technologies Article The NESTORE e-Coach: Designing a Multi-Domain Pathway to Well-Being in Older Age † Leonardo Angelini 1,2, * , Mira El Kamali 1 , Elena Mugellini 1 , Omar Abou Khaled 1 , Christina Röcke 3 , Simone Porcelli 4 , Alfonso Mastropietro 4 , Giovanna Rizzo 4 , Noemi Boqué 5 , Josep Maria del Bas 5 , Filippo Palumbo 6 , Michele Girolami 6 , Antonino Crivello 6 , Canan Ziylan 7 , Paula Subías-Beltrán 8 , Silvia Orte 8 , Carlo Emilio Standoli 9 , Laura Fernandez Maldonado 10 , Maurizio Caon 2 , Martin Sykora 11 , Suzanne Elayan 11 , Sabrina Guye 12 and Giuseppe Andreoni 9 1 Humantech Institute, University of Applied Sciences and Arts Western Switzerland (HES-SO), 1700 Fribourg, Switzerland; mira.elkamali@hes-so.ch (M.E.K.); elena.mugellini@hes-so.ch (E.M.); omar.aboukhaled@hes-so.ch (O.A.K.) 2 School of Management, University of Applied Sciences and Arts Western Switzerland (HES-SO), 1700 Fribourg, Switzerland; maurizio.caon@hes-so.ch 3 URPP Dynamics of Healthy Aging, University of Zurich, 8050 Zurich, Switzerland; christina.roecke@uzh.ch 4 Istituto di Tecnologie Biomediche (ITB), Consiglio Nazionale delle Ricerche, 20054 Segrate, Milano, Italy; simone.porcelli@itb.cnr.it (S.P.); alfonso.mastropietro@itb.cnