Personal characteristics.

The research team consisted of three health psychology researchers, one computer scientist and one general practitioner. The lead author (DH) conducted the interviews. At the time the interviews were conducted, DH had completed an undergraduate degree in applied psychology and a master’s degree in health psychology. DH was a PhD student completing research in the field of health psychology. He was a 25-year-old man. To date, DH had completed a systematic review and thematic synthesis exploring older adults’ experiences and perceptions of IVR [16]. DH was a frequent user of ubiquitous digital technologies such as smart phones, personal computers, and activity watches. DH also had three years of experience using IVR technologies by the commencement of this study.

Relationship with participants.

No relationship was established with the participants prior to study commencement. Participants knew that the interviewer was a PhD student exploring if IVR could be used to support retired and non-working adults over the age of 55 to reduce their time spent sedentary.

Patient and public involvement.

A patient and public involvement (PPI) panel was formed to contribute to the design of the study. The panel consisted of two retired adults over the age of 55. During the study design phase, the PPI contributors were invited to consult on the development of the interview schedule (see S1 Text). Their feedback led to significant changes to the wording of the interview schedule, to make the questions clearer and more accessible to the general public. The PPI contributors were also consulted about the wording and appearance of the study advertisement flyer.

Theoretical framework.

Reflexive thematic analysis was the chosen method of analysis for this study, providing an epistemologically and ontologically flexible approach to qualitative analysis. As a result, it is a method that can be used across a range of research contexts. The current study aimed to explore the content for a behaviour change intervention with retired and non-working adults. Therefore, this study is grounded in a critical realist ontology and contextualist epistemology [21], to allow for subjective meaning to be explored with each participant–such as their views on how comfortable the IVR equipment is or their preferences regarding goal setting–but also rooting this subjectivity within the context of a single reality [22]. This requires the researcher to interpret, to an extent, why each participant holds certain beliefs by considering forces such as cultural norms or physical capabilities. Furthermore, reflexive thematic analysis enables patterns to be generated across the data.

Ethical statement.

Ethical approval was granted for this study by the University of Galway Research Ethics Committee (application reference number: 2021.05.008). At the beginning of each interview session, participants were invited to read the participant information sheet which explained why this research was being conducted and what was involved in taking part. Once participants verbally confirmed that they understood everything on the participant information sheet and agreed to continue with the study, formal written consent was obtained from each participant.

Participant selection.

Purposive and convenience sampling as well as snowballing were employed to recruit participants for this study. The recruitment strategy and inclusion criteria were developed based on the aims of the study as well as the broader PhD research project. These are reported in Tables 1 and 2 below.

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Table 1. Recruitment Strategy.

https://doi.org/10.1371/journal.pdig.0000210.t001

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Table 2. Inclusion Criteria.

https://doi.org/10.1371/journal.pdig.0000210.t002

Potential participants were approached through several channels. A flyer was created containing information about the study, the lead author’s contact information and a prompt to make contact if interested. Members of the PPI panel assisted with recruitment by providing retirement organisations with the study flyer. Study flyers were posted on social media and national newsletters of various retirement organisations and other support groups for older adults. Twelve participants were included in the study. No participants who were contacted directly after providing their contact details refused to participate, and no participants dropped out. Recruitment continued until it was determined that information power had been reached [23].

Setting.

Data collection took place in a spacious, ventilated room on the University of Galway campus. A second researcher was present during the first IVR activity to mitigate any risks of falling during this activity. It was decided after this interview, however, that a second researcher would not be necessary as there were no safety risks that required their assistance.

Data collection.

The interview schedule was informed by systematic review data exploring older adults’ experiences and perceptions of IVR [16], the TDF [19], and the wider literature relevant to the study. Participants were asked to complete the “sitting time” section of the International Physical Activity Questionnaire [24] (see S1 Table), to confirm they spend six or more hours each day sedentary, as well as a demographic questionnaire (Tables 3 and 4, and S2 Text). Four participants described themselves as “not working” and the reasons given included medical conditions, child rearing and caregiving. No repeat interviews were carried out. An audio recording device was used to collect the interview data, which was then transcribed verbatim. Interviews lasted between 33 and 86 minutes. Field notes were collected after each interview in the form of a reflexive journal.

