Health Informatics Journal

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Daily Use of Motion-tracking Devices: Pattern and
Perspective of Independently living Thai Seniors
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Journal: Health Informatics Journal

Manuscript ID HIJ-21-0076
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Manuscript Type: Original Research Article

Motion-tracking devices, adoption of health-related wearables,

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Keywords: independently living Thai seniors, health promotion, elderly's movement

patterns and health data

This study examines how the elderly use and perceive activity-
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monitoring devices routinely. Fifty seniors participated in a semi-

experimental study for fourteen days to obtain anecdotal evidence. They
were divided into two groups: half of them, the control group, recorded
their movements manually; the other half wore Sookjai, a motion
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tracking device. Results show that the latter group spent most of their
time in the sit/stand posture; they tossed and turned when they napped
Abstract: and slept. Furthermore, both groups presented similar forms of
stances/movements; however, average hours per day of each motion
type differed significantly between the two groups. The control group
napped, slept, and travelled more but sat and walked less than the other
group. The device did not meet the seniors’ expectations owing to the
design; however, they did indicate a positive intention to use wearables.
Thus, design of tracking wearables should consider the psychological
issues and concerns of the elderly.

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3 Daily Use of Motion-tracking Devices: Pattern and Perspective of Independently living Thai Seniors
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6 Abstract
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8 This study examines how the elderly use and perceive activity-monitoring devices routinely. Fifty seniors
9 participated in a semi-experimental study for fourteen days to obtain anecdotal evidence. They were divided into
10 two groups: half of them, the control group, recorded their movements manually; the other half wore Sookjai, a
11 motion tracking device. Results show that the latter group spent most of their time in the sit/stand posture; they
12 tossed and turned when they napped and slept. Furthermore, both groups presented similar forms of
13 stances/movements; however, average hours per day of each motion type differed significantly between the two
14 groups. The control group napped, slept, and travelled more but sat and walked less than the other group. The
15 device did not meet the seniors’ expectations owing to the design; however, they did indicate a positive intention
16 to use wearables. Thus, design of tracking wearables should consider the psychological issues and concerns of
17 the elderly.
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Keywords:
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20 Motion-tracking devices, adoption of health-related wearables, independently living Thai seniors
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23 Introduction
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To cope with the aging society, the governments of developing countries, such as Thailand, must increase the
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26 healthcare budget for the elderly. Although government subsidies for health-related expenses have increased in
recent years, the rising cost of healthcare for seniors living at home with their families still significantly burdens
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the government budget. Sasiwongsaroj and Burasit discussed the problem of the public healthcare management
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system in Thailand;1 they pointed out that a report from the Ministry of Public Health indicated that the Thai
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government increased its healthcare budget for medical technologies. Like other developing countries, appropriate
30 public healthcare policies combined with cyber healthcare procedures can address healthcare cost issues.2
31 However, the determination of the kind of medical instruments and their equal distribution to the elderly in need
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32 becomes challenging.
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34 An alternative to providing costly healthcare services is to provide health improvement plans that aid the elderly
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in maintaining good health and an independent living for as long as possible. Lupton reviewed various aspects of
36 health promotion in the digital age and pointed out that effective health improvement programs employ personal
37 self-tracking devices that collect massive amounts of digital data to generate insights and knowledge for
38 preventive medicine and health improvement.3 Collecting health and activity data automatically with a self-
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39 tracking device will enable the elderly to be aware of their routines, e.g., daily movements. For example, some
40 seniors might sit and watch television all day long; others might walk and exercise a little bit in the morning then
41 sit and nap the rest of the day, causing insomnia and restlessness at night. Numerous older adults do not recognize
42 that prolonged hours of inactivity might jeopardize their long-term health and well-being.
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44 Caldeira and colleagues interviewed seniors who live independently in retirement communities about the
45 perception and emotional responses of self-tracking tools. They suggested further investigation on how to
46 integrate activity trackers into community care.4 Although mixed perceptions of the use of self-care devices by
47 the elderly were found, the study concluded that a health monitoring device for activity tracking can be part of the
48 solution for health improvement and fall detection of the elderly.
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A movement initiated by healthcare professionals and public health workers to initiate and foster seniors’ self-
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care by using self-tracking devices has been in action for over a decade.5, 6 The data from self-tracking devices
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can be readily made available to medical and public health promoters to monitor health-related habits and suggest
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preventive medicines or personalized health improvement programs. Nevertheless, the elderly may have
53 reservations about the use of these health tracking devices. However, individuals must realize that to obtain
54 convenient healthcare services, they may need to adopt health monitoring technologies and compromise their
55 health data privacy. Additionally, seniors also need to continuously learn and keep up with new technologies to
56 promote their quality of life.7
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3 Health Monitoring Wearables
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5 Many healthcare wearables introduced by popular brands, such as Apple Watch, Garmin Forerunner, Fossil Sport,
6 and Fitbit, tend to focus on the young and middle-aged adult markets. These wearables have numerous functions
7 for monitoring general health and exercises, with certain built-in functions, such as counting steps, heartbeat
8 monitoring, weight monitoring, and calorie-burning counts. Health monitoring applications in many smartphones
9 nowadays provide the same functions. Furthermore, many brands can connect to social networks so that users can
10 share their data to a broader audience. Health monitoring devices have matured as popular units in the Internet of
11 Things (IoT), which dominated the Gartner 2014–2017 Hype Cycle. The cycle displays technology evolvement
12 over time in five phases, starting with Innovation Trigger and then progressing to Peak of Inflated Expectations,
13 Trough of Disillusionment, Slope of Enlightenment, and Plateau of Productivity.8 Although artificial intelligence,
14 machine learning, and big data have been dominating the Hype Cycle in recent years, the sensor rich data of
15 wearables are gaining acceptance in healthcare communities owing to the development of the IoT’s no-touch user
