approached by the practice nurse for a comprehensive assessment. Data on the effect, process, and economic evaluation will be available in 2012.
Trial Registration
PMCID: PMC2936429  PMID: 20731836
7.  Feasibility of a cognitive behavioural group intervention to reduce fear of falling and associated avoidance of activity in community-living older people: a process evaluation 
Fear of falling and associated avoidance of activity are common among older people and may have negative consequences in terms of functional decline, quality of life and institutionalisation. We evaluated the effects of a cognitive behavioural group intervention to reduce fear of falling and associated avoidance of activity among older persons. This intervention showed favourable effects on fear of falling, avoidance of activity, daily activity, and several secondary outcomes. The aim of the present study is to assess the feasibility of this cognitive behavioural group intervention for participants and facilitators.
The intervention consisted of eight weekly group sessions lasting two hours each and a booster session after six months. Self-administered questionnaires, registration forms and interviews were used to collect data from participants (n = 168) and facilitators (n = 6) on the extent to which the intervention was performed according to protocol, participant attendance, participant adherence, and participants' and facilitators' opinion of the intervention. Quantitative data from the questionnaires and registration forms were analysed by means of descriptive statistics. Qualitative data were categorised based on matching contents of the answers.
Facilitators reported no major protocol deviations. Twenty-six percent of the participants withdrew before the start of the programme. Of the persons who started the programme, 84% actually completed it. The participants reported their adherence as good, but facilitators had a less favourable opinion of this. The majority of participants still reported substantial benefits from the programme after six and twelve months of follow-up (71% and 61% respectively). Both participants and facilitators provided suggestions for improvement of the intervention.
Results of this study show that the current cognitive behavioural group intervention is feasible for both participants and facilitators and fits in well with regular care. Minor refinement of the intervention, however, is warranted to further improve intervention effectiveness and efficiency. Based on these positive findings, we recommend implementing a refined version of this effective and feasible intervention in regular care.
Trial registration
PMCID: PMC2194766  PMID: 17900336
8.  The development of a multidisciplinary fall risk evaluation tool for demented nursing home patients in the Netherlands 
BMC Public Health  2006;6:74.
Demented nursing home patients are at high risk for falls. Falls and associated injuries can have a considerable influence on the autonomy and quality of life of patients. The prevention of falls among demented patients is therefore an important issue. In order to intervene in an efficient way in this group of patients, it is important to systematically evaluate the fall risk profile of each individual patient so that for each patient tailor-made preventive measures can be taken. Therefore, the objective of the present study is to develop a feasible and evidence based multidisciplinary fall risk evaluation tool to be used for tailoring preventive interventions to the needs of individual demented patients.
To develop this multidisciplinary fall risk evaluation tool we have chosen to combine scientific evidence on the one hand and experts' opinions on the other hand. Firstly, relevant risk factors for falling in elderly persons were gathered from the literature. Secondly, a group of Dutch experts in the field of falls and fall prevention in the elderly were consulted to judge the suitability of these risk factors for use in a multidisciplinary fall risk evaluation tool for demented nursing home patients. Thirdly, in order to generate a compact list of the most relevant risk factors for falling in demented elderly, all risk factors had to fulfill a set of criteria indicating their relevance for this specific target population. Lastly the final list of risk factors resulting from the above mentioned procedure was presented to the expert group. The members were also asked to give their opinion about the practical use of the tool.
The multidisciplinary fall risk evaluation tool we developed includes the following items: previous falls, use of medication, locomotor functions, and (correct) choice and use of assistive and protective devices. The tool is developed for the multidisciplinary teams of the nursing homes.
This evidence and practice based multidisciplinary fall risk evaluation tool targets the preventive interventions aimed to prevent falls and their negative consequences in demented nursing home patients.
PMCID: PMC1479328  PMID: 16551348
9.  Effects of a programme of multifactorial home visits on falls and mobility impairments in elderly people at risk: randomised controlled trial 
BMJ : British Medical Journal  2000;321(7267):994-998.
To evaluate whether a programme of multifactorial home visits reduces falls and impairments in mobility in elderly people living in the community.
Randomised controlled trial with 18 months of follow up.
Six general practices in Hoensbroek, the Netherlands.
316 people aged 70 and over living in the community, with moderate impairments in mobility or a history of recent falls.
Five home visits by a community nurse over a period of one year. Visits consisted of screening for medical, environmental, and behavioural factors causing falls and impairments in mobility, followed by specific advice, referrals, and other actions aimed at dealing with the observed hazards.
Main outcome measures
Falls and impairments in mobility.
No differences were found in falls and mobility outcomes between the intervention and usual care groups.
Multifactorial home visits had no effects on falls and impairments in mobility in elderly people at risk who were living in the community. Because falls and impairments in mobility remain a serious problem among elderly people, alternative strategies should be developed and evaluated.
