Gelonch et al. BMC Geriatrics (2019) 19:110 https://doi.org/10.1186/s12877-019-1132-0 RESEARCH ARTICLE Open Access Acceptability of a lifelogging wearable camera in older adults with mild cognitive impairment: a mixed-method study Olga Gelonch1, Mireia Ribera2, Núria Codern-Bové3, Sílvia Ramos4, Maria Quintana1, Gloria Chico1, Noemí Cerulla1, Paula Lafarga4, Petia Radeva2 and Maite Garolera1* Abstract Background: The main objective of this research was to evaluate the acceptance of technology based on a wearable lifelogging camera in a sample of older adults diagnosed with mild cognitive impairment (MCI). Methods: A mixed-method design was used, consisting of a self-report questionnaire, numerous images taken by users, and a series of focus group discussions. The patients were involved in an individualized training programme. Results: Nine MCI patients and their caregiver relatives were included. They showed good acceptance of the camera and downloaded an appropriate number of images on a daily basis. Perceived severity and ease of use were the main factors associated with the intention to use the device. Conclusions: Older adults with MCI can become competent users of lifelogging wearable cameras with a good level of acceptance. Privacy concerns are outweighed by the potential benefits for memory. Limitations, strengths and implications for future research are discussed. Keywords: Mild cognitive impairment, Lifelogging, Technology, Acceptability, Mixed-method study Background with dementia. Research has shown that environmental Mild Cognitive Impairment (MCI) refers to a condition and assistive technology is capable of developing cogni- affecting people who suffer memory impairment beyond tive prostheses specifically aimed at promoting and sup- what would be expected for their age, but who maintain porting the autonomy, well-being and functionality of relatively normal levels of general cognitive functions people with dementia [3, 4]. and are able to carry out activities associated with daily A new Assistive Technology Device (ATD), in the life. When those suffering this condition are followed form of a lifelogging camera, has been developed for use through longitudinal studies, a significant proportion as a memory prosthesis. This is a small camera, worn progress to clinically probable Alzheimer’s Disease, around the neck, which automatically takes hundreds of which is the most common form of dementia [1]. Nu- pictures per day from a first-person perspective. These merous interventions have been proposed to help delay images can then be easily uploaded onto a computer and or reverse the progression to dementia in people with viewed in relatively quick succession, providing a rich MCI but, to date, no pharmacological therapies have set of photos of an individual’s daily activities [5, 6]. Re- proven effective [2]. In recent years, several solutions in- cent research has shown that reviewing daily images im- corporating Information and Communication Technol- proves the recall of episodic memory in clinically ogy (ICT) have been developed with the aim of impaired populations, such as people suffering from an- compensating for decreased cognitive abilities in people terograde amnesia due to brain injury, alcohol-related brain damage, or Alzheimer’s Disease [6–9]. The thera- * Correspondence: mgarolera@cst.cat peutic potential of using a lifelogging camera as a thera- 1 Clinical Research Group for Brain, Cognition and Behavior, Consorci Sanitari peutic intervention to improve memory has gained de Terrassa, Carretera Torrebonica, S/N, 08227 Terrassa, Spain interest in recent years, although research in this area Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Gelonch et al. BMC Geriatrics (2019) 19:110 Page 2 of 10 has so far been limited by small sample sizes and In the present study, which is the initial phase of the single-case research designs [10, 11]. Very few studies ReMemory project, we were particularly interested in have hitherto explored the benefits of using lifelogging discerning whether older adults with MCI could compe- cameras in patients diagnosed with MCI or Alzheimer’s tently use the lifelogging wearable camera and in know- disease, although promising results have been reported, ing their intention to use it. We also wanted to explore with identified improvements in recall and confidence other factors associated with the use of wearable cam- and a reduction in anxiety [8, 12, 13]. eras, such as checking whether privacy concerns could In recent years, the public health sector has shown a constitute a significant limitation to their use. Our work- growing interest in the use of lifelogging wearable cam- ing hypothesis was that, with appropriate training and eras as an aid for memory, but new dilemmas have information, older adults would be both able and willing emerged relating to privacy and usability. This approach to use wearable cameras. We also anticipated that priv- is of notable importance since such cameras allow pa- acy concerns could be relevant and could reduce the tients to automatically capture continuous images while willingness of some patients to use