16 interface design.9
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18 Health wearables for the elderly are gaining momentum; two of the most valuable functions of these wearables
are fall detection using Global Positioning System (GPS) and SOS or emergency code signaling for help. For
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example, the Dring Smartcane, which is not a wearable and received the 2017 CES Innovation Awards, detects a
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fall using motion sensors, an accelerometer, and gyroscope technology.10 Fall detection devices employ multiple
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channels, e.g., telephone, email, and SMS, to alert the caregivers and relatives in case of an emergency or a fall.
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22 The devices learn and understand with embedded artificial intelligence (AI) technology. In the case of abnormal
23 movements, i.e., movements that increase fall risk, a warning signal can be sent to medical personnel and relatives.
24 In Thailand, similar devices are available in academic laboratories; for example, fall-detection belts from
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25 Chiengmai University and King Mongkut’s Institute of Technology Ladkrabang in Thailand. However, most of
26 these wearables are not available commercially.
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28 Fall detection belts have the highest precision among wearables because they are positioned in the middle of the
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29 torso, but they are not user-friendly because they are bulkier than a regular belt. Although watches are the most
30 popular wearable, they are the least accurate devices for fall detection. To leverage recurring income, most
31 companies believe that one-time sales of the device are not sufficient; thus a subscription revenue model for fall
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32 protection and other home services is often used when a large customer base is expected.
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34 Many fall detection systems comprise a wearable pendant that connects to a base station or a hub. If a fall is
35 detected, the elderly can press an emergency button on the device to get assistance. The hub will send signals to
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36 the call center to direct an ambulance to the location where the accident occurred. Some well-known companies,
37 including Philips Lifeline, Medical Guardian, MedicalAlert, Alert1, and Life Alert, offer a wide range of
38 devices and services. The devices come in the form of clip-on gadgets, smartwatches, GPS-enabled mobiles,
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39 classic pendants, and base station sets. These brands’ business models charge a monthly fee for services with a
40 protection system. The customer will receive a wearable, a base unit, and a 24/7 medical alert system connected
41 to a monitoring center for approximately one US dollar a day.
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Owing to the language barrier and localized connections to Thailand medical centers and network operators,
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subscription to the mentioned services is not readily obtainable. Moreover, the living allowance for the elderly is
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less than USD 30 per month. This amount is barely enough for the elderly living alone with no family support to
45 cover the day-to-day living costs. With a fall detection device in mind, one entrepreneur in Thailand11 recognized
46 the economic limitation of Thailand’s aging society as a market opportunity. He worked with researchers in
47 various universities and developed a prototype pendant called Sookjai (meaning “happiness”). Sookjai is an
48 intelligent aid for the elderly that won the IFIA Best Invention Medal in the 2018 International Invention and
49 Innovation Show INTARG® in Poland.12 It also won the 2018 National Innovation Award in Economic.13
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51 Compared to other fall detection systems, this fall detection device made in Thailand is the most suitable. The
52 language barrier is no longer a problem for less educated individuals. Additionally, local wireless networks and
53 emergency services will no longer pose questions of connectivity and coordination. Sookjai has gone beyond just
54 fall detection. The hardware and its algorithm were improved to monitor subjects’ movements and analyze their
55 activity patterns. Moreover, users will receive feedback via a mobile application instantaneously; if longitudinal
56 data are available, a personalized activity pattern model can be formulated, leading to a customized health
57 promotion program, more extended independent living, and a better quality of life. Thus, to track the motions of
58 the elderly, this research chose the Sookjai system as the activity tracking wearable for the semi-experimental
59 study.
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3 Adoption of Health-related Wearables by Older Adults
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5 Only a few empirical studies are available to understand what makes the elderly accept health-related
6 technology;14 even fewer are found in developing countries, where retirement stipends barely cover the cost of
7 living.15 Garavand et al. did a systematic review of the factors influencing the adoption of health information
8 technologies.16 They asserted that the original technology acceptance model (TAM),17 the unified theory of
9 acceptance and use of technology,18 and the theory of planned behavior19 are appropriate to assess the adoption of
10 health information technology. Garavand et al. also reviewed the acceptance of health information technologies
11 and mobile health.20 There are many mobile health studies conducted with physicians and other treatment staff in
12 developed countries; however, similar studies regarding the elderly’s adoption in developing countries are scarce.
13 Most research is either general or addresses Internet adoption. For example, Sivathanu conducted a survey and
14 received 815 older adult respondents in Pune city and its suburbs in India. He used the behavioral reasoning
15 theory21 to examine the arguments in favor of and against IoT-adoption. The adoption factors include convenience,
16 relative advantages, ubiquity, and compatibility, whereas the adoption barriers include usage difficulty and risk
17 of healthcare data leakage.22
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One emerging solution in today’s healthcare policy is to use health-related technology to assist and promote the
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health of the elderly to live independently for as long as possible. However, designers of commercially available
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devices tend to bypass the daily use details and focus on the appearance, pricing, and acceptable technical design.
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Thus, more evidence is needed to understand how older adults use a motion-tracking device daily, especially in
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22 developing countries, where the cost of healthcare increases when the proportion of aging population increases.
23 Chittinandana et al. stated that by 2035, Thailand will become a hyper-aged society. They referred to the United
24 Nations (UN) definition: an aging society has 10% of its population aged 60 y/o and 7% above aged 65 y/o; an
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25 aged society has 20% of its population aged 60 y/o and 14% above aged 65 y/o; and a super-aged or hyper-aged
26 society has 20% of its population aged 65 y/o and above.23
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28 Some limitations from previous studies on physical activity tracking include the use of an interview battery or
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29 survey methods to assess the acceptance, card sorting exercise and focused group to determine monitoring needs,
30 and fitness trackers as health monitoring for older people.24-27 These studies provide retrospective insights on the
31 attitude and perception of device acceptance factors; however, they fall short of accessing real usage experience,
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32 especially by seniors, on a daily basis.