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Table 3. Participant Demographic Information (1).

https://doi.org/10.1371/journal.pdig.0000210.t003

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Table 4. Participant Demographic Information (2).

https://doi.org/10.1371/journal.pdig.0000210.t004

Using IVR during the interview session required participants to wear the equipment and interact with the computer-generated environments displayed to them through the head-mounted display using the hand-held controllers. The Meta Quest 2 was used to facilitate participants’ virtual reality experience [25]. A recent systematic review [16] indicated that Meta Quest equipment was suitable to be used with older adult cohorts. Participants experienced a virtual environment co-developed by the lead researcher in collaboration with a human-computer interaction researcher and a games developer. The training environment was named VR FOUNDations (Virtual Reality Familiarisation envirOnment for older adUlts with aND without dementia). Images of this training environment can be found in Fig 1 below.

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Fig 1. Images of the VR FOUNDations Training Environment.

https://doi.org/10.1371/journal.pdig.0000210.g001

Immersive virtual reality: The cover versus the contents.

This theme illustrates participants’ views on IVR prior to use followed by their views after experiencing it during the interview session. The majority of participants had never used IVR before, but the few who had recounted a positive experience with the technology:

“I find that the facility [a virtual environment] to be able to walk through your house, room by room, and, and the outside gardens, and upstairs and downstairs, an unbelievable experience to have”.

A pattern identified while exploring participants’ thoughts on IVR prior to use was their uncertainty around how this technology could be used in their own lives, particularly to reduce their sedentary behaviour:

“I think when I use it [IVR] maybe… I really have to use it to see what is [sic] going to give me or what benefit it will be for me, you know?”.

Variations of this uncertainty were made by all participants prior to experiencing IVR. Some concerns were also raised prior to use, with a number of participants worried they would feel claustrophobic during the experience or would not be able to use the equipment. Despite these hesitancies, however, almost all participants were interested in finding out what IVR could offer as a tool to manage health, such as reducing sedentary behaviour, as well as a way of trying something that could be enjoyable. For example, prior to experiencing IVR during the session, one 72-year-old man with previous experience using IVR shared his thoughts on the potential for the technology, “it’s unbelievably good… opens a mind-boggling sphere of opportunities for older people”.

Participants’ impressions after experiencing IVR were generally positive, with words such as “spectacular” and “fantastic” used to describe it. Participants saw IVR as a novel type of learning environment which brought with it the opportunity to broaden their imagination in new and challenging ways. Participants were pleasantly surprised by the capabilities of IVR, not realising it could offer such an immersive experience, “Because it could be so vivid… I wasn’t expecting it to be… in as much detail as it was”, with many even finding it difficult to put the experience into words. In contrast, participants also felt a technology such as this could be misused:

“I think it has the potential of, of wonderful stuff. It’s no more than the internet. It could… bring [you] to the end of the world, it could also bring you torture”.

The comparison to the internet here suggests that this participant is aware of IVR’s potential for good but also cautious about what unforeseen adverse effects a technology like this could have.

After experiencing IVR, participants shared that they were intrigued by feelings such as presence, immersion, and the added agency which IVR could simulate. Almost all participants felt physically present in the virtual environment. This feeling brought about a range of different reflections, with participants awe struck by the experience, amazed that a digital technology could make them feel like they are somewhere else, “that you could feel you’re, in a place that’s 1000s of miles away, maybe? It really is… It’s hard to believe that it can be done”. The feeling of being physically present in the virtual environment was universally received as a novel experience that brought about a sense of wonderment and for some participants it was seen as an opportunity to escape reality for a while, like a form of respite or retreat.

Many participants also acknowledged the added agency IVR brought about by its interactive nature. The hand-held controllers gave participants a form of “power” over their actions in the virtual environment, enabling them to interact with objects in similar ways to the real world, such as picking up different objects and moving them to different places. A common pattern across the responses of participants who discussed this phenomenon was that the more freedom, or fewer limits, they were afforded to explore the virtual environment on their terms, the more enjoyable and meaningful the experience was. In contrast, some participants experienced a reduced sense of agency as a result of the novelty of the immersive experience–with participants nervous about falling as they did not trust their footing when immersed in the virtual environment and blinded from the real world.

