This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR mhealth and uhealth, is properly cited. The complete bibliographic information, a link to the original publication on http://mhealth.jmir.org/, as well as this copyright and license information must be included.
Chronic pain, including arthritis, affects about 100 million adults in the United States. Complexity and diversity of the pain experience across time and people and its fluctuations across and within days show the need for valid pain reports that do not rely on patient’s long-term recall capability. Smartwatches can be used as digital ecological momentary assessment (EMA) tools for real-time collection of pain scores. Smartwatches are generally less expensive than smartphones, are highly portable, and have a simpler user interface, providing an excellent medium for continuous data collection and enabling a higher compliance rate.
The aim of this study was to explore the attitudes and perceptions of older adults towards design and technological aspects of a smartwatch framework for measuring patient report outcomes (PRO) as an EMA tool.
A focus group session was conducted to explore the perception of participants towards smartwatch technology and its utility for PRO assessment. Participants included older adults (age 65+), with unilateral or bilateral symptomatic knee osteoarthritis. A preliminary user interface with server communication capability was developed and deployed on 10 Samsung Gear S3 smartwatches and provided to the users during the focus group. Pain was designated as the main PRO, while fatigue, mood, and sleep quality were included as auxiliary PROs. Pre-planned topics included participants’ attitude towards the smartwatch technology, usability of the custom-designed app interface, and suitability of the smartwatch technology for PRO assessment. Discussions were transcribed, and content analysis with theme characterization was performed to identify and code the major themes.
We recruited 19 participants (age 65+) who consented to take part in the focus group study. The overall attitude of the participants toward the smartwatch technology was positive. They showed interest in the direct phone-call capability, availability of extra apps such as the weather apps and sensors for tracking health and wellness such as accelerometer and heart rate sensor. Nearly three-quarters of participants showed willingness to participate in a one-year study to wear the watch daily. Concerns were raised regarding usability, including accessibility (larger icons), notification customization, and intuitive interface design (unambiguous icons and assessment scales). Participants expressed interest in using smartwatch technology for PRO assessment and the availability of methods for sharing data with health care providers.
All participants had overall positive views of the smartwatch technology for measuring PROs to facilitate patient-provider communications and to provide more targeted treatments and interventions in the future. Usability concerns were the major issues that will require special consideration in future smartwatch PRO user interface designs, especially accessibility issues, notification design, and use of intuitive assessment scales.
About 100 million adults in the United States are affected by chronic pain, including pain caused by arthritis, costing US $560-$635 billion annually [
Smartphones have increased in popularity as convenient digital EMA tools for real-time assessments [
We hypothesized that since a smartwatch can be worn all day, this will potentially result in a higher compliance rate compared to a smartphone. A smartwatch, coupled with the embedded sensors including accelerometer, global positioning system (GPS), ultraviolet (UV), and heart rate sensor can provide additional information such as physical activity intensity and duration, location, UV exposure, and heart rate. Previous EMA interventions based on basic watch-type EMA tools for assessing fatigue have been reported to be successful at characterizing the temporal changes of fatigue [
We recruited 20 older adults aged 65-89 years, and 19 of them participated in the focus group. The inclusion criteria included age ≥65 years and diagnosis of unilateral or bilateral symptomatic knee osteoarthritis. Some of the exclusion criteria included failure or inability to provide informed consent; significant cognitive impairment, defined as a known diagnosis of dementia; and being unable to communicate because of severe hearing loss or speech disorder (see
The PROMPT framework is made up of two components: (1) the server software and (2) the smartwatch app. This integrated framework is designed and developed to perform several tasks including remote data collection, storage, retrieval, and analysis.
The PROMPT app was developed to show assessment notification every 4 hours by asking users to enter their current pain, fatigue, and mood assessments. No messages were shown during the nighttime to avoid any sleep disruptions. Messages were provided only from 8 a.m.-8 p.m. Sleep quality was programmed to be assessed every morning with a message randomly displayed between 8 a.m.-12 p.m. Using the PROMPT interface, the assessment ratings could be easily entered by rotating a bezel and could be saved by pressing a button located on top of the bezel (
The same bezel rotation and saving mechanism was also used to capture current user activities (
The PROMPT (Patient Reported Outcome of Mood, Pain, and faTigue) framework: the smartwatch app and the server application.