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34 This study examines the day-to-day use of an activity monitoring device. The semi-experimental research divided
35 participants into two groups: one group used a motion-tracking wearable device, and the other (control group)
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36 recorded manually their own motion-activity. The sample selection used the stratified random sampling technique.
37 Participants were drawn from the research survey respondents, focusing on three factors that influence the
38 intention to use health monitoring wearables: acceptance of personal health data collection, acceptance of
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39 technology, and acceptance of a health monitoring device.28 Theories behind the present study framework include
40 the health belief model (HBM),29 the technology acceptance model (TAM),30, 31 and behavioral aspects of personal
41 health record systems (PHRS).32, 33 Therefore, an integration of behavioral theories and biophysical characteristic
research frameworks should address today’s high priority research issue. In addition, research evidences from the
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present study should add to the scarcity of research regarding the perception and use of wearables for tracking
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physical stances in everyday life of older people in Asian countries.34 Moreover, the study overcomes the pitfalls
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of the literature because it is designed with a control group and a sample size (50 seniors) greater than the median
45 (26) found in a literature review of empirical studies of persuasive technologies.35 Furthermore, the findings can
46 add to the literature of usability and adoption of mobile tracking technology,36, 37 acceptance of in-home health
47 monitoring for aging in place,38 and data analysis model of a real-time personalized tracking experience.39
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49 Research Ethics
50 All participants were informed about the study objective and signed consent forms. Project number [omitted for
51 anonymized review] received ethical approval (CAO [omitted for anonymized review]) by the institutional review
52 board (IRB Human Group 1).
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55 Methods
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57 Sampling and setting
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59 The sampling frame consists of the elderly living in a Thai nursing home; the facility comprises eight buildings
60 with apartments for seniors having medical personnel available on-site 24/7. Most of the subjects are

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3 independently living single female retirees who are using their pension for their living expenses. In a related study
4 that entails pre-post surveys examining factors influencing the intention to use the wearable devices, 108 seniors
5 answered the pre-questionnaire, and 60 answered the post-questionnaire. The sample selection used stratified
6 random sampling to select 60 out of the 108 seniors who answered the pre-questionnaire: 30 of them were to wear
7 the device, and the other 30 were to manually record activities with a diary. The researchers sent out the invitation
8 letter explaining the semi-experimental study’s objective and description; 26 out of 30 (86.67%) volunteered to
9 use the wearable device called Sookjai and 28 out of 30 (93.33%) to record the activities in a diary manually. The
10 experimental group, consisting of the seniors who wore the Sookjai device, will henceforth be called the “Sookjai
11 group,” and the control group, composed of those who recorded their activities in a diary, will be referred as the
12 “Diary group” hereafter.
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14 Each participant is assigned an anonymous identification: “s#” is for those participants who use the wearable
15 device; “d#” for the participants who use a diary booklet to record movement and activities. After 14 days, only
16 50 respondents completed the experimental study owing to complications during this period: one of the
17 participants of the wearable group passed away after the data collection; his signal data were also incomplete
18 (s23). Thus, only 25 participants were counted for the Sookjai group. Two diary records from the Diary group
were unusable (d21, d26), and 80% of the data from another participant were missing (d19). Thus, only 25
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participants were counted for the Diary group. The final response rate was 83.3%.
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22 Table 1: Profile of Participants

23 Characteristic Experimental Control Total
24 Sookjai (n1= 25) Diary (n2 = 25) (n1+n2 = 50)
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25 Age 60–69 yr 7 (28%) 11 (44%) 18 (36%)

26 70–79 yr 9 (36%) 11 (44%) 20 (40%)
27 >= 80 yr 9 (36%) 3 (12%) 12 (24%)
28 Edu < Undergraduate 4 (16%) 5 (20%) 9 (18%)
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29 Undergraduate 17 (68%) 9 (36%) 26 (52%)

30 Graduate 3 (12%) 11 (44%) 14 (28%)
31 Congenital Disease No 6 (24%) 8 (32%) 14 (28%)
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32 Yes 19 (76%) 15 (60%) 34 (68%)

33 Fall No 14 (56%) 19 (76%) 33 (66%)
34 Yes 11 (44%) 6 (24%) 17 (34%)
35 Avg. Sensory Problems Mean, SD 1.77, 0.49 1.69, 0.49 1.73, 0.49
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(On a 5-point scale)

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Avg. Health 6 Months Mean, SD 3.08, 1.07 2.84, 1.06 2.96, 1.06
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(On a 5-point scale)
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Avg. Depression (9Q) Mean, SD 1.29, 0.24 1.41, 0.31 1.35, 0.28
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(On a 5-point scale)
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The participants’ profile is summarized in Table 1. The experimental group was older, less educated, had more
42 falls but had better health and less sensory problems and stress. Most of the respondents were female. The two
43 groups scored good on their health in the past six months (Health6mo). They saw themselves as having some
44 problem hearing, seeing, eating, and sleeping (PHSES). Their average scores of the 9 Questions Depression Rating
45 Scale for Thai Central dialect (Depress9Q) were low.
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47 Data collection
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49 Automatic Motion Tracking with the Sookjai Wearable
50 Subjects wore the Sookjai pendant to track their motions automatically in conjunction with a mobile phone
51 wireless network. Sookjai devices use materials that are safe for humans. The case is made of ABS plastic that
52 has a V1 level of fire resistance. The button and necklace strap are made of a silicone material: the two
53 Neodymium magnetic ends of the strap are attached to the pendant’s two hands (Fig. 1). The device has a fall-
54 detection feature with a button for sending an emergency signal to get help via a smartphone 24/7. The Sookjai’s
55 firmware works on standard protocols IPv6 over LoWPAN (low power wireless personal area networks) with
56 2.4GHz on an IEEE 802.15.4 standard. The pendant uses the USB type C charger and pairs with the Bluetooth of
57 a smartphone.
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16 Fig 1: Sookjai Pendant
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18 The Sookjai sends motion signals via the Internet using the mobile phone that links to a centralized server. The
19 server processes the signals and translates them into different stances or postures. One of Sookjai’s most useful
20 functions is to detect falls. If a falling motion is detected, the device will sound and send an alert signal to the
21 server that automatically connects to caregivers or relatives listed in the database.
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23 The application on the mobile phone displays the user’s motion on the fly. For example, the amount of time a
24 person is sitting, standing, or sleeping is recorded. Authorized personnel, such as the researchers or caregivers,
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25 can see the status of many users simultaneously. As shown in Fig. 2, users can see their average movement data
26 daily, weekly, and monthly as sections of a circle. There is an icon indicating the posture at any given time.
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39 Fig 2: Example screen on a mobile application that uses the Sookjai device
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41 The diary format for the control group passed the test of two experts who commented on the layout and ease of use
42 through two hours of in-depth interviews. Six elderly persons ran a trial diary record for seven days and did not
43 encounter any problem. From a pool of 108 people who answered the questionnaire, a stratified random sampling
44 across three age groups, 60–69, 70–79, and 80 years and above, was used to select 60 elderly individuals. The
45 experimental group and control group were required to wear the device or fill in the diary for 14 days. The
46 researcher spent 2 h explaining the research objective, training the participants on charging the wearable’s
47 battery, pairing the device with the mobile phone, working with the application, understanding its display,
48 among other things. Replacement of the device was made easy with the on-site coordinator, who helped answer
49 simple questions and monitored the situation to ensure that there were few signal transmission interruptions.
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51 Sookjai’s Algorithm and Codification
52 To develop the algorithm for Sookjai, the company invested in extensive research in the Thai context, i.e.,
53 employing Thai people in all tests and verification of fall positions, regular stances, and movement patterns. First,
54 an analysis of different postures or stances was performed to develop a general algorithm. The device with all the
55 necessary hardware was built and an algorithm that incorporates 16 fall positions programmed. Then, sample
56 data were collected to develop a robust model, verify and adjust its hardware and software to achieve the most
57 precise circuitry and appropriate algorithm for device construction. The developer chose the decision tree
58 classifier machine learning algorithm, owing to its greater fall/stance classification accuracy compared to other
59 algorithms, such as the random forest (ensemble), logistic regression, and deepnet. The chosen machine learning
60 algorithm considers the limitations of the IoT E-fall system’s components in Thailand, including a wearable