them. they are carrying out their daily activities [14, 15]. To To better understand this scarcely studied issue, we date, little is known about the kinds of privacy chal- used a mixed-method research design, integrating both lenges that these new devices are likely to pose, although quantitative and qualitative data. It was thought that the several studies have highlighted factors that influence quantitative data would provide comparable imput, the use of such technology. Negative perceptions of their while the qualitative data would provide a better explan- ease of use and utility are the main obstacles that seem ation of the meaning behind the numbers. to be involved, judging from questions concerning user acceptance of this technology [16]. Several studies have Methods also sought to investigate the acceptance of such tech- Design nology by patients, and particularly older people, as it This was a mixed-method study that involved the use of has been reported that they may be reluctant to use both quantitative and qualitative components. The therapeutic tools incorporating new technology [17]. quantitative measures included a self-report question- Similarly, previous research has shown that people with naire on the acceptance of technology and the computa- MCI have a reduced ability to manage everyday technol- tion of useful images recorded and downloaded by each ogy and often perceive it as significantly more difficult subject on a daily basis. The qualitative input consisted to use than those without cognitive impairment [18]. In of analysing focus group discussions centred on issues this sense, designing ATDs for people with MCI requires related to the acceptance of cameras and privacy. The consideration of their capabilities and limitations, in- results of both the quantitative and qualitative analyses cluding their need for, and acceptance of, technological were jointly interpreted, as complementary approaches, support. These factors may influence the engagement of in pursuit of the study objectives. such therapies and also the results of programmes in- cluding their use [19]. Despite evidence of this need, Materials there has previously been a notable lack of research in The lifelogging camera used in this study was a Narra- this area, and particularly related to the use of ATDs by tive Clip® (http://getnarrative.com): a small, wearable the population suffering cognitive impairment [4]. camera which automatically takes pictures every 30 s. It This research was designed as an exploratory study to is small (36x36x9 mm or 1.42 × 1.42 × 0.35 in.) and light investigate the use and acceptance of an approach involv- (weighing about 20 grammes or 0.7 oz). The camera is ing the use of a wearable lifelogging camera by older hung around the patient’s neck, using a necklace or adults with MCI. It was organized in order to remedy the piece of string, and takes images of everything that they previous dearth of information and prior knowledge relat- do throughout the day. At the end of each day, the pa- ing to this topic. This constitutes a previous, but neces- tient – or a helper - must then download the images, at sary, stage within the research conducted by our group home, by simply connecting the camera to a Universal (“ReMemory, a cognitive training tool based on Serial Bus (USB) port on a computer. They must also life-logging for mild cognitive impairment” -http://www. leave the camera connected to their computer to re- rememory.cat-). The next phase of the research will focus charge the battery. on checking the effectiveness of a cognitive intervention programme for people with MCI based on reviewing im- Subjects ages of daily episodes captured by a lifelogging wearable The study included 9 patients who had been diagnosed camera. The images captured by those wearing the cam- with MCI and their informal caregivers. The patients were eras will be then used to stimulate episodic memory as recruited from two adult day centres for people with MCI part of a cognitive intervention programme. and mild dementia located in Terrassa (Spain). They were Gelonch et al. BMC Geriatrics (2019) 19:110 Page 3 of 10 asked to collaborate in this study in order to test a wear- needed to perform (Fig. 1). The material was reviewed by able camera and help ascertain whether it could be appro- 10 subject experts (three patient caregivers, two neuropsy- priately used by people with MCI to obtain personal chologists, two occupational therapists and two experts in images of day-to-day events that could subsequently be Human-Computer Interaction (HCI) who completed the used as part of a treatment to help improve their memory. PEMAT inventory. This material was later given to the pa- The inclusion criteria were: a) age 65–90; b) diagnosis of tients for reference. MCI by a neurologist; c) meeting the criteria for single do- Phase II consisted of providing training. The patients main amnestic MCI [1, 20]; d) having a caregiver or reli- all received one hour of individualized training on how able informant who could monitor the patient’s daily to use the camera and upload the images; they were also activities; and