Introduction

Most people have a strong desire to remain in their own homes for as long as possible [1]. Middle and older aged adults report feeling strongly connected to their home and community [2]. Home is described as a place to enjoy privacy and feel free and comfortable [3]. Both the home and the objects within the home provide the sense of being surrounded by memories [4]. Furthermore, the home is considered to be the person’s base within their community which contributes to their identity and lifestyle [5]. The alternatives to remaining at home include moving to another house or to residential care either within or outside of one’s existing neighbourhood. Negative views about residential aged care are common and there is a perception that residents are lonely, lack autonomy and have poor quality of life [6].

Approximately 74% of older Australians rate their health as being good, very good or excellent [7], and most older Australians either rent or own private dwellings (99% of people aged 65–74 years and 75% of people aged 85 and over) [1]. However, as age advances, the ability to remain at home may be compromised [7] with only 66% of people aged 90–94 living in a private dwelling. Functional decline, cognitive impairment, limited social support and onset of chronic health conditions are the main predictors of nursing home admission [8–10]. Poor home environment may also trigger a move or change in housing and living arrangements. Large properties, homes that require significant maintenance, poorly designed bathrooms and flights of stairs are among design features that pose challenges to remaining in one’s home. Middle and older aged people face complex choices as to whether update or modify existing homes or move to a home which is more appropriate for ageing. Despite common perceptions, moving to a retirement village is uncommon [1]. A further consideration is whether the person may move into alternative housing but remain within their existing community [11]. Pani-Herreman et al., describe the complexity of the ‘ageing in place’ literature where the ‘place’ is not just the home but includes the person’s social networks and supports [12].

The World Health Organization is calling for improved age-friendliness of communities [13] but at an individual level there are many home modifications [14] that can be made to increase the accessibility and age-friendliness of a house including installation of grab bars, shower modifications (installation of seat and hose), removal of loose flooring (rugs) and improved lighting. These types of modifications are recommended and prescribed by an occupational therapist following a home assessment. Occupational therapists may draw on a range of existing home assessment tools to assist their practice [15,16]. Most tools have been developed for administration by a health professional, for use with older people who already have disability and the goal of most tools is to prevent falls or injury [17]. There is strong evidence from randomised trials that home assessments completed by an occupational therapist improve function in older people and reduce the rate and risk of falls among older adults [18]. However, access to occupational therapy home visits is limited; they are usually available only after injury or illness and are often limited in rural areas. Workforce shortages of allied health, particularly in aged care, further compound the problem and mean that exploration of other solutions is warranted.

This current project is part of a program of work which seeks to develop and validate digital tools so that middle and older people can take a proactive approach and assess their own homes in preparation for ageing within the home. The tool is intended to be used for future planning and therefore predominantly for use with people who do not yet have significant disability but are thinking about how they may manage at home as they age. A proactive approach to ensuring age-friendly housing may result in prevention of injury, supporting older people to stay safely at home for longer and reduced costs to the individual and society. Self-assessment methods are becoming more popular over time for several reasons. Firstly, there is good evidence that patients that are active in managing their own health and social care have better health outcomes and more positive care experiences [19]. Secondly, the public are increasingly searching online for health information. An estimated 80% of Australians report searching for health information online [20]. It is important that the public have access to tools which have credibility and validity. Thirdly, many countries are experiencing both an ageing population and workforce shortages and so solutions to manage demand are required.

Participatory research and co-design processes are being increasingly used to develop new technologies which are both useful and usable for the intended group. Involving end-users in the design process may also increase empowerment in participants [21]. Research to date has shown that participants involved in the process require information, time and a range of interactive activities in order to fully participate as designers rather than strictly as consumers of health care products [22]. Older adults, in particular, may benefit from low-tech and varied approaches to co-design [23]. This project uses a co-design process and a variety of activities to understand older adults’ perspectives on a suitable home for ageing and create a useful and usable tool. The development process differs from the development of other home assessment tools which have been developed by health care professionals with the aim of maximising safety and managing risk.

Methods

Co-design workshops were held with older people to understand their experiences and capture their views and preferences for the development of the digital tool. This research was approved by the Flinders University Human Research Ethics Committee (Project number 4523). The co-design process included involving end users in the process of design. There are various approaches to co-design including some specifically intended for digital health development and inclusion [24].

In this research, the co-design process was structured according to the British Design Council’s Double Diamond Design Process [25]. Four overlapping stages took place and included:

1. Discover: Working with community members to understand their experiences and generate a wide variety of potential inputs into the design process
2. Define: Working with community members to distil the initial contributions into a series of challenges that might be taken forward into a prototyping process
3. Develop: Using rapid prototyping tools to develop initial ideas for a digital intervention
4. Deliver: Translating the outputs from the co-design process into a series of design principles that have been taken forward into development.

Qualitative data were collected via written work and audio recordings.

Results

Fifteen members of the public (nine women and six men) aged over 60 were recruited to participate and attend the two workshops. Of the 15 recruited, two were unable to attend workshops due to illness, and one was only able to attend one workshop due to its location. Attendance therefore was 12 participants in the first workshop and the same participants along with one additional participant (n = 13) in the second workshop.

Develop and deliver (Workshop 2)

Appraisal of existing tools.

Three small groups appraised existing self-assessment tools to identify helpful and non-helpful features. Positive attributes identified included simple checklists and language that was easy to understand but that didn’t “talk down” to the audience. Presenting the checklist as questions for the reader (with answers) was viewed as being more engaging and inviting participation in contrast to fact sheet type information. Websites that contained visually appealing images and were easy to navigate (“so you didn’t go round in circles”) were highly regarded. Negative attributes included small and dense text including too much jargon. Sites which looked “home made” and lacked visual appeal (“lack of contrast”, “images too small”) were poorly received. Information which was patronising or adopted a “fearful” tone were also unpopular. Participants also were sceptical of credibility of information (“what does 300^th most walkable neighbourhood mean?”, “Evidence–from where?”).