Participants also shared why they would return to IVR in the future and the conditions under which they would do so. At the beginning of the interview session, it was made clear to each participant that the aim of this project was to explore if they would be interested in using IVR to reduce their time spent sedentary. However, after trying the technology, some participants were only interested in using IVR to take part in activities they could ascribe meaning to, rather than to reduce their time spent sedentary, “I would use virtual reality simply because I would enjoy [it]. It would be nothing to do with being sedentary”. Participants also believed that persistent use would make them more proficient users of IVR, indicating that many believe this technology is one they can master. There were also a range of activities that participants were interested in experiencing in IVR (see S2 Table). Interestingly, a number of participants wanted these activities to be risky and stimulating, and more specifically, activities that they would be too frightened to do in reality. This feedback illustrates that participants see IVR as a means to broaden the range of activities they can take part in.

Ironing out the (Behavioural) details.

This theme focuses primarily on how best the IVR experience can be facilitated for retired and non-working adults. Feedback from this part of the analysis was mapped onto domains of the TDF where appropriate (see S3 Table) and also organised into new interpretations that stand outside of this framework.

Learning the Ropes. This subtheme focuses on the preferred conditions under which retired and non-working adults would like to learn how to use IVR. Participants generally found the IVR learning curve easy, “…I found it okay. Nothing complicated about it, really”. Most only needed a few minutes to become comfortable with the controllers and navigating the virtual environment. Most participants also indicated that they would prefer to learn how to use IVR with someone present who had experience using the technology. Participants generally felt this was necessary as a kind of “stand-by” support to make sure nothing goes wrong, rather than the need for any major assistance, “…you’re kind of vulnerable and you want I suppose you want someone there just in case something happens”. Participants gave up their sense of sight while in the virtual environment, making it critical for many of them to have someone physically present initially to get used to that experience. There was also wide support for accessible written instructions which users could reference if they were ever uncertain about any of the features of IVR. The various combinations of instructions suggested by participants can be found in the supported information section (see S4 Table).

A number of participants were also interested in learning how to use IVR in a group environment. Group learning was seen as a motivator for them to learn how to use IVR as well as a more enjoyable means of doing so:

“I think maybe even presenting it to a group of people in a group. Because that way, you have a bit of interaction, and you can make it a fun thing”.

Importantly, participants believed other people who were also learning how to use IVR could be more approachable than a more experienced, and supposedly younger, facilitator alone–indicating a need for an approach where experienced and less experienced IVR users learn together. This form of social support appeared to be important for some participants when considering how best to learn how to use IVR. Some participants noted that they would like a graded learning experience, with various conditions attached to these (see Table 2). Of note, the learning environment they were presented during the interview (VR FOUNDations) was deemed sufficient, suggesting a similar template could be used in future iterations to introduce participants to IVR. Some participants stressed that IVR is more appropriate for practical activities, referring to refining the skills required to interact with the virtual environment, rather than information gathering–referring to the passive consumption of information; whether it be in video, audio or text format in the virtual environment. This conflicted with some aspects of the designed intervention, which had proposed providing health information on sedentary behaviour in IVR. Tailoring the way information is delivered to participants is therefore an important element to highlight here.

To Strategize or Not to Strategize. This subtheme explores feedback on different types of strategies retired and non-working adults could use to take part in meaningful non-sedentary activities. It considers whether strategizing is something retired and non-working adults would be interested in doing and if so, what kind of strategies they would be interested in adopting.

When asked about their thoughts on using strategies to change their sedentary behaviour, there was a variety of responses given (see S3 Table). This illustrates how complex the topic of strategies is, with a clear need for them to be tailored to the individual. A common pattern across these suggestions was that they did not involve the use of digital technology–although some were open to this mode of delivery (see S3 Table).

Views on goal setting were divided (see S3 Table). Participants who were in favour of goal setting believed that having goals to take part in IVR activities would motivate them and would provide a sense of achievement when goals were successfully completed. In contrast, other participants believed that goal setting would take away from the IVR experience as it would make it competitive when they are not competitive people. Participants also believed that simply being able to use the technology and take part in activities they enjoyed was achievement enough, without any need to create a specific goal to do so.

Some participants were in favour of monitoring their sedentary behaviour, using techniques such as reminders to take part in IVR activities to break up their sedentary bouts. The ways in which participants imagined how these would materialise varied, however. Participants were open to both digital solutions such as on-screen reminders and a digital activity logbook that appeared in the IVR device (see S3 Table) as well as more traditional reminders such as internal self-monitoring or a physical timetable.

What was universal across the diverse range of strategies suggested, was that activities participants take part in would need to be done on their terms, referring to when, or if, they wanted to do it, rather than being told to take part by some form of external que, “No, it takes away the freedom to either use it or just get on with something else and then go to it at a time when you’re completely relaxed…”.