e) having received cognitive training for given abbreviated instructions to take home and uses as three months or more at an adult day centre. The exclu- a reference whenever needed. The patients were also ad- sion criteria were: a) an unstable medical condition; b) a vised not to wear the cameras in public toilets, changing presence, or history, of severe psychiatric disorder, cere- rooms or banks and told that they could opt not to take brovascular disease or neurological disorder; c) illicit drug photos by simply covering the camera lens. or alcohol abuse or dependence; d) relevant hearing, vi- Phase III involved the patients using the camera in sion, motor and/or language deficits; e) fewer than 4 years real-life situations. This phase lasted seven days. During of formal education; and f) an insufficient knowledge of this time, they had to wear the camera throughout the the Spanish language. The criteria chosen included the day and connect it to a computer to charge the battery homogeneity of the functional and clinical characteristics and upload images every night. of the sample and an appropriate level of heterogeneity re- Phase IV consisted of collecting and analysing quantita- lating to gender, level of education and knowledge of tive and qualitative information relating to the experience. technology. Data collection Procedure Sociodemographic data about the patients and caregivers The study was conducted in four phases. and data relating to patients’ cognitive impairment, de- Phase I consisted of adapting the training material to pression symptoms and experience in the use of technol- meet Patient Education Materials Assessment Tool ogy were collected at the baseline. The Mini Mental (PEMAT) guidelines [21]. The training material used in State Exam (MMSE) was used to evaluate the level of the study included several information sheets containing patients’ cognitive impairment [22] and the Geriatric De- instructions on all the procedures that the patients pression Scale was used to quantify the intensity of any Fig. 1 Training instruction sheets given to the patients, including instructions about the whole intervention programme procedure. Note: the images were created by the authors, except for the images of the battery, camera and laptop (sheet number 2), which were extracted from a website that provides a database of free pictures (www.pd4pic.com) Gelonch et al. BMC Geriatrics (2019) 19:110 Page 4 of 10 symptoms of depression [23]. Following Rubin & Chis- correctly and to check whether an adequate number of nell [24], the patients were categorized as having low, images had been obtained to represent significant daily medium or high levels of experience in the use of tech- episodes that could subsequently be used in the cognitive nology. This was done through specific questions that intervention programme. The task of selecting the images were presented to them and related to the previous use was performed by computer vision tools that contained a of similar appliances. deep learning algorithm. This enabled them to organize Patient acceptance of technology was assessed using the large-scale collection of images captured by the pa- the integrative framework from the Wearable Technol- tients on a daily basis [29]. The deep learning algorithm ogy Acceptance in HealthCare (WTAH) survey devel- was specially designed to automatically discriminate be- oped by Gao [25]. This is an instrument designed to tween informative and non-informative images. It was also evaluate the factors associated with a user’s willingness programmed to discard non-informative images, such as to adopt wearable technology in healthcare. It is based dark images, blurred images or images without content, on the unified theory of acceptance and the use of tech- such as when the camera photographed a wall, the nology 2 (UTAUT2) [26], the protection motivation the- ground, a ceiling, or the sky, etc., and also any repeated ory (PMT) [27], and the privacy calculus model [28]. In images. The cognitive intervention of the ReMemory Pro- this research, we slightly adapted Gao’s original con- ject requires 60 informative images for each daily episode. struct in order to fit it into the context of using a wear- Assuming that the camera will collect a large number of able lifelogging camera to improve memory. Each non-informative images (we calculate that approximately construct contained 3 items and each item was mea- 75% of the images captured tend to be non-informative sured on a five-point Likert scale, with scores ranging given that the camera automatically takes images once from 1 (“strongly disagree”) to 5 (“strongly agree”). The every 30 s), it is expected that each patient should be able last construct used, called the Behavioural Intention (BI), capture at least 300 relevant images per day. was the dependent variable. The different constructs are The qualitative data were obtained from two focus groups described in Table 1. A composite score was obtained (one for each patient centre) in which the patients and their for the different constructs by calculating average scores caregiving relatives participated. The