Presentation
Can Pictograms Help Older Adults to Assess Their Own Level of Function? Using Human Centered Design Methods to Develop and Validate Pictograms for the Functional Assessment of Activities of Daily Living
DescriptionAmong older adults, limited functional capacity is often a reflection of cognitive or physical health issues and can result in high healthcare use, and multiple adverse events such as loss of functional independence, recurrent emergency department visits, hospitalizations, and need for home care services. Function is typically measured in terms of one’s ability to perform a set of activities of daily living (ADLs) required to sustain basic physical needs (basic ADLs) and to live independently in the community (instrumental ADLs [IADL]), such as eating, walking, toileting, or housekeeping. The functional assessment of ADLs and IADSs may be conducted in a variety of care settings, including both community and institutional settings (e.g., long-term care or nursing homes), and/or by the individuals themselves. For older adults, self-assessment can improve their understanding of their own functional status, changes in their perceived functional capacity, and can help to inform their personal care planning. However, the text-based nature of the tool poses a potential barrier to the use of self-assessment tools for older adults. Older adults using a text-based tool or survey may face various cognitive demands, including the comprehension of the questions, the recall of the requested information from memory, the evaluation of the link between the retrieved information and the question, and the communication of the response, and are required to be literate in reading the language of the survey.
To our knowledge, the available instruments used to assess function, whether performance-based or self-reported, are almost exclusively text-based. The challenges associated with text-based assessment instruments presents an opportunity to leverage other modes of communication, specifically visuals (i.e., pictograms) in functional assessments of older adults. Pictograms are graphic images of an idea or concept used to communicate information. Pictograms can be used to communicate information in a clear, concise and simple manner, and may also serve as a communication aid allowing individuals to communicate non-verbally through, for example, pointing or interacting with a relevant image, such as identifying which level of assistance is required to perform an ADL. Pictograms may act as a memory aid for individuals with memory difficulties or conditions including Alzheimer’s disease or dementia, given visual cues can trigger memory. Despite the potential value of an image-based tool, few visual-based assessment tools, or mixed-modality tools incorporating pictograms, for function exist.
We are therefore conducting a human centered design study with the objective of designing a set of pictograms, for the North American context, to capture functional impairment in ADLs and IADLs. This novel pictogram-based tool will then be used to improve the accessibility of self-administered functional assessment tools for older adults and clinicians. The development of pictograms to measure such a concept requires careful consideration to ensure the graphical representational aligns with the intended meaning, which is context dependent, and culturally influenced. As such, the project is grounded in an iterative human centered design approach and will proceed in three phases: Phase 1 will explore the design guidelines and development of the visual tool; Phase 2 will evaluate the tool’s usability and accessibility; and Phase 3 will validate the visual tool against other existing clinical assessment scales for functional capacity.
In Phase 1, a set of pictograms were developed, where a caregiver is depicted providing increasing level of support to indicate decline in an older adult’s functional independence, and ordered sequentially to illustrate changes in independence in a story-like manner. Following the development of the pictograms, ten one-hour co-design interviews were conducted facilitated by a virtual collaborative whiteboard, where participants (older adults and clinicians) engaged in a card sorting activity to inform the clarity and relevancy of the pictograms in assessing the level of functional ability or impairment in older adults. The ultimate goal was to solicit feedback on the pictograms depicting levels of functional capacity.
An evaluative qualitative analysis approach was used to code the co-design interview transcripts, applying deductive and inductive coding techniques including provisional, in vivo, magnitude, and recommendation coding. The deductive code book leveraged a human factors framework, designing for older adults, and addressed the participants ability to identify the activity, sort the cards, and self-identify with the characters.
Results from Phase 1 have presented the following challenges and opportunities for applying visual pictograms to a text-based self-assessment tool: 1) Activity identification: participants were almost always able to identify the activity presented in the pictogram without the use of text, with the exception of a few instances where a sub-category of an activity was identified versus the broader category (e.g., activity identified as transferring versus mobility, or teeth brushing versus hygiene). 2) Ability to order cards: Without the use of text, participants were able to successfully order the pictograms in the correct order when fewer images (i.e., scale levels) were presented; with the addition of pictograms, and complexity in imagery (e.g., additional items, colour, accessories in the images), more errors in card ordering were presented; and 3) Cognitive versus physical tasks: In relation to the assessment of function, it was identified that some scales could benefit from separating cognitive and physical tasks on two separate visual scales, such as, for example, the ADL activity of telephone use, where the cognitive task would require the ability to navigate technology and recall of how to make a phone call, versus the physical task of dialing a number, and holding the phone.
Overall, Phase 1 has established design guidelines for the further iteration of pictograms of function, in addition to demonstrating that ADLs can be identified and comprehended in the form of pictograms. However, pictograms also present the challenge of appropriately capturing the diversity of scenarios visually (i.e., environments, accessories, characters), to most appropriately represent the individuals experience, including gaps in the individual's ability to self-identify in the activity imagery. Phase 2 will continue to explore how to best capture an individual’s experience in progression of function, in the most inclusive, but also succinct and easy to interpret manner. This human centered design approach will support the development of a community-informed, self-reported, visual functional assessment tool for older adults. The development of pictograms for self-administered function assessments tools aims to increase the accessibility and ease of use for older adults, given the limitations of current text-based tools.
To our knowledge, the available instruments used to assess function, whether performance-based or self-reported, are almost exclusively text-based. The challenges associated with text-based assessment instruments presents an opportunity to leverage other modes of communication, specifically visuals (i.e., pictograms) in functional assessments of older adults. Pictograms are graphic images of an idea or concept used to communicate information. Pictograms can be used to communicate information in a clear, concise and simple manner, and may also serve as a communication aid allowing individuals to communicate non-verbally through, for example, pointing or interacting with a relevant image, such as identifying which level of assistance is required to perform an ADL. Pictograms may act as a memory aid for individuals with memory difficulties or conditions including Alzheimer’s disease or dementia, given visual cues can trigger memory. Despite the potential value of an image-based tool, few visual-based assessment tools, or mixed-modality tools incorporating pictograms, for function exist.
We are therefore conducting a human centered design study with the objective of designing a set of pictograms, for the North American context, to capture functional impairment in ADLs and IADLs. This novel pictogram-based tool will then be used to improve the accessibility of self-administered functional assessment tools for older adults and clinicians. The development of pictograms to measure such a concept requires careful consideration to ensure the graphical representational aligns with the intended meaning, which is context dependent, and culturally influenced. As such, the project is grounded in an iterative human centered design approach and will proceed in three phases: Phase 1 will explore the design guidelines and development of the visual tool; Phase 2 will evaluate the tool’s usability and accessibility; and Phase 3 will validate the visual tool against other existing clinical assessment scales for functional capacity.
In Phase 1, a set of pictograms were developed, where a caregiver is depicted providing increasing level of support to indicate decline in an older adult’s functional independence, and ordered sequentially to illustrate changes in independence in a story-like manner. Following the development of the pictograms, ten one-hour co-design interviews were conducted facilitated by a virtual collaborative whiteboard, where participants (older adults and clinicians) engaged in a card sorting activity to inform the clarity and relevancy of the pictograms in assessing the level of functional ability or impairment in older adults. The ultimate goal was to solicit feedback on the pictograms depicting levels of functional capacity.
An evaluative qualitative analysis approach was used to code the co-design interview transcripts, applying deductive and inductive coding techniques including provisional, in vivo, magnitude, and recommendation coding. The deductive code book leveraged a human factors framework, designing for older adults, and addressed the participants ability to identify the activity, sort the cards, and self-identify with the characters.
Results from Phase 1 have presented the following challenges and opportunities for applying visual pictograms to a text-based self-assessment tool: 1) Activity identification: participants were almost always able to identify the activity presented in the pictogram without the use of text, with the exception of a few instances where a sub-category of an activity was identified versus the broader category (e.g., activity identified as transferring versus mobility, or teeth brushing versus hygiene). 2) Ability to order cards: Without the use of text, participants were able to successfully order the pictograms in the correct order when fewer images (i.e., scale levels) were presented; with the addition of pictograms, and complexity in imagery (e.g., additional items, colour, accessories in the images), more errors in card ordering were presented; and 3) Cognitive versus physical tasks: In relation to the assessment of function, it was identified that some scales could benefit from separating cognitive and physical tasks on two separate visual scales, such as, for example, the ADL activity of telephone use, where the cognitive task would require the ability to navigate technology and recall of how to make a phone call, versus the physical task of dialing a number, and holding the phone.
Overall, Phase 1 has established design guidelines for the further iteration of pictograms of function, in addition to demonstrating that ADLs can be identified and comprehended in the form of pictograms. However, pictograms also present the challenge of appropriately capturing the diversity of scenarios visually (i.e., environments, accessories, characters), to most appropriately represent the individuals experience, including gaps in the individual's ability to self-identify in the activity imagery. Phase 2 will continue to explore how to best capture an individual’s experience in progression of function, in the most inclusive, but also succinct and easy to interpret manner. This human centered design approach will support the development of a community-informed, self-reported, visual functional assessment tool for older adults. The development of pictograms for self-administered function assessments tools aims to increase the accessibility and ease of use for older adults, given the limitations of current text-based tools.
Authors
Event Type
Oral Presentations
TimeTuesday, April 19:30am - 10:00am EDT
LocationPier 2/3
Digital Health (DH)