Together is (mostly) Better. This subtheme explores retired and non-working adults’ thoughts on taking part in IVR activities with others. Furthermore, it explores how participants thought about being represented in the virtual environment and how they would interact with others in that environment.

A number of participants were not consciously aware of how they were represented in the virtual environment. Although they only embodied hands in the virtual environment, the common response to this was that they simply accepted this for what it was; it did not impede on their ability to interact with the virtual environment, “Oh, no, no. Once, once I got used to the idea [of just having hands], I actually forgot completely”. Many participants added that the hands enabled them to interact with the environment and that was all that mattered to them–they were a “tool” that gave them more “power”. Closely linked to agency discussed above, participants attributed their ability to successfully interact with the virtual environment, at least in part, to the representation of their hands. It represented the same way they would interact with physical objects in the real world and therefore appeared to be given value in the virtual world.

Although participants did not have the opportunity to engage with their own avatar or other avatars in a meaningful way in VR FOUNDations, when asked what they thought about the inclusion of avatars in the virtual environment in various ways, many were open to the idea (see S2 Table), stating they would be motivated to meet other people in IVR to share the experience together as it would be a way of enhancing social connection. In contrast, others believed an avatar was not necessary for individual experiences and even where it could be social, they thought it would probably lack the social cues to have meaningful social interactions with others embodied as avatars.

A number of participants suggested integrating a technology like IVR into community organisations. Some participants saw community organisations as a pivotal way to promote, teach how to use, and utilise IVR as another way of interacting with each other outside of meeting in person:

“…one sensible approach then would be to come to a group like ours [retirement organisation], where you have maybe 100 old people in one group… And you’re getting a larger group of people who’d [at] least try it”.

Community organisations were seen as an engine through which IVR could be introduced and adopted by retired and non-working adults in the community. They are seen as a safe environment for retired and non-working adults to learn how to use IVR with each other and eventually interact with each other in it.

Offering and Influencing Opportunities to IVR Use. This subtheme explores what opportunities IVR offer retired and non-working adults with regards to reducing sedentary behaviour–as well as many other opportunities. It also explores what would influence retired and non-working adults’ ability to use the technology in the future. This subtheme bares strong links with the “opportunity” element of the COM-B model [18], exploring both social and physical barriers and enablers to IVR use.

The opportunities offered by IVR that were suggested by participants were diverse (see S2 Table). Participants generally saw it as a new tool to bring new positive change into their lives, offering them an escape from negative thinking, the opportunity to take part in activities they may be insecure to do in public, the opportunity to alleviate boredom and, an alternative to activities such as TV watching. The key in this theme is that participants saw opportunity with this technology. They saw the potential it had to enhance their lives in various ways that they would otherwise not have the opportunity to do:

“…in recent years, I have developed arthritis in my hands, which has affected my grip… So I can see if… I could play my tennis on that and play with other people and satisfy that competitive streak and then also be active”.

With regards to opportunities influencing IVR use, all participants said they would have space in their home to set up the IVR equipment. The current price of the equipment was also not seen as an issue for those who commented on it. In general, when discussing any potential physical barriers to use with regards to opportunity, participants did not see any major ones. Some did stipulate, however, that they would require some social support when setting up the equipment. This is linked closely to previous comments made about needing someone else there in person to learn with–such as within a community organisation.

When two worlds collide.

This theme explores retired and non-working adults’ beliefs about sedentary behaviour and whether digital technology can or should be adopted by them to assist in reducing this behaviour.

Constructing Beliefs and Identity. This subtheme offers insight into how retired and non-working adults’ sense of identity relates to their beliefs about health and digital technology. It offers insight into these beliefs and how their identity has been shaped by various events throughout their lives.

It was clear that almost all participants understood that sedentary behaviour has negative effects on health, with some indicating that it is a common-sense belief. They observed the negative impact of prolonged sedentarism in their own lives with some sharing that they feel unwell or depressed when they spend too much time sedentary. Participants were also affected by the negative health outcomes for others in their lives who lived sedentary lifestyles. For some participants, there was a belief that physical activity made up for their time spent sedentary–regardless of whether they were sedentary for prolonged periods of time each day:

“most of the group you’re going to meet [participants from the same retirement organisation] are not all that [sedentary] they’ll often be out walking quite a bit, they keep active”.