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3 device, a wireless communication network, an IoT gateway, and cloud services.40 However, the decision tree
4 model takes more time and is more complicated than other models because the if-else clauses for more than 37
5 nodes is computationally expensive for the wearable device’s microprocessor unit. Thus, the principal component
6 analysis (PCA) technique was employed to reduce the input data dimensionality prior to classification. When in
7 use, the device’s algorithm will analyze the pendant’s position and movement and determine what stance the user
8 is in (through classification) and send a corresponding code continuously, as shown in Table 2.
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10 Table 2: Algorithm for Pendant’s Position and Code for Subject’s Motion
11 Remove Signal Freq. The algorithm will check and evaluate the pendant’s
12 Stance Code
Device (Second) movement and
13 If it detects a fall position, it will wait for 10 seconds before
14 Fall 0 No 1 sending out the fall signal just in case the user would press
15 the button to cancel the fall data.
16 Sleep 1 No 2 Determine whether it is a sleeping position.
17 Toss &
18 2 No 2 Determine whether it is a turning position.
Turn
19 Sit 5 No 2 Determine whether it is a sitting position.
20 Stand 6 No 2 Determine whether it is a standing position.
21 Walk 7 No 2 Determine whether it is a walking position.
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22 When a fall position is detected and the user presses the

23 Dismiss button, the pendant will repeat Code 14 three times to
14 No 1
24 Fall cancel the fall signal. The device will reset itself within 4
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25 seconds before evaluating the next stance.

26 Charge The device will automatically send Code 15 when the
15 No 10
27 Battery battery is charged, regardless of what stance the user is in.
28 Depending on When the user presses the button, holds, and releases, the
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Remove
29 N/A Yes the stance at device will be in the removal mode. The active status will
Device
30 the time resume automatically after one hour.
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32 The mobile application and the device are linked through Bluetooth. The application takes the stance codes from
33 the database server, incorporates the GPS location information, recodes them, and displays each refined motion’s
34 timestamp and duration (Table 3).
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36 Table 3: Motion Recode and Process for Mobile Application Display

37 Display Recode Recode Criteria
38 Sitting or Standing (Code 5/6) + GPS location check in the application (no change or
Sit/Stand* 5
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39 very little change)

40 Walk* 7 Walking (Code 7) + GPS location check in the application (small changes)
41 Sit, stand, or walk (Code 5/6/7) + GPS location check in the application (small
Run* 9
changes)
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Travel* 12 Sit, stand, or walk (Code 5/6/7) + GPS location check in the application (big changes)
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* The analysis between sitting and standing shows no difference because the users spend little time on both stances; thus, the
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evaluation combines both.
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* Sit/Stand, Walk, Run, and Travel incorporates the motions evaluated by the device algorithm and the GPS location check
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from the application. If the mobile sends erroneous GPS data, the display stance would be incorrect.
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* Sit/Stand, Walk, Run, and Travel incorporates the motions evaluated by the device algorithm and the GPS location check
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from the application. The GPS data is used to calculate the speed of movement.
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Graph displays are based on approximating data (i.e., stance that lasts less than 5 minutes are removed) to reduce the visual
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display’s complexity and help see the overall picture.
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Motion Tracking with the Diary Booklet
53 Two specialists commented on the booklet’s font, layout, size, and method to fill the diary. The booklet was
54 printed on color paper (A4 size), folded in half, and packed in a light handbag with an erasable pen. The diary
55 recording process was designed to ensure mobility and ease of handling by the elderly. Six elderly individuals
56 tested the recording in the diary for seven days; they did not find any difficulty in recording their daily activities
57 and corresponding motions/stances. As when training for the elderly wearing the Sookjai device, the researcher
58 spent 2 h explaining the objective, obtaining a signed consent form, and distributing the diary booklet. Seniors
59 were asked to record their activities in the diary for 14 consecutive days.
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3 Two well-trained coordinators were designated to provide any assistance required by the participants. One person
4 was the caregiver at the nursing home, and the other was the research associate who was on-call 24/7. Both
5 coordinators monitored the device signals on a tablet that shows the status of all Sookjai users simultaneously.
6 They also assisted the Diary group with any questions that arose from the manual recording participation. The 14
7 days of data collection were during the last two weeks of January 2020. A post-questionnaire survey was sent to
8 all seniors in the nursing home in April 2020. Only 54 of them responded because many left the nursing home
9 and went to stay with their relatives during the first wave of COVID-19 in Thailand. The nursing home did not
10 allow any visitors for three months. In the middle of June 2020, the researchers had permission to organize the
11 focus group and obtain the movement results. The seniors, on-site caretakers, and the nursing home staff
12 participated in two group discussion sessions.
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14 Data Analysis
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16 From the semi-experiment, the movement data of the Sookjai and Diary groups were compared by first depicting
17 the average per hour of each stance for every person and then by age group. These averages per hour were cross-
18 checked with the data collected from a short open-ended questionnaire answered prior to the experiment asking
the subjects’ wake-up time and sleep time, daily routine activities (such as cooking, exercises, rest, and hobbies),
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the approximate number of hours spent on each activity, and whether there was a difference in these routines for
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weekdays and weekends. Then, Analysis of Variance (ANOVA) and T-test were used to analyze differences in
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the two groups’ stances on various dimensions of their health data.
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23 Since the wearable device used in this study can send toss and turn (T&T) signals, a descriptive analysis of these
24 signals of the Sookjai group is provided. An examination of the relationships of T&T signals during naps and
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25 sleeps with health data employs Kendal Tao-b statistic instead of Pearson Correlation owing to the small sample
26 size.
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28 Finally, a focused group discussion was carried out to verify the semi-experimental results and obtained
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29 feedbacks from selected participants of both the Sookjai and Diary groups. Descriptive anecdotal evidence is
30 provided on the experiences the seniors had during the semi-experiment, the problems and obstacles they
31 encountered, factors that would encourage them to use the device, and so on.
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34 Results
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36 This section organizes the analyses into four subsections: (1) comparison between the Sookjai and Diary
37 participants’ motions/stances; (2) examination of the relationships between the movement patterns and
38 demographic and health data; (3) analysis of the toss and turn data of the wearable device users with sleep
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39 duration; and (4) result verification and participant’s feedback.