The Samsung Gear S smartwatch used in the PROMPT (Patient Reported Outcome of Mood, Pain, and faTigue) study. Ratings are entered by rotating the bezel to select pain ratings. The color schema also changes as the ratings are increased or decreased. Ratings are saved by pressing the top button (physical button), located on top of the bezel.
Users can choose activities by rotating the bezel.
The focus group was conducted by a team consisting of a moderator and 2 assistant moderators. The focus group formation and content analysis were guided by memo writing, qualitative sampling, and metacoding [
The first 30 minutes of the focus group was dedicated to introducing the smartwatch technology, explaining the rationale of the study, and showing screenshots of the interface. Then the participants were provided with 10 Gear S3 smartwatches preloaded with the PROMPT app. They were assisted in using the PROMPT app, as necessary. The watch configuration was changed to show notifications every 5 minutes to better allow for exploration of the app in a timely manner. Last, to better capture design preferences, the participants were asked to sketch their own smartwatch face design.
The focus group was designed to be an open-ended forum, starting with several directed questions. We asked 12 questions that related to the impression of the smartwatch technology and mimicked questions that are traditionally used to evaluate computer app and mobile app interfaces, including the System Usability Scale [
The rationale for including questions a.1 (watch size) and a.2 (first impression) was to identify the general acceptability of a smartwatch in daily settings, or in a one-year study (questions d.1 and d.2). The rationale for including questions b.1-6 was to assess the existing user interface and identify possible issues and to outline smartwatch interface guidelines for older adults’ population. Finally, questions c.1 and c.2 were included to specifically solicit information on assessing PROs through a smartwatch interface.
Following the focus group, the notes were compiled and summarized by the assistant moderators. Major topics were identified across the discussions by the assistant moderators and were grouped based on the underlying themes. The theme codes were developed based on note data to categorize data into overarching interpretive themes. The codes were then refined to fit data through an iterative summative process [
Focus group questions summarized according to their topic.
Topic | Questions |
a. Smartwatch impression | a.1 What is your opinion about watch size and its accessory bands? |
a.2 What is your first impression of the watch itself? | |
b. PROMPT interface | b.1 Do you like the PROMPT color schema for PRO assessment? |
b.2 Do you like the app flow? Any need for a back button? | |
b.3 Would you like to add emoticons to the assessment screen? | |
b.4 Do you like the activity icons? Would you prefer icons or text? | |
b.5 What type of notification do you prefer to receive, and why? | |
b.6 Is the text large enough to read? | |
c. PRO assessment | c.1 How many times per day would be too burdensome to ask you? |
c.2 Other issues you would like the researchers and doctors to know? | |
d. Study logistics | d.1 How likely are you to participate in a one-year research study asking you to wear the smartwatch daily for up to a year? |
d.2 What other options would help you to participate? |
Wong-Baker FACES Pain Rating Scale (left). PRO assessment with and without emoticons. Source: Wong-Baker FACES Foundation.
Of the 20 participants who consented to the study, 19 participated in the focus group study. The session lasted about 90 minutes.
The content analysis revealed several major subtopics and themes under each major topic (
Theme percentages do not include the tally questions. Some discussion items were included under multiple themes. The discussion on user interface options was the most comprehensive (just over half of all the topics discussed), spanning issues from accessibility for visually impaired users to specific details of design. The participants expressed a desire for customization, for example, to choose how to be notified when it is time to enter the PRO assessments (eg, sound, vibration, and music) or to customize the list of activities or medications. Initially, most participants showed interest in using emoticons like the Wong-Baker FACES Pain Rating Scale [
The participants were asked about several issues regarding the PROMPT app user interface, including the need for emoticons on PRO scales, the use of back button, font size, and displaying additional information such as heart rate or step count (
The participants were asked about their notification method of choice (
Characteristics of the focus group participants (N=19).
