Central Annals of Gerontology and Geriatric Research

Cite this article: Satariano WA, Maus M, Tseng W, Skjorshammer D, Sanford A (2016) Word Walk: A Feasibility Study of an iPad-Based Protocol for a Future Intervention Study to Enhance Health and Functioning among Older Adults. Ann Gerontol Geriatric Res 3(3): 1044.

*Corresponding authorWilliam A. Satariano, School of Public Health, University of California, Berkeley, CA 94720, USA, Tel: 510-642-6641; Email: bills@berkeley.edu

Submitted: 20 October 2016

Accepted: 09 November 2016

Published: 09 November 2016

ISSN: 2378-9409

Copyright© 2016 Satariano et al.

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Keywords•Healthy aging•Physical activity•Cognitive function•Social interaction•iPad exergaming

Short Communication

Word Walk: A Feasibility Study of an iPad-Based Protocol for a Future Intervention Study to Enhance Health and Functioning among Older AdultsWilliam A. Satariano1*, Marlon Maus1, Winston Tseng1, Dmitri Skjorshammer2, and Alison Sanford1

1School of Public Health, University of California, USA2Social Apps Lab at CITRIS, University of California, USA

Abstract

A research trial was implemented to assess the feasibility of a protocol for a future study to determine whether a Pad-based game (Word Walk), played in multiple person teams, can enhance social interaction, physical activity, and cognitive function among older adults. Today, one of the important public health objectives is to preserve and enhance the health and functioning of a growing and increasingly diverse aging population. There is a need for effective and accessible approaches to achieve this objective. Word Walk may represent one such approach.

INTRODUCTIONHealthy aging is associated with being able to live

independently and complete tasks of everyday life. In addition to overall health, physical and cognitive function and social interaction are central to healthy aging.

Walking and other forms of physical activity enhance health and well-being in older populations, including reduction in the occurrence and severity of leading chronic health conditions and functional disabilities [1-5]. Studies clearly suggest that physical activity improves physiologic impairments such as muscle weakness and low cardio respiratory fitness. There is also strong evidence that physical activity improves function limitations. However, because of the complexity of their relationship, the effects of physical activity on disability are much less clear. [4,6]

Despite these recognized benefits, only 35 – 44% of adults 75 years or older are physically active, and 28-34% of adults ages 65-74 are physically active [7]. Barriers to walking include chronic health conditions; functional limitations, such as reduced lower-body strength, balance problems, and fatigue; sensory limitations, such as vision and hearing difficulties; cognitive limitations; depressive symptoms; and fear of falling.

In addition, there is evidence that limited social contacts and characteristics of the neighborhood environment, such as broken sidewalks and high volumes of car traffic, can adversely affect

levels of walking and physical activity in older populations [8-12]. Programs have been developed to enhance walking in older populations. These programs take various forms, including those based on indoor exercise, indoor mall walking, and neighborhood walking [13-16].

Community-based programs of this kind may be improved by incorporating mobility technology (cell phones and tablet computers). There is a growing literature on technology and aging [17-19]. Mobile technology is being used increasingly to monitor health status as well as send messages to encourage healthful behaviors [20-25]. While this technology is promising, there are challenges. Older adults are less likely than younger adults to access it, although that age difference varies by the type of technology. The extent and frequency of use also seems to be increasing, especially among adults aged 65 to 74. Despite these positive trends, age differences remain. Age-related barriers may be due to a number of factors, including less access, familiarity, and confidence in the use of mobile technology as well as age- related cognitive and sensory limitations and associated ergonomic issues that adversely affect ease of use [26-28].

Interactive “gaming” is recommended as one way to enhance technology use [29,30]. Interactive games, because they can be engaging, entertaining, and non-threatening, may reduce anxieties and enhance confidence in the use of technology. In addition, interactive games may also represent an opportunity to

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engage and interact with others. Tablet computers, in particular, such as an iPad, can overcome ergonomic barriers noted previously. The size of the screen improves visibility; the touch-screen may enhance ease of use; and its relative lightweight may allow for outdoor mobility. Thus, a mobile interactive game, played on a tablet computer in small teams, may serve to promote and sustain neighborhood walking.

While this research is promising, there is a need to develop and evaluate games in diverse populations of seniors. In addition, it is important to examine whether it is possible to develop interactive games which improve physical activity, cognitive function, and social interaction. Word Walk is designed to achieve that end. The purpose of the present study is to establish whether the intended protocol is feasible for a community trial in the future.

MATERIALS AND METHODSThe feasibility study tested a 12-week Word Walk intervention

over a 13-week period. IRB approval was obtained from the Committee for Protection of Human Subjects at University of California, Berkeley.

The study sample consisted of 23 participants recruited at the test-site, a city-run facility, the North Berkeley Senior Center, in Berkeley, California. The eligibility criteria included: adults aged 55 and older, sufficiently fluent in English and cognitive function to communicate and follow simple instructions, no major restrictions in physical mobility (use of a cane, walking device, or motorized mobility device was not a reason for exclusion), visitors of the senior center, and no report from the participant that his or her physician had determined that the participant should be restricted in mobility (1/2 mile circuit on foot, with or without a walking aid). There were no restrictions by gender, race/ethnicity, or socioeconomic status. Participants were recruited through a health fair, distribution of flyers by the front entrance, and word of mouth at the senior center.

The app, Word Walk, was played on a portable iPad by Apple connected via a mobile phone provider to mobile data access.

During week 1, two 90-minute information sessions were conducted at the test site. Approximately half the participants attended the first session and the other half attended the second session. At these sessions, the potential participants were informed in detail about the study and informed consent was obtained from those who chose to participate. They then received instruction in the use of the iPad and Word Walk exergame and completed the baseline interview using the interview tool. This tool was designed as a questionnaire consisting of 74 questions divided into various sections including demographics, neighborhood, social networks, medical conditions, physical activity, general health, physical functioning, senior center attendance and use of technology.

The same tool was used exclusively for all three interviews: the baseline at the start of the study, at the midpoint (six weeks) and at the end of the 12-week program.

During week 2 through 13 of the study, participants were asked to attend two 90 minute Word Walk sessions per week. Several sessions were offered during the same two days per week to allow some flexibility for the participants and their schedules. Participants were not required to come in at the same time every

session unless they chose to do so. Participants were either randomly assigned to a new team each session or they were given the choice of creating or maintaining their own teams throughout the study. Groups could choose the time they wanted to attend on the scheduled days.

In part 1 of the game at each of two weekly sessions, the teams of two or three older adults followed a½ mile predetermined walking route along neighborhood streets, beginning and ending at a designated location in the senior center. The walking route is similar to a navigation application and is displayed as a blue line on a map on the iPad. A moving target circle shows the location of the iPad on the route. The iPad is held by one of the team members who is chosen by the group at the start of each session (Figure 1). The map is visible on the screen throughout the walk but participants were encouraged to stop walking when they were actively looking at the screen. When the team reaches a pre-selected point along the route, four randomly generated letters automatically appear on the screen. Each letter has a numeric value from 1 to 10, similar to the game of Scrabble. There are six designated points along the route resulting in a total of 24 letters by the time the team has walked the course and returned to the starting point.

Part 2 of the game takes place in a room at the senior center where they access the 24 letters obtained during the walk. Working together, the team members have 15 minutes to construct as many words as possible by using the iPad touch-screen function. A space is provided at bottom of the screen to display and then submit their proposed words. A space is provided at the bottom of the screen to display and then submit their proposed words. Once submitted, the word is judged programmatically by the app to determine whether it is a legitimate word (with the Apple Dictionary Function), and whether or not the team has previously submitted the word. Each word receives a score based on the total numeric value of the letters used to construct the word. A running score (based on the numeric value of each individual word) is displayed on the screen, along with the team’s remaining time to complete the task. Teams compete based on the number of words they constructed to come up with their total team score (Figure 2).

After each session, information was recorded for each participant and for the team including ID’s and the total team score and duration of the walk. At the end of the study a focus group was held with select participants to gain greater insight into their perceptions and comments.

RESULTS AND DISCUSSIONApproximately 80 possible subjects expressed initial interest

in participating in the study. Of these, 34 attended the recruiting sessions and completed the informed consent and baseline interviews. 23 subjects participated in at least 1 or more Word Walk sessions.

The start dates for the groups were staggered so that the subjects had the opportunity to participate in the full 12-week program. The game was played in various group combinations giving participants a choice as to when to start the program. As the study progressed several individuals stopped attending the walks. The level of attrition was recorded for each individual. In Figure (3), the attrition rate is shown as a function of the number of walks that each individual participated in.

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Figure 1 Example of walking route.

Figure 2 Word Walk final game screen.

Of the initial 23 participants who signed up for the study, 17 completed the mid-point interview. All 17 of these participated in at least 1 or more Word Walk sessions. The final interview was completed by 20 people, of which 17 had participated in at least 1 or more sessions and 3 people did no Word Walk sessions.

Several teams chose to maintain the same members for the duration of the study, others changed from session to session depending on who showed up for the sessions. Several groups did not like the idea of allowing others to play with them even if one of their members was absent. Other individuals expressed an interest in playing with other participants as a way to meet other people and possibly change the group scores. Several groups did not know each other before the start of the study and expressed great delight in having created new friendships. They also stated

that they were saddened by the end of the project and had looked forward to the walk twice a week.

Although the teams had exactly 15 minutes to create words from the letters, several teams chose to spend up to an hour during or after the walk planning what words they would use for the word game component. This allowed them to increase the final scores. Individuals that participated in a greater number of Word Walk sessions had achieved higher overall scores than those with more limited participation, although the relationship appears to be more complex (Figure 4). It was also apparent that groups that plan a word strategy appeared to achieve higher scores and consequently individuals in those groups also had higher scores.

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Figure 3 Attrition rate for individual participation in the walking sessions.

Figure 4 Scores obtained by participants as a function of the number of sessions attended.

Feedback obtained from participants, both informally and in a focus group setting helped identify protocol areas that can be modified for a larger pilot study. These include changes to the Word Walk app itself such as the route options and levels of physical activity to the number of letters that should be permitted in forming words. The format of the program could also be changed to a formal class setting which could facilitate sustained participation and decrease the attrition rate.

CONCLUSIONOlder adults today expect to age not only with an “absence

of disease” but, as stated by the World Health Organization, able to remain active both as individuals and populations. One of the goals of public health professionals should be to help people realize their potential for physical, social, and mental well-being throughout the life course. Word Walk, a mobile interactive

game, attempts to provide an accessible technological platform that combines three important elements that have been shown to contribute to the process of healthy ageing: physical activity, cognitive function exercises and social interaction. In this report we looked at the feasibility and the design of the intervention. In this feasibility study we have determined the response and attrition rates for the program and obtained feedback from the participants. These results will be used to plan a formal and more extensive pilot study. The study will include a larger number of senior centers and additional “experimental centers” for comparison which will serve as controls for the intervention outcomes.

Future studies will explore the implementation of the program at the greater community level and will assess the long term health effects of a game that fosters and sustains neighborhood walking for older adults.

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ACKNOWLEDGEMENTSWe wish to acknowledge James Holston, Co-Director, CITRIS

Social Apps Lab, for helping develop Word Walk and Andres Iniguez, UC Berkeley student, for his help with the field work and Jordan Schultz, CDC Public Health Associate, for help with data analysis. Funds for the study were provided through the Berkeley Endowed Chair in Geriatrics (Satariano).

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Satariano WA, Maus M, Tseng W, Skjorshammer D, Sanford A (2016) Word Walk: A Feasibility Study of an iPad-Based Protocol for a Future Intervention Study to Enhance Health and Functioning among Older Adults. Ann Gerontol Geriatric Res 3(3): 1044.

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