duration of each focus for the 3 items used in each construct. To ensure that group’s activity was approximately 90 min and both focus the patients had correctly understood the content of the groups were led by the same person. This person, who was survey items, a member of the research team was a member of the research team and had relevant experience present when each patient completed the survey and in organizing this type of task, acted as moderator for these helped them to resolve any questions and to clarify the groups. The group leader followed a pre-established script content. The WTAH survey has been made available as and facilitated discussion. They also had the support of an Additional file 1. assistant moderator, who took notes throughout each ses- Another quantitative analysis consisted of computing sion. The resulting script was structured around three the rate of obtaining useful images with respect to the major topics: a) ease of use of the camera; b) privacy, and c) total number of images recorded and downloaded by each a general assessment: acceptance, expectations and recom- subject on a daily basis. This measurement was used to as- mendations for improvement. The proceedings of the focus sess the extent to which the patients had used the camera groups were recorded and transcribed. Table 1 Constructs included in the Wearable Technology Acceptance in Health Care (WTAH) survey Performance Expectancy (PE) The degree to which using this technology will bring effectiveness to users in performing daily activities Hedonic Motivation (HM) The pleasure or enjoyment derived from adopting and using the technology Effort Expectancy (EE) The degree of ease related to the patient’s use of the technology Functional Congruence (FC) Product quality in terms of comfort, fashion and reasonable pricing Self-Efficacy (SE) The patient’s capacity to use the wearable device to self-monitor and self-manage their memory functioning Social Influence (SI) The extent to which the patient’s decision-making is influenced by others’ perceptions Perceived Vulnerability (PV) The possibility of the patient experiencing memory problems Perceived Severity (PS) The extent of the threat from behaviour that is unhealthy for memory and the importance of following medical prescriptions that are good for memory Perceived Privacy Risk (PPR) The patient’s perceptions of risk when professionals attempt to collect, use, and distribute information about them and their behaviour Behavioural Intention (BI) The intention to use the device in the future Adapted from Gao [22] Gelonch et al. BMC Geriatrics (2019) 19:110 Page 5 of 10 Quantitative and qualitative analysis Table 2 Descriptive characteristics of the sample (percentages Means and standard deviations were used to describe or means and SDs) the quantitative variables, while absolute frequencies and Patients Caregivers percentages were used for qualitative measurements. In (n = 9) (n = 9) addition, and in light of the relatively small size of our Age 70.3 (5.38) 68.3 (5.74) sample, we performed exploratory correlation analyses Sex (%) in order to examine any potential association between male 56.0 44.0 the Behavioural Intention construct of the WTAH and female 44.0 56.0 the rest of the constructs, as well as investigating the Education (%) sociodemographic and clinical variables of the patients studied. This was done using Spearman’s nonparametric high (university or college) 22.0 0.0 correlation. medium (secondary school) 11.0 56.0 A thematic qualitative analysis was carried by the same low (primary or lower) 67.0 44.0 person who led the focus groups and was performed Marital Status (%) from a socio-constructivist perspective [30]. It focused married 89.0 89.0 on understanding how patients constructed and inter- widow/er 11.0 11.0 preted the experience of bringing the camera into their daily lives. The analytical procedure was an adaptation Relationship patient-caregiver (%) of the steps suggested by Braun and Clarke [31]: a) read- parents & adult children 11.0 ing and re-reading for familiarization with the data and spouses 89.0 the generation of initial codes; b) discussion and initial Living conditions (%) re-coding of the codes; c) code analysis and grouping living alone 11.0 data into categories based on thematic criteria; and d) living with spouse 78.0 discussion of the categories and (e) report writing. living with spouse and children 11.0 Results MMSE (mean scores) 26.1 (2.15) Patient characteristics Yesavage Depression Scale (mean scores) 11.4 (5.92) The characteristics of the patients are presented in Knowledge of technology (%) Table 2. high 22.0 medium 56.0 Wearable technology acceptance in HealthCare survey (WTAH) low 22.0 The results of the WTAH survey showed that the pa- tients exhibited a good level of acceptance of the cam- Computation of the images downloaded era; a mean score of 4.2 (SD 0.8) was recorded in the On average, each patient recorded 935 images a day and Behavioural Intention construct. Moreover, the patients the algorithm discarded 46% of the total number of im- considered the camera easy to use; a mean score of 4.7 ages downloaded by each patient. The total number of (SD 0.4) was recorded in the Effort Expectancy con- images obtained by each patient was considered appro- struct. The results also showed a low perceived privacy priate since it exceeded the pre-established minimum of risk in the exchange of information about memory diffi- 300 images per day. Due to technical problems involving culties; a mean score of 1.5 (SD 0.9) was recorded in the filing on the first day of the procedure, 1 day of record- Perceived Privacy Risk construct. The distribution of the ings was lost for 4 of the users (see Table 3). scores for each construct is shown in Fig. 2. In terms of associations between sociodemographic and Focus group clinical factors and the BI construct, we only identified a Two focus groups were organized with the participants. The strong association with the Geriatric Depression Scale (r = results were classified into the following three categories: 0.93, p < 0.01). The factors measured by the WTAH survey that showed associations with the BI construct were Per-  Learning to wear the camera. Most of the ceived Severity (r = 0.87, p < 0.01) and Self-Efficacy (r = − participants (both caregivers and older adults with 0.70, p < 0.05). No significant relationships were found be- MCI) considered that it was easy to use the camera tween the BI construct and the remaining constructs of the during the test. However, the participants also WTAH. We also found a significant association between referred to the fact that using the camera entailed a Geriatric Depressive Symptoms and the Perceived Severity learning process during which they needed to be construct (r = 0.92, p < 0.01). trained and they highlighted certain factors that Gelonch et al. BMC Geriatrics (2019) 19:110 Page 6 of 10 Fig. 2 Boxplot showing the distribution of the WTAH constructs for the sample. Note: The bottom and top vertical lines show the lower and upper scores. The top of the rectangle (dark grey colour) corresponds to the third quartile; the horizontal line near the middle of the rectangle indicates the median; the bottom of the rectangle (light grey colour) relates to the first quartile facilitated the learning process. First, the previous connecting and loading the camera, were also key for training session helped them to become familiar them continuing with the experiment (see Table 4). with the technology. Second, they said that  Reluctance to use the camera. Some of the patients consultations with a professional during the study with MCI said that they felt embarrassed or were enabled them to allay doubts and to overcome worried about the comments that the camera might problems, most of which related to the use of the provoke, or that they hid the camera depending on technology. Finally, in some cases, the MCI patients where they went. The camera can also capture said that the support and supervision provided by certain intimate aspects of day-to-day life (e.g. their caregiver in certain tasks or actions, such as personal hygiene, eating habits, going to the toilet) Table 3 Results of the images downloaded each day and kept by each patient Patient Valid days Total images downloaded per day Images kept (%) 1 7 1115 743 (67%) 2 6 960 668 (70%) 3 7 994 546 (55%) 4 6 885 309 (35%) 5 6 1411 644 (46%) 6 6 693 398 (57%) 7 7 838 495 (59%) 8 7 702 390 (56%) 9 7 820 363 (44%) Mean for the total sample 6,5 935,3 506,2 (54,3%) Gelonch et al. BMC Geriatrics (2019) 19:110 Page 7 of 10 Table 4 Sample of responses organized by theme and sub-theme Topics Subtopics Illustrative Quotations LEARN HOW TO WEAR THE CAMERA Learning Patient 04: Well, the first time, the first time I tried to open the clasp on the cord, I didn’t turn it as I should have and I wasn’t able to open it…but from then on… Caregiver 04: We told him to look at it as if it was a ring and from then on, everything went very well (US04, FUS04, focus group 1). Caregiver 09: on the first day, we couldn’t connect the cable to the USB port, we tried but it didn’t fit. Then we tried the middle port and it fitted perfectly (US09, FUS09, focus group 2). Training session Caregiver 02: During the session the trainer explained everything well and therefore everything went well (FUS02, focus group 1). Support of caregivers Patient 03: When I couldn’t do something, for whatever reason, he did it and that was it! (US03, focus group 1). RELUCTANCE TO USE THE CAMERA It can be seen Patient 03: Yes, people look at you Patient 04: I sometimes had to cover the camera, ... but Patient 01: When you interact with other people, if people are close to you, they understand it well. But if people don’t know you, they look at you as if they are thinking “well, what is he doing?”, it’s a study...in the end, when I found myself in that situation, I took the camera off and I put it in my pocket because I thought that people were uncomfortable with all of this (US01, US03, US04, focus group 1). It’s watching us Caregiver 01: It was like the reality show “Big Brother” [...] the camera watches everything, including relatives, or in the kitchen, if someone is cooking, or if there are things to wash, when you open the cupboards ... Patient 02: Yes, yes, it makes you feel a bit uneasy, everybody can see everything (FUS01, US02, focus group 1) Emotional impact Patient 01: The truth is that I wasn’t bothered. Well you’re always a little aware of the camera, but when I took it off, I felt relieved... (US01, focus group 1). ACCEPTANCE OF THE CAMERA Decisional balance Patient 02: I believe that this camera will serve us or those who come after us. To not lose our head even more Patient 01: I think it’s positive for us, because it can correct us when we fail and help us to improve Patient 05: Although my family and I were sometimes bothered by the camera, there were moments that I didn’t remember having it on me. In fact, I’ve gone about my normal life without thinking about the camera. Recommendations Patient 03: the camera is black and people look at it a lot. I think that if it were a more natural colour, people would look at it less. that could be a threat to privacy. Being aware that benefits, ease of use, and autonomy of being able to they could be recorded in their intimacy causes turn the camera off in situations of privacy or people feelings of vulnerability and arouses in then discomfort, provided sufficient reasons for negative emotions that may make them reluctant to acceptance. The majority of the recommendations wear the camera. However, despite this situation, made by the participants (whether family carers or none of the patients changed their daily activities older adults with MCI) related to reducing the and the majority even forgot that they were wearing difficulties in its use. These included questions such the camera. Whatever the case, most of the patients as improving the way in which the camera is worn, and their caregivers reported that they felt relieved or the design of its string, incorporating a signal to when the study ended, which supports the idea that differentiate between the front and the back of the there is an emotional load associated with wearing camera, and organizing a tutorial on how to use the the camera (see Table 3). camera (see Table 3).  Evaluating the acceptability of the camera. The vast majority of the patients with MCI regarded Discussion recording their daily life as useful, as this helped This is a piece of preliminary research which constitutes them to receive more personalized memory the first stage of a larger project that aims to develop a cog- treatment. Furthermore, they were able to compare nitive intervention programme for people with MCI based the potential difficulties, or threats, associated with on images captured by a lifelogging wearable camera. The wearing the camera with the advantages. Most of main purpose of the current stage of the project was to the participants stated that despite the contribute to the existing body of knowledge about patient inconveniences encountered, the therapeutic acceptance of using the wearable lifelogging camera in Gelonch et al. BMC Geriatrics (2019) 19:110 Page 8 of 10 older people with MCI. This was designed as an explora- could be explained by the high correlation between the tory study to help define the problem more precisely, given latter and Perceived Severity. Contrary to previous find- the previous lack of adequate knowledge about this subject. ings, the quantitative results of this study showed a The convergent design that summarizes the quantitative negative association between self-efficacy and behav- and qualitative results provided a more solid basis for data ioural intention. Even so, the qualitative analysis allowed collection and helped to improve the explanation of some us to interpret this apparently paradoxical result. We of the numerical results and to compare some of the quali- found that some patients were more reluctant to use the tative perceptions, in the same way in which they have pre- wearable camera than others despite having a high level viously been reported in the literature [32]. of self-efficacy. When we checked, we found that these The first conclusion from the study allows us to answer people led very active social lives and we think that this our first question about the ability of older adults with could explain their reduced willingness to use the device. MCI to use this technology efficiently. We have demon- Due to the relatively small sample size and the explora- strated that they can be competent users of a lifelogging tory nature of the statistical analyses undertaken, these wearable camera designed to record their everyday activ- results must - at least for the moment – be regarded as ities. Our analysis of the computed rate of useful images merely preliminary. Nevertheless, our findings provide downloaded by each subject on a daily basis showed us initial arguments to support the case for recognizing the that they were all able to record and download images perception of a problem and show the ease of use as a from day to day and that the set of images obtained for potential solution; these are relevant factors for under- each subject was sufficient to obtain a significant set of standing the willingness of patients to adopt this images of their daily life. The comments registered during procedure. the focus groups further confirmed this appreciation. This The qualitative analysis performed in this study pro- conclusion minimizes some of the technological difficul- vided us with sufficient information to conclude that ties that some other authors had predicted that people concern over privacy is an important factor and one that with MCI would report when using this technology [18]. must be considered. The patients expressed certain feel- It is important to underline that the present study in- ings of discomfort and vulnerability relating to the auto- volved a well-structured training programme, appropri- matic capture of all aspects of their life experience and ately adapted training material, and continued support they thought that this implied an invasion of their priv- provided by professionals. The relevance of these factors acy. Some of them also stated that they felt a sensation was also highlighted by most of those participating in the of relief when the study ended. Previous studies had also focus group discussions. We are convinced that the ap- reported the reluctance of patients to use this type of de- proach was capable of minimizing the disabling conse- vice because of privacy concerns [34] and the refusal of quences of the conditions affecting the patients and that subjects to wear the camera for long periods [35]. What- this favoured the success of the experience. ever the case, the potential benefits for memory which Regarding the willingness of patients to use the device, are expected to accrue from using the device and the the results were partly in line with the PMT and UTAU ability to decide when and when not to take pictures T2 models. PMT is a social cognitive model that argues helped the patients in our sample to overcome their ini- that the willingness to adopt practices associated with tial reluctance to use the device based on invasion of healthy behaviour will be determined by the severity of privacy. Similar results were reported by Mattheus et al. the illness, perceived vulnerability, and an appraisal of [36] in their study of the usability of a wearable camera the efficacy of certain practices constituting healthy be- system for family caregivers working with patients suf- haviour [27]. UTAUT2 is a model that explains behav- fering from dementia. We believe that acceptance of the iour associated with the use of health-related technology used in this study: the Unified Theory of Ac- technologies. It defines the following constructs that are ceptance Use of Technology (UTAUT) [26], should be implicit in behaviour: expectations concerning perform- complemented with other measures to fully allay any po- ance, expectations relating to effort, social influence, he- tential user and third-party concerns. donic motivation, cost effectiveness and habit [26, 33]. The combined application of quantitative and qualitative Limitations of the study methods used in our study revealed that the perceived Some limitations must be considered when interpreting severity of the process and expectations relating to the our data. The first, and perhaps most important, was the effort required (or ease of use, as explored in the focus small sample size; it was reduced at the expense of in- groups) were the main factors that could explain the corporating a demanding methodological design. This willingness of the patients consulted in our sample to research should, however, be considered as what it was: use the device. The association between the intention to an initial, exploratory study. Our data should therefore use the device and severity of depressive symptoms be regarded as a series of preliminary observations that Gelonch et al. BMC Geriatrics (2019) 19:110 Page 9 of 10 will need to be confirmed in larger cohorts of MCI pa- depth, and especially those regarding privacy; this could tients. Despite its small size, the variables used to de- even extend to bystanders. It would also be advisable to scribe the sample maintained their homogeneity and expand the study of the acceptability of this device to discursive heterogeneity with respect to the objectives of other people with cognitive impairment, such as patients the study, in terms of age, gender, educational levels and with dementia or brain injuries. different levels of knowledge of the technology employed. A range of views were obtained, and data sat- Conclusions uration was achieved after the second focus group. An- These results demonstrate that lifelogging wearable cam- other limitation that must be considered was the short eras can be used by older people with MCI as long as duration of the experience: the trial only lasted for 7 they are accompanied by a well-structured programme days. Further research over a longer period will be including specially adapted material. The recognition of needed to validate these results. Finally, the lack of the the existence of a problem and the perception that the measures on the quality of the images as well as the device can be of help were key elements in favour of it, value to the participants from reviewing the images are as was its ease of use. This led us to the conclusion that other limitations of these research that must be taken the wearable lifelogging camera is an interesting device into account. whose potential utility as a therapeutic aid to memory for older people with MCI merits further investigation. Strengths of the study On the positive side, it is possible to highlight several Additional file strengths of this study. Firstly, it is innovative, as there has hitherto been an absolute lack of standardized re- Additional file 1: Wearable Technology Acceptance in Health Care search into patient acceptance of lifelogging cameras. Survey. Based on Yiwen Gao, He Li & Yan Luo, 2015. This is the Wearable Technology Acceptance in Health Care Survey (Gao et al., 2015), adapted Secondly, the methodological quality of this study was by the authors to fit it into the context of using a wearable lifelogging rigorous. Thirdly, the results obtained have significant camera to improve memory. (DOCX 33 kb) clinical relevance. We have shown that the wearable life- logging camera can be a useful device which is easy to Abbreviations use for older people with MCI. This is something that ATD: Assistive technology device; BI: Behavioural intention; EE: Effort expectancy; FC: Functional congruence; HCI: Human-computer interaction; had not been adequately demonstrated previously. This HM: Hedonic motivation; ICT: Information and communication technology; is an important question because it helps to lay down MCI: Mild cognitive impairment; MMSE: Mini mental state exam; the foundations for our next study which will allow us PE: Performance expectancy; PEMAT: Patient education materials assessment tool; PMT: Protection notivation theory; PPR: Perceived privacy risk; to assess whether the images captured by the camera PS: Perceived severity; PV: Perceived vulnerability; SE: Self-efficacy; SI: Social can be used in therapy within programmes for stimulat- influence; USB: Universal serial bus; UTAUT: Unified theory of acceptance and ing episodic memory. use of technology; WTAH: Wearable technology acceptance in healthCare Overall, the complementarity of the data gathered Acknowledgements helped to detect some elements that may otherwise have The authors would like to thank Natalia Cuenca, Gabriel de Oliveira and Marc hindered the use of this technology. This also helped to Bolaños for their excellent technical assistance. improve the protocol and to test some of the instru- Funding ments used to gather data about acceptance. In particu- This work was financially supported by a grant from the Fundació la Marató lar, we learnt the importance of reviewing quantitative de TV3, Spain (project 20141510). results in conjunction with qualitative explanations, as Availability of data and materials well as the need to delve into private concerns and to The datasets generated and/or analysed during the current study are find out more about how the patients valued the training available from the corresponding author on reasonable request. sessions. All of this will be taken into account and im- Authors’ contributions proved upon in future stages of the project. Future stud- OG, MR, NC-B and MG all participated in the conception and design of the ies will similarly contemplate the possibility of patients study, analysed the data, and contributed to writing and editing the final manuscript. PL, SR, GC, NC, MQ and PR participated in the analysis and being able to select their own images in conjunction interpretation of data and critically revised the manuscript for important with an algorithm. This would allow them to keep what intellectual content. All the authors read and approved the final manuscript. they consider to be the most significant and meaningful images. Furthermore, real-life implementation of wear- Ethics approval and consent to participate The study was approved by the Institutional Ethics Committee of the able lifelogging systems should consider their use over Consorci Sanitari de Terrassa (Spain) and was carried out in accordance with relatively short periods since fatigue and overload the Helsinki Declaration. All of the patients provided their written informed seemed to be important issues and ones that could consent to participate in the study. otherwise limit their use. In future research, it will be Consent for publication necessary to explore all of these questions in greater Not applicable Gelonch et al. BMC Geriatrics (2019) 19:110 Page 10 of 10 Competing interests 20. Petersen RC. Mild cognitive impairment as a diagnostic entity. J Intern Med. The authors declare that they have no competing interests. 2004;256:183–94. 21. Shoemaker SJ, Wolf MS, Brach C. The Patient Education Materials Assessment Tool (PEMAT) and User’s Guide An Instrument To Assess the Publisher’s Note Understandability and Actionability of Print and Audiovisual Patient Springer Nature remains neutral with regard to jurisdictional claims in Education Materials. 2014. https://www.ahrq.gov/sites/default/files/ published maps and institutional affiliations. publications/files/pemat_guide.pdf. Accessed 10 Apr 2018. 22. 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