What the app might look like.

Common features were grouped into categories. Categories and examples are presented in Table 1.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 1. Desirable features of a home assessment application.

https://doi.org/10.1371/journal.pdig.0000069.t001

Implementation considerations.

Participants identified friends, local advocacy groups for older people (i.e., Council of the Aged), local councils, newsletters, social media, mainstream media, general practitioners and government websites as possible sources of dissemination for the digital health tool. Being available on a website or their mobile phone’s App Store were the most likely sources of access. They believed they would use it if they were interested in the topic or had been recommended use by a family member or friend. This may have also been triggered by a change in functional ability. Participants identified that it would be helpful to have some sort of record stemming from the self-assessment which they could use as an action plan and could use this to work from as time and budget allowed. They also felt it would be useful to being able to amend their assessment over time.

Discussion

The data generated from the workshops enabled the development of a blueprint for a digital tool for self-assessment of the home environment. The co-design workshops revealed that participants had good insights into the effects of ageing and how this might impact on their ability to live within their own home. They were able to identify what was important to them about ‘home’ and had ideas about what would be needed in order to modify their own homes. The two workshops provided participants with the time and information needed as well as varied activities to enable the participant to think as a designer.

Our research questions included wanting to understand what features a home self-assessment tool may include and a clear idea of important features was established (as presented in Table 1). The data revealed which characteristics of self-assessment tools were desirable and undesirable and participants reported that clarity, credibility, tone of language, easy navigation and visual appeal were important. In preparation for implementation, it was important to understand how such a tool could be implemented in practice and participants suggested dissemination through a range of avenues including media.

Data from the ‘day in the life’ activity suggested that most participants believed that a digital tool would be useful in developing an action plan for improving the age-friendliness of their homes, and that it could increase the scale and reach of existing home safety programs. In particular, the digital approach was as acknowledged as being an opportunity to provide advice and guidance before a critical event triggered the need for immediate action. This shift from reactive to proactive engagement in home modification was implicit in the rationale for the project but not specifically raised with participants which makes its emergence through the co-design process a positive affirmation of the digital assessment approach.

Participants reported the need to consider many features of the home which are currently addressed in home assessment checklists designed for use by health professionals. Current home visit checklists tend to focus primarily on safety and access. Existing tools frequently consider safety features such as handrails and slippery floors [15,26]. It was clear from the participants that while these were important there were many other features of the home that contribute to comfort. There is less often discussion about the home as a space for being creative and to pursue leisure activities. Our participants suggested adaptations to the home and spaces over time are necessary yet changes in home layout and use of spaces are seldom considered in practice. Participants also frequently discussed the need for home to be a pleasant and comfortable environment with access to outdoors, fresh air, views, warmth and light (as seen in the data provided in the appendices). These features of a home were discussed as being desirable but are not currently addressed in home assessment tools used by occupational therapists in clinical practice [15–17].

The provision of spaces for leisure activities while also keeping the home “free of clutter and obstacles” presents an interesting insight into the challenge of downsizing or moving to a retirement village. In contrast to the belief that as people age “extra bedrooms” are no longer necessary, the use of these spaces as leisure and creative spaces may be underestimated. Similar findings have been found in other recent research [27] with social, creative and cultural activities highlighted as important uses of “extra bedrooms”.

Another issue raised by participants was not just their ability to age successfully within the home but within the community. Current approaches tend to assume that older people are relatively immobile and rarely leave the home. In contrast, data shows that many older people are active in their communities with 87% visiting people outside their home and 28% going on holiday with others in the last 3 months [7]. These findings demonstrate the importance of considering the person’s community environment in addition to their home environment. Maintaining social and community participation as much as possible over time are associated with successful ageing and both individual and community efforts are required to achieve this outcome [28,29]. It is also possible that the purpose of a home assessment may be to help the person come to the realisation that the current home or community is not suitable for ageing and that moving to another dwelling within their community or to another community may be more appropriate than pursuing home modifications. It may be appropriate to stimulate these conversations at a time when people have the financial, emotional and physical resources to move (earlier in the ageing journey).

At the conclusion of the workshop, the desirable features and characteristics of a digital health tool for home self-assessment were apparent. The next step in this research is to develop the prototype and test the usability of the digital health tool with the intended population and refine the tool as needed. Finally, we will explore levels of agreement between self-assessment (conducted by a middle or older aged member of the public) and an occupational therapist will be explored.

A number of limitations in this co-design project should be acknowledged. Recruitment of participants via social media (Facebook) likely resulted in a lack of diversity excluding those from lower sociodemographic backgrounds and with lower levels of digital literacy. However, the profile of the end users of the digital health tool is likely similar to those who use Facebook. The workshops did not include people with disabilities significantly affecting their mobility as their access needs and therefore modifications required are likely to be much more complex requiring occupational therapy assessment and input. Work is required to consider alternative solutions for other populations.

Conclusion

In conclusion, supporting older people to remain independent in their own homes and communities is a mutual goal of older people, policy makers and governments. This co-design process affirmed that a digital tool would be acceptable and useful in assisting middle and older people with decision making. Participants identified important aspects of ageing in place beyond standard home modifications which will be incorporated by the researchers in the next phase of this research.

Supporting information

Acknowledgments

We wish to thank the participants who attended and actively and generously participated in the workshops.