Characteristics | Total | Female | Male | |
Participants, n (%) | 19 | 14 (74) | 5 (26) | .01 |
Age (years), mean (SD) | 72.7 (6.1) | 72.0 (6.7) | 75.5 (5.8) | .22 |
Access to Wi-Fi, n (%) | 17 (89) | —a | — | — |
Own a smartphone, n (%) | 14 (74) | — | — | — |
Own a smartwatch, n (%) | 1 (5) | 1 (7) | 0 (0) | 1 |
Active in water, n (%) | 4 (21) | — | — | — |
aData were not collected per female/male, only collectively.
Themes and subthemes reported by the focus group participants (percentages are the percent reported with respect to all the other themes).
Topic, themes, and subthemes | n (%) | |||
Time displaya | 1 (5) | |||
Appsa | 3 (16) | |||
Water resistancea | 1 (5) | |||
Backlighta | 1 (5) | |||
Securityd | 1 (5) | |||
Weathera | 3 (16) | |||
Emaila | 1 (5) | |||
Phonea | 2 (11) | |||
Heavy bodyb | 2 (11) | |||
Accessory bandsa | 4 (21) | |||
Band durabilityc | 1 (5) | |||
Step counta, heart ratea, GPSa | 2 (11) | |||
Accessibility for color-blind individualsc | 2 (11) | |||
Customized color schemac | 3 (16) | |||
Mapping colors to mental statesc | 3 (16) | |||
Icon ambiguityb | 2 (11) | |||
Expanded list of activitiesc | 1 (5) | |||
Customized list of activitiesc | 1 (5) | |||
Activity intensityc | 1 (5) | |||
Emoticonsc | 4 (21) | |||
Notification preferencesc | 3 (16) | |||
Disruptive notificationsd | 2 (11) | |||
Notification type customizationc | 1 (5) | |||
Context-dependent notificationsc | 1 (5) | |||
Silent modea | 1 (5) | |||
Number of notificationsd | 7 (37) | |||
Start time customizationc | 1 (5) | |||
Easy setupa | 4 (21) | |||
Automatic messagesa | 1 (5) | |||
Speech inputc | 1 (5) | |||
Larger font sizec | 3 (16) | |||
Large iconsc | 3 (16) | |||
Notification customization for visually or hearing impairedc | 1 (5) | |||
Scale visual aidc | 2 (11) | |||
Neutral value visual aidc | 1 (5) | |||
Back navigation buttonc | 1 (5) | |||
Ability to indicate fluctuation and intermittent painc | 2 (11) | |||
Ability to indicate activity dependent measuresc | 1 (5) | |||
Ability to indicate pain locationc | 1 (5) | |||
Weekly or daily summaryc | 1 (5) | |||
Ability to indicate medication usec | 3 (16) | |||
Ability to indicate stiffnessc | 1 (5) | |||
Receiving more positive feedback instead of negativec | 4 (21) | |||
Ability to track sleepc | 3 (16) | |||
Use during travelc | 1 (5) | |||
Frequent clinic visit, Impact on personal data pland | 1 (5) |
aPositive existing feature (I liked it).
bUndesirable existing feature (I did not like it).
cDesired future feature (I would like to see that).
dUndesirable/concerning future feature (I would be concerned about that).
Selected participants’ quotes on discussed themes grouped according to topic.
Topic and subtopic | Example quotes | |
Function | “Can you download its apps like on a smartphone?” | |
Apps | “I would wear it as it is; it is excellent, but the more apps, the better.” | |
Appearance | “I like the extra band, lighter.” | |
Sensors | “Can its GPS be used to track if I am at the gym?” | |
Color schema | “When it shows my good mood as green, I don’t like it, not my mental model of happiness.” | |
Icons | “Standing can represent both washing dishes or cooking.” | |
Notifications | “My hearing is bad, and I might be active and might not see it.” | |
Usability & accessibility | “Voice-activated recording might be helpful to record details of activities.” | |
Assessment scales | “For feeling down, is the scale going up or down?” | |
Flow | “I would like an erase or back button when I make a mistake.” | |
Capturing pain | “I have intermittent pain walking for five minutes, then no pain, coming and going.” | |
Other patient-reported outcomes | “It is important to emphasize when you are feeling good, feeling up. To emphasize fatigue, it is negative, and it is going to be measured in a negative way.” | |
Study participation | “How would the watch affect my data plan usage?” |
Participant preferences on various user interface issues related to PROMPT (Patient Reported Outcome of Mood, Pain, and faTigue). Bars indicate the percentage of users who responded "Yes".