PMCID: PMC27508  PMID: 11039967
10.  Effects of preventive home visits to elderly people living in the community: systematic review 
BMJ : British Medical Journal  2000;320(7237):754-758.
To assess the effects of preventive home visits to elderly people living in the community.
Systematic review.
15 trials retrieved from Medline, Embase, and the Cochrane controlled trial register.
Main outcome measures
Physical function, psychosocial function, falls, admissions to institutions, and mortality.
Considerable differences in the methodological quality of the 15 trials were found, but in general the quality was considered adequate. Favourable effects of the home visits were observed in 5 out of 12 trials measuring physical functioning, 1 out of 8 measuring psychosocial function, 2 out of 6 measuring falls, 2 out of 7 measuring admissions to institutions, and 3 of 13 measuring mortality. None of the trials reported negative effects.
No clear evidence was found in favour of the effectiveness of preventive home visits to elderly people living in the community. It seems essential that the effectiveness of such visits is improved, but if this cannot be achieved consideration should be given to discontinuing these visits.
PMCID: PMC27318  PMID: 10720360
11.  Effectiveness of home care programmes for patients with incurable cancer on their quality of life and time spent in hospital: systematic review 
BMJ : British Medical Journal  1998;316(7149):1939-1944.
Objective: To investigate whether for patients with incurable cancer comprehensive home care programmes are more effective than standard care in maintaining the patients’ quality of life and reducing their “readmission time” (percentage of days spent in hospital from start of care till death).
Design: Systematic review.
Methods: A computer aided search was conducted using the databases of Medline, Embase, CancerLit, and PsychLit. The search for studies and the assessment of the methodological quality of the relevant studies were performed by two investigators, blinded from each other. Prospective, controlled studies investigating the effects of a home care intervention programme on patients’ quality of life or on readmission time were included in the analyses.
Results: Only 9 prospective controlled studies were found; eight were performed in the United States and 1 in the United Kingdom. Their methodological quality was judged to be moderate (median rating 62 on a 100 point scale). None of the studies showed a negative influence of home care interventions on quality of life. A significantly positive influence on the outcome measures was seen in 2 out of the 5 studies measuring patients’ satisfaction with care, in 3/7 studies measuring physical dimensions of quality of life, in 1/6 studies measuring psychosocial dimensions, and in 2/5 studies measuring readmission time. The incorporation of team members’ visits to patients at home or regular multidisciplinary team meetings into the intervention programme seemed to be related to positive results.
Conclusions: The effectiveness of comprehensive home care programmes remains unclear. Given the enormity of the problems faced by society in caring for patients with terminal cancer, further research is urgently needed.
Key messages Only nine controlled prospective studies have compared the effects of home care intervention programmes for patients with terminal cancer with those of standard care, in relation to patients’ quality of life and time spent in hospital between start of care and death The methodological quality of these studies seemed to be moderate Home care programmes did not have a negative influence on quality of life or time spent in hospital; some studies observed positive effects on these outcome measures Enabling team members to visit patients at home and holding regular multidisciplinary team meetings seem important elements for obtaining favourable results The general belief that home care programmes are effective for patients with terminal cancer is not supported scientifically
PMCID: PMC28590  PMID: 9641929
12.  Effectiveness of interdisciplinary primary care approach to reduce disability in community dwelling frail older people: cluster randomised controlled trial 
Objective To evaluate whether an interdisciplinary primary care approach for community dwelling frail older people is more effective than usual care in reducing disability and preventing (further) functional decline.
Design Cluster randomised controlled trial.
Setting 12 general practices in the south of the Netherlands
Participants 346 frail older people (score ≥5 on Groningen Frailty Indicator) were included; 270 (78%) completed the study.
Interventions General practices were randomised to the intervention or control group. Practices in the control group delivered care as usual. Practices in the intervention group implemented the “Prevention of Care” (PoC) approach, in which frail older people received a multidimensional assessment and interdisciplinary care based on a tailor made treatment plan and regular evaluation and follow-up.
Main outcome measures The primary outcome was disability, assessed at 24 months by means of the Groningen Activity Restriction Scale. Secondary outcomes were depressive symptomatology, social support interactions, fear of falling, and social participation. Outcomes were measured at baseline and at 6, 12, and 24 months’ follow-up.
Results 193 older people in the intervention group (six practices) received the PoC approach; 153 older people in the control group (six practices) received care as usual. Follow-up rates for patients were 91% (n=316) at six months, 86% (n=298) at 12 months, and 78% (n=270) at 24 months. Mixed model multilevel analyses showed no significant differences between the two groups with regard to disability (primary outcome) and secondary outcomes. Pre-planned subgroup analyses confirmed these results.
Conclusions This study found no evidence for the effectiveness of the PoC approach. The study contributes to the emerging body of evidence that community based care in frail older people is a challenging task. More research in this field is needed.
Trial registration Current Controlled Trials ISRCTN31954692.
PMCID: PMC3769159  PMID: 24022033

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