In this case, the participant was aware of the benefits of physical activity but were unaware of the potential negative effects of prolonged sedentary behaviour, which each of the participants reported taking part in. These beliefs highlight the importance of conveying the difference between physical activity or inactivity versus prolonged sedentary behaviour or non-sedentary behaviour. Thoughts about future health were also highlighted as a key motivator to take part in non-sedentary activities in the present:

“I do kind of think, Gosh, in another 10 years what will I be like, will I be able to move at the same speed that I’m able to do at the minute?”.

The formation of participants’ identities in the context of their sedentary behaviour was also discussed during each interview. A pattern that developed across a number of participant accounts was the way time, and the age-related changes associated with time, shaped the way they identified with being sedentary or non-sedentary throughout their lives. Participants spoke about how consistent hard work across time instils and maintains non-sedentarism as part of their identity. They also shared how social support can help maintain such an identity and terms such as “retirement” attributed to them when they reach a certain age can be potentially stigmatising and influence their identity–with the suggestion that now is the time for them to “slow down” and rest more rather than being active. Additionally, closely linked to participants’ beliefs about their ability to use IVR equipment was how this in turn formed part of their identity. The responses from participants about their beliefs about capabilities and identity in this case suggests a temporal arrangement of the two–with the belief first forming through the encouragement of their use of IVR, as well as their actual use of it, and later the formation of this instilled belief as part of their identity.

Participants expressed that simply trying IVR strengthened their beliefs about their capabilities in using it. For many, using IVR broke down the prior assumption that they would not have the ability to do so:

“I think, to reassure them [retired and non-working adults], that they they’re capable of doing it, like people are afraid, oh that’s too high tech for me… I think if they give it a go, and, you know, try it, and be open to change and open to new ideas”.

An important stipulation made by some participants was that IVR needs to first be presented to them in an accessible way. Participants pointed out that it is prior fears and uncertainties about their capabilities that would influence their decision to try it, so presenting IVR in a positive and accessible way was considered important.

Technology and Health: A Strange New World. This subtheme explores participants’ views and experiences with digital technology to date and what their preferences would be for delivering health information using digital technology, if at all.

Many participants shared their thoughts on their prior experience with digital technology, primarily discussing it in the context of health management. Some participants said they do not use digital technology to help manage their health as they would not have any meaningful use for it, and because they believed they are too old to benefit from it, “What’s the point at this stage of my life?”. Participants generally used digital technology to browse the internet and connect with others on social media. In contrast, others have found utility for digital technology to help manage their health, seeing it as means to give them more control and confidence. External factors influencing a few participants’ views on digital technology use included having younger people, who were perceived as more tech-savvy, available to assist them in using it as well as the pandemic which began in 2019 and forced some to adopt digital technology to do things like staying in touch with others, “…my wife can Zoom [online communication medium] now where she could barely click on a mouse before this [pandemic]”.

After experiencing IVR during the interview session, almost all participants indicated that they would be interested in trying it in the future to reduce their time spent sedentary. Participants’ reflections on this point generally indicated that IVR would act as a motivator to take part in non-sedentary activities due to the experiences it would offer them as well as simply acting as an additional outlet to be non-sedentary. However, some participants showed preference to other forms of non-sedentary activity and remained unconvinced of the benefits IVR for their health, “Well, at the moment, I’m not convinced… of the health benefits of it, let’s say”. Other participants shared that they would need more experience with IVR before deciding on whether it is something they would use.

Delivery preferences for receiving information about sedentary behaviour were also discussed. This is linked to the TDF element, knowledge, which is a posited determinant of health behaviour change that emphasizes the importance of individuals first needing to know why and how they need to change their behaviour before going about changing it. The majority of participants were open to receiving health information in IVR in a variety of different forms (see S4 Table). Some participants liked the idea of another avatar presenting health information as it would be more interesting. In contrast, others preferred the idea of receiving health information via a video in IVR rather than from an avatar. Participants also suggested other preferences for health information delivery outside of IVR (see S4 Table). Beyond the mode of delivery itself, participants emphasized that it is important for the information to be accessible, transparent, reliable and actionable. Participants saw their doctor, family members and friends as people who they would trust to receive this information from. In general, the central concept formed across each of these suggestions was that a tailored approach to health information delivery inside and outside IVR is necessary to facilitate everyone’s preferences.