Participant preferences on notifications type.
Participant preferences on notifications frequency.
A review of the literature shows the lack of systematic evaluation of smartwatch technology among older adults. While several recent studies have developed smartwatch apps for fall detection [
This study allowed us to explore the attitudes and perceptions of older adults towards smartwatch technology, specifically for PRO assessment. Most participants in our study expressed enthusiasm for wearing the smartwatch, despite its weight and lack of several desired features, which points to the potential feasibility of using such a device in long-term studies or daily settings. In general, while it has been shown that older adults are less likely to use new technology compared with younger adults [
Several previous studies also have found that anxiety is positively correlated with age while self-efficacy is negatively correlated, resulting in lower self-confidence and higher anxiety in older adults when facing new technology [
In general, the participants perceived the smartwatch technology and its use for PRO assessment as an empowering tool as it allows them to provide real-world symptomology to caregivers. This is particularly true for chronic pain, which is often highly variable [
We found that participants’ mental models of assessment scales can greatly impact how they assess their outcomes (“For feeling down, is the scale going up or down?”). For example, initially we used NRS [
We also found that, in general, the touchscreen interface on the smartwatch was difficult to operate by some older adults due to the small size of icons, as well as their decreased motor resolution and coordination, as observed in previous studies on older adults with smartphones [
The participants also expressed interest in several future features, most notably the capability to keep their health care provider in the loop through a health care provider portal or through Electronic Health Records integration. They also showed interest in a patient Web portal for viewing their collected data in more detail on a larger screen device. Connectivity to other smart devices such as smart scales was also discussed by participants.
Different pain assessment scales used before and after the focus group. NRS: Numerical Pain Rating Scale; VRS: Verbal Pain Rating Scale.
Finally, an emergency option, the ability to call 911 or relatives in case of emergency, was on top of their future desired features.
Though our results point to interesting insights, our study had several limitations. Our focus group participants were recruited locally and might not represent the broader population of older adults. This is reflected in a higher rate of smartphone ownership among our participants compared to the national smartphone ownership in the older adult population. The results also are based on a single focus group session following limited interaction with the technology, and different results could emerge if feedback was obtained after wearing and using the device for an extended period. Finally, we studied the smartwatch technology primarily in the context of pain assessment and participants reporting knee pain. These results might differ if the focus group was conducted on the use of smartwatch for different applications or when targeting populations with different medical histories. Nonetheless, our results point to the feasibility of using smartwatches for PRO assessment in older adults, and they offer invaluable insights for improving the current interface and technology.
Future studies are needed to explore the perceptions of older adults toward such PRO assessment interfaces and how their perceptions change after wearing the smartwatch for a given period. We plan to use our PRO assessment app for quantifying and comparing PROs such as pain among different populations of older adults in real-life settings. Future work will also compare the use of PRO assessment tools on different devices, including smartphones, tablets, and smartwatches, to better identify the differences among such mediums. Finally, there is a need to integrate patient-generated information with routine care data in a format that is useful to care providers.
Our study examined the acceptability for using smartwatch technology as a PRO assessment in older adults in a focus group setting. Our questions on participants’ willingness to take part in a one-year study, as well as questions on the appeal of smartwatch size and interface design, reflect the potential feasibility of using a smartwatch in long-term studies or daily settings. Usability and intuitive design, personalization, and accessibility were found to be important for adopting and using PROMPT smartwatch technology. The choice of different PRO assessment methods (eg, visual vs verbal scales) was also found to impact how older adults use smartwatch technology for reporting their pain, mood, fatigue, and sleep quality. Finally, the participants expressed interest in the ability to observe these assessments in more detail on a Web portal and to be able to share them with their health care providers. These findings can be used to guide the future smartwatch software design, as well as to guide developing new EMA methods for PRO assessment.
Inclusion and exclusion criteria.
ecological momentary assessment
global positioning system
Numerical Pain Rating Scale
patient-reported outcomes
Patient Reported Outcome of Mood, Pain, and faTigue
ultraviolet
None declared.