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41 Motions/stances of Sookjai versus Diary
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43 This section compares the stances/motions of the seniors in the Sookjai and Diary groups. Fig. 3 shows scatter
44 plots of 50 participants in the semi-experiment. The y-axis in each scatter plot graph shows the average hours an
45 elderly spends on that stance. The x-axis was not displayed in the stance plots because sorting the data points
can give a better comparative view between the two groups of participants. Each square icon represents an
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individual from the Sookjai group, each triangle icon from the Diary group. Not all data values are shown in the
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figure because they would clutter the figure and distort the clarity of comparative data display in the two groups.
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Thus, only the maximum and minimum data values are given. The scatter plots show that although both groups
49 depict similar forms of stances/movements, the two groups’ average hours per day of each motion type differ
50 significantly. The Sookjai group sat and walked less, but napped, slept, and traveled more than the Diary group.
51 However, regardless of the age group, the Sookjai group spent the most average hours per day sleeping,
52 followed by sitting/standing. In contrast, the Diary group spent more time sitting/standing, followed by sleeping.
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32 Fig 3: Individual Seniors Ranked by Hours/Day of Stances and Motions

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34 Fig. 4 compares Sookjai and Diary groups based on the average hours per day of each stance or motion
35
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according to age groups. The pattern of stances appears to be similar among the three age levels of the Sookjai
36 and Diary groups. Elderlies who are 80 or more years old in the Sookjai group slept more than any other group.
37 The Diary group sit/stand more than the Sookjai group whilst sleep less and walk more regardless of age levels.
38 Those who are 60–69 years old in the Diary group sit/stand more than other groups.
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4 The t-test and analysis of variance (ANOVA) showed significant differences in the average hours per day of
5 various motions or stances exhibited by the elderly in the two groups (Table 4). The group wearing the Sookjai
6 pendant has a shorter average time of sitting/standing (6.55 h/day) than the Diary group (9.91 h/day). However, the
7 Sookjai group’s naptime (3.25 h/day) was more prolonged than that of the Diary group (0.76 h/day). Likewise,
8 the hours for night sleep and travel to places outside the nursing home for Sookjai users (10.04 h/day and 1.59
9 h/day, respectively) were higher than those of Diary recorders (7.17 h/day and 0.81 h/day, respectively). The
10 average time duration in every posture between the two groups differs at the 0.01 level of significance.
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12 Table 4: t-test and ANOVA of the Elderly’s Stance for the Sookjai Group versus the Diary Group
13
Motion/ Stance Sookjai (n1 = 25) Diary (n2 = 25) t-test, p F(df), p
14
Sit/stand 6.55(1.86) 9.91(1.66) t = -6.70*** F(1,48) = 44.98***
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Walk 0.69(0.49) 2.98(0.65) t = -14.01*** F(1,48) = 196.47***
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Nap 3.25(1.82) 0.76(0.54) t = 6.53*** F(1,48) = 42.70***
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Sleep 10.04 (1.25) 7.17 (0.80) t = 9.63*** F(1,48) = 92.73***
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Transport 1.59 (0.90) 0.81 (0.63) t = 3.52** F(1,48) = 12.43**
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Others 0.49 (0.35) 1.35 (1.67) t = -2.06* F(1,48) = 6.25*
20 ***p<.001, **p<.01, *p<.05
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22 The sleep hours from the short open-ended, self-reported verification questions were summarized and found to be
23 consistent with the automatic and manual diary data. According to the questionnaire, the Sookjai group slept more
24 than the Diary group: 7.72 h/day compared to 6.35 h/day. However, the semi-experimental data showed longer
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25 hours of sleep than the open-ended verification questions. The discrepancy might come from the elderly’s
26 estimation of their habitual sleep routine (i.e., go to bed at 10.00 PM, get up at 5.00 AM). The open-ended data,
27 combining those of both groups, show that one-third of the elderly reported that they cook often, do not play
28 sports, and regularly do exercise, such as walking, Tai chi, yoga, and cycling. Moreover, these seniors’ relaxation
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29 activities include watching television, listening to music, napping, reading books, and using social media. Finally,
30 approximately 75% indicated no difference between their weekday and weekend activities.
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32 Movement Patterns and Elders’ Demographic and Health Data

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34 Whether demographic and health data have any bearing on how the elderly move their torso was also tested; this
35 could provide some insight into the following: how to promote their health, age (Age), level of education (Edu),
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36 congenital disease (Illness), and whether they suffered a fall (Fall). These categorical data were subjected to an
37 ANOVA; the detailed analyses results are provided in Table A1–A4 in Appendix A. Other health measures,
38 sensory problems (PHSES), evaluation of own-health in the past six months (Health6mo), and depression
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39 inventory (9Q) from the Mind Center Thailand were subjected to Kendall’s tau-b correlation.
40
41 In most cases, the age group and movement pattern of participants were not significantly different. It should be
42 noted that the older the device wearers, the more time they spent sitting/standing and sleeping and less time was
spent on walking and traveling. In the Diary group, age does not make a difference in the time spent
43
sitting/standing. Seniors eighty years and older spent the most time sleeping and napping.
44
45
No statistically significant difference was found between the stance/motion and the educational level, or between
46 the stance/motion and the absence or presence of a congenital disease. For the sit/stand motion of the Sookjai
47 group, the elderly people who did not fall in the past two years sit/stand slightly more than those who did (Means
48 (SDs) = 7.10 (1.90), 5.84 (1.64), F = 3.008, p = .096). However, the Sookjai group with no college education
49 appear to sit/stand and walk more than those with higher education but nap, sleep, and travel less.
50
51 As summarized in Table 5, Kendall’s tau-b was used instead of the Pearson correlation coefficient, owing to the
52 small sample size, to determine the relationship between the movement patterns and health data. No statistical
53 relationship was found between PHSES, Health6mo, and Depress9Q. However, the Sookjai wearers who have
54 higher PHSES tend to walk and travel less, whereas the Diary people who have more PHSES appear to sit/stand
55 and sleep more.
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3 Table 5: Kendall’s tau_b of the relationship between Movement patterns and Health data
4 Group Sookjai’s Health data (n=25) Diary’s Health data (n=25)
5 Motion/Stance PHSES Health6mo Depress9Q PHSES Health6mo Depress9Q
6 Sit/stand .019 .147 -.123 .175 -.177 .074
7 Walk -.213 .016 -.054 -.150 .185 .011
8 Nap .012 -.131 .062 .063 -.063 .176
9 Sleep .174 -.098 .146 .188 -.071 .000
10 Travel -.237 .147 -.089 .070 .181 .014
11 Others -.132 -.041 .127 -.121 .059 -.120
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13 Toss and Turn from Sookjai Signals
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15 One feature of the Sookjai device is the ability to send toss and turn signals. Fig. 5 shows the toss and turn data
16 for each individual participant (y-axis) in the Sookjai group. The first two columns depict the average number of
17 T&Ts for both naps and sleeps (x-axis); the last two columns show the number of T&Ts per hour (x-axis).
18 Except for two seniors, S01 and S26, the numbers of T&Ts during sleep are much higher than those during
19 naps, owing to longer hours of sleep than nap. However, no obvious pattern can be observed from the number of
20 T&Ts per hour of participants of the Sookjai group. Each person appears to have his or her own T&T behavior.
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45 Fig 5: Sookjai Elderly Toss and Turn Data
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47 Analyzing the data of all Sookjai’s participants, Table 6 indicates that the tosses and turns per hour (T&Ts/h)
48 during a nap is about four times greater than that during sleep (11.99 times versus 3.29 times). A little over half
49 of the elderly (14/25) have less T&Ts/h at night. The length of sleep time shows some relationship with T&Ts:
the more the number of T&Ts during sleep, the more the number of T&Ts during a nap (Kendall’s Tau-b =
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0.411, p = 0.004). Moreover, the longer the nap time, the greater the number of T&Ts during both day
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(Kendall’s Tau-b = .400, p=.005) and night (Kendall’s Tau-b = .417, p=.003). The number of T&Ts was
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correlated with the elderly’s health data. No relationship was found between the number of T&Ts and PHSES,
53 Health6mo, and DEPRESS9Q. Neither was the relationship found with fall experience in the past two years of
54 the elderly.
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56 Table 6: Analysis of Sookjai Participants’ Toss and Turn data
57 Sookjai Group Nap Sleep
58 Avg. h 3.26 10.04
59 No of T&Ts 35.14 32.69
60 T&Ts/h 11.99 3.29

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4 Result Verification and Participant’s Feedback
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6 Seven device users and six diary recorders were in the focused groups. The discussion centered on the
7 experiences that the seniors had had during the semi-experiment, the problems and obstacles they encountered
8 from using the device, suggestions on the appearance of the device, factors that would encourage them to use
9 the device, and services that they might want from the device platform.
10
11 The device users indicated that they were stressed because they were conscious about wearing the device.
12 Notwithstanding the fact that the pendant was big and robust, the elders had an impression that they had to be
13 careful (S10). They worried whether they forgot to charge the battery or take it off while taking a bath (S08).
14 Nevertheless, one of the biggest problems was that they did not believe the data recorded by the devices. For
15 example, one senior did not think that she slept for 7–8 h even though the sensor’s automatic detection said so.
16 They also noted that the sensors did not show their correct stance: the devices reported a standing posture, but
17 they believed they slept through the night; the device said sleeping, but the elder said that she thought she was
18 driving but she might have laid down comfortably in the car. The seniors were also annoyed about the
separation between the silicone necklace and the pendant (S05). Because the strap is not adjustable, it rolled
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back and forth during the T&T, creating a fear that the wearer may be strangled while sleeping (S07).
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Some participants preferred a device that is not noticeable while wearing it. They also indicated that they did not
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22 want to be stressed by the faulty sensors (S10/fs6), that a brooch might be better (S05), or a smaller device with
23 a soft pendant and strap would be more user friendly (S03). Some were concerned that, because not all
24 apartment owners subscribe to an Internet service, the present device platform may not work.
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26 To motivate the independent living elderly further, the price of the device matters: renting is perhaps better than
27 buying because one would get services from the platform owner (S10). Additionally, most people would not
28 trade their government-subsidized allowances for the device. In terms of services, the elderly desire an
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29 interpretation of the data rather than the provision of mere data. For example, with the T&T tracking feature, the
30 elderly would like to know whether their T&T data were good or bad (S05). They also mentioned that the most
31 useful monitoring was the fall detection. Furthermore, personal tracking services to remind them of the distance
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32 they are away from home or to provide directions to prevent getting lost were preferred. In other words, they
33 would like a service that automatically signals caregivers or condominium staff to come and rescue them when
34 they lose their way (S03, S05). For this purpose, GPS location tracking will be most useful.
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36 Both the device users and diary recorders would like something such as games to reduce the possibility of
37 getting Alzheimer’s disease, (D30) or a robot to remind them to exercise, take their medicine, train their
38 eyesight, and move their hands and legs.
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40 The award-winning activity tracking device, Sookjai, is a relatively large pendant made from lightweight
41 materials and straps with two clipped magnets for easy attachment and removal. However, when being used on a
day-to-day basis, the attachment falls off, and the long leash sways while walking. The strap’s rubbery nature
42
causes the pendant to send unintentionally standing signals online because it is in a vertical position. Sookjai,
43
thus, does not present an altogether pleasant experience to the elderly because it was set up to be oversensitive
44
in fall detection. The false positive for fall detection is intentional, and the device did detect actual fall incidents
45 during the data collection period.
46
47 Pairing a wearable with a mobile phone becomes a de-facto standard of the health-related devices industry. The
48 activity tracking device used in the present study also has a mobile application to display the real-time signals
49 using easy to understand visualizations. The ability to see one’s movement instantaneously has its pros and
50 cons. The advantages were that seniors were eager to use the devices, cooperate with the experimental study,
51 and feel confident about possible fall detection. However, the problem is that the device’s wearers were worried
52 and kept comparing the instantaneous stance with what they saw on the mobile screen; if the movements are not
53 the same, then they felt agitated. For example, if the screen shows that they are sleeping while sitting, they
54 questioned the device’s accuracy. The constant checking of each motion activity was stressful for them.
55 Moreover, as the duration of the study was only two weeks, some elders appeared to feel the effect of
56 participating in the study and might not have acted naturally; they knew and were informed of being tracked by
57 the device automatically. Thus, the Hawthorne effect came into play.
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3 Discussion
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5 Modeling and analysis of individual motions from the signals transmitted from a wearable device can be quite
6 challenging. Seniors were sensitive to the device’s stability and the signal processing algorithm that links
7 directly to the mobile application. The current study points out the problems with the prototype device used in
8 this experimental study. The algorithm developer had set the Sookjai wearable to shake and make noises every
9 time a possible fall is detected; this playing-it-save principle was disturbing to some people. However, during
10 the study period, the device did send correct fall signals to the research associate’s tablet. The on-site helper
11 contacted the elder right away and was informed of falls. Thus, the prototype wearable does live up to its
12 reputation of being an excellent fall detection device.
13
14 The participants were also susceptible to the mismatch between the mobile display and the instant motion. This
15 finding shows a similar result to a study on a fitness band accuracy.41 The prototype device did not detect the
16 movement of older people accurately. Independently living seniors are perhaps more sensitive than others; they
17 are aware of the need to be self-sufficient all the time. Thus, a potential topic for future research is the
development of a personalized false-positive algorithm that caters to individual people. The signal processing
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with this type of algorithm would gain more acceptance than a one-size-fits-all algorithm. The combination of
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data science and user experience research that accounts for individual differences will promote continued
20
engagement and long-term benefits.42
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22 As suggested by Bourbonnais et al., studies on the need for technologies in a nursing home setting is relatively
23 scarce. A few studies emphasized the administration and leadership of nursing homes’ technological
24 implementation.43, 44 In contrast, the present study focused on the nursing home’s residents. The findings of this
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25 study support previous literature findings stating that demographic and health data influence seniors’ self-care
26 behaviors. Those anxious about self-care activities are likely to be more educated.45, 46 Health-conscious people
27 tend to seek information from the Internet and adopt health-related technology.46, 47
28
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29 Designers of wearable devices are often technologically driven. However, an efficient and useful device requires
30 collaboration between designers and users.39, 48 For example, home-use medical devices and activity tracking
31 wearables can have both a positive and a negative psychosocial impact on the users.49 It should be noted that
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32 although the device tracks motion in real-time, a hypothetical bias may occur because the participants might do
33 things differently from what they would do daily during the experimental study.50
34
35 Similar to previous research, this study found that the Sookjai wearers want to evaluate their ability to live
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36 independently51; seniors in this study fit the profile: they live alone, want to be independent for as long as
37 possible, and are interested in using the device for health promotion. They expect the device to be stable, detect
38 falls accurately, link to mobile applications seamlessly, and feature the GPS system to receive immediate help
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39 when needed. One important feature the elderly would like to have is location tracking, because the participants
40 foresee getting lost when they go outside the apartment complex owing to their deteriorating memory. The built-
in GPS will give peace of mind to these independently living seniors.
41
42
43
44 Conclusion
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In Thailand, older people want to live in their own home, even if it means to live alone. Research addressing the
46
personalized, predictive model of activity pattern with the local language is essential to the elderly. To develop a
47
reliable analytic predictive model for individual motions, the input from automatic signals and other vital signs
48
are required; however, security and the amount of data needed for prediction has become a limitation with the
49 relatively limited economic resources. Although the device’s appearance and stability are influential factors, the
50 algorithm developed in this research can be used as a prototype for further development into a personalized
51 version. The ability to analyze the motions and activity patterns of each individual can help deploy an effective
52 health promotion policy.
53
54 The findings from this research add to the empirical evidence supporting a hypothesis stating that a routine use
55 of a motion tracking device would be beneficial for personalized health promotion for the elderly. For example,
56 the stance patterns that emerged from the seniors’ routine could deteriorate their health in the long run. Knowing
57 these patterns allow seniors, caretakers, and healthcare professionals to select a suitable health promotion
58 program. However, the semi-experimental study has limitations owing to a short duration of intervention study
59 from a single site and the use of an imperfect tracking device. Although the study used the older adults from an
60 Asian country, no comparison has been made regarding monitoring activities with the independently living

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3 seniors from any western countries. A possible underestimate and overestimate of stance times found in this
4 study may exist, and further investigations of seniors’ behaviors from eastern and western regions would be
5 useful for contributing to the literature in this field.52 Future research should overcome these limitations in order
6 to attain better data to develop a more accurate activity model that can cater to the individual needs of each
7 senior, thus eventually yielding personalized health promotions schemes and a better quality of life.
8
9 Acknowledgment
10
11 The authors disclosed receipt of the following financial support for the research. This research is part of a larger
12 research project supported by [detailed omitted for double-anonymized peer review]. We thank all seniors and
13 personnel in charge at the nursing home [detailed omitted for double-anonymized peer review]. We also would
14 like to thank Editage (www.editage.com) for English language editing.
15
16
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17 studies for assessing free-living sedentary behaviour. PloS one 2017; 12: e0186523. 2017/10/19. DOI:
18 10.1371/journal.pone.0186523.
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3 Appendix A
4 Stance/Motion and Demographic Data
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6 Table A1: Mean (SD) of Motion by Age Group (n)
7 Group Sookjai Diary
8 Age group 60-69 (7) 70-79 (9) >=80 (9) F (2,23), p 60-69 11) 70-79 (11) >=80 (3) F (2,23), p
9 Sit/stand 6.10(2.07) 6.57(1.64) 6.87(2.05) F=0.32, .730 10.23(1.56) 9.54(1.93) 10.07(4.76) F=0.46, .633
10 Walk 1.12(0.54) .66(0.30) 0.39(0.39) F=6.09, .008 2.90(0.55) 3.02(0.79) 3.06(0.59) F=0.11, .892
11 Nap 3.72(2.25) 2.78(1.25) 3.36(1.86) F=0.52, .600 0.52(0.35) 0.88(0.53) 1.27(0.85) F=3.12, .064
Sleep 9.73(0.94) 9.53(1.01) 10.79(1.41) F=3.00, .070 7.09(0.95) 7.16(0.74) 7.54(0.46) F=0.35, .703
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Travel 1.77(0.58) 2.17(0.94) 0.86(0.53) F=7.74, .003 0.69(0.74) 0.91(0.61) 0.86(1.74) F=0.33, .724
13 Others 0.71(0.41) 0.46(0.39) 0.51(0.35) F=2.31, .123 1.11(1.23) 1.77(2.16) 0.68(0.61) F=0.68, .517
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15 Table A2: Mean (SD) of Motion by Educational Level (n)
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17 Education <Undergrad Undergrad Graduate F (2,23), p <Undergrad Undergrad Graduate F (2,23), p
18 Level (3) (17) (3) (5) (9) (11)
19 Sit/stand 7.92(1.06) 6.53(1.76) 4.92(2.79) F=1.57, .227 9.26(2.46) 9.84(1.27) 10.26(1.61) F=0.61, .551
20 Walk 0.99(0.64) 0.70(0.48) 0.70(0.42) F=0.53, .663 2.67(0.86) 3.02(0.49) 3.07(0.68) F=0.66, .524
21 Nap 1.99(0.92) 3.37(1.81) 4.50(2.49) F=1.28, .308 0.75(0.50) 0.79(0.61) 0.75(0.56) F=0.19, .981
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Sleep 9.76(0.70) 9.85(1.28) 10.17(.65) F=0.34, .795 6.99(0.81) 7.07(0.51) 7.34(1.01) F=0.42, .663
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Travel 1.45(0.76) 1.62(0.92) 2.17(0.85) F=0.66, .583 0.99(0.47) 0.59(0.60) 0.90(0.71) F=0.85, .439
23 Others 0.36(0.07) 0.57(0.40) 0.29(0.13) F=0.74, .541 2.44(2.79) 1.37(1.45) 0.83(0.99) F=1.68, .209
24 Note: 2 missing data in the Sookjai group
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26 Table A3: Mean (SD) of Motion by Congenital Disease (n)
27 Group Sookjai Diary
28 Congenital disease No (6) Yes (19) F(1,24), p No (8) Yes (15) F(1,22), p
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29 Sit/stand 5.83(1.95) 6.77(1.83) F=1.154, .294 9.59(1.70) 9.94(1.71) F=0.226, .640

30 Walk 0.56(0.34) 0.73(0.53) F=0.581, .454 3.13(0.39) 2.87(0.76) F=0.807, .379
31 Nap 3.78(2.14) 3.09(1.74) F=0.650, .428 0.66(0.71) 0.77(0.48) F=0.219, .645
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32 Sleep 9.71(0.92) 10.15(1.34) F=0.551, .466 7.26(0.71) 7.25(0.83) F=0.002, .962

Travel 1.77(1.10) 1.53(0.85) F=0.325, .574 0.72(0.81) 0.82(0.52) F=0.119, .733
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Table A4: Mean (SD) of Motion by Fall Experience (n)

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Fall experience Never fall (14) Fall (11) F(1,24), p Never fall (19) Fall (6) F(1,24), p
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Sit/stand 7.10(1.90) 5.84(1.64) F=3.008, .096 9.71(1.64) 10.52(1.76) F=1.075, .311

39 Walk 0.79(0.46) 0.56(0.50) F=1.361, .255 2.95(0.67) 3.07(0.62) F=0.155, .697
40 Nap 2.84(1.69) 3.78(1.91) F=1.692, .206 0.77(0.61) 0.76(0.25) F=0.000, .996
41 Sleep 9.71(1.38) 10.46(0.94) F=2.363, .138 7.22(0.87) 7.05(0.57) F=0.190, .667
42 Travel 1.77(0.89) 1.35(0.89) F=1.344, .258 0.82(0.69) 0.77(0.41) F=0.032, .859
43 Others 0.50(0.34) 0.48(0.38) F=.037, .849 1.41(1.81) 1.14(1.24) F=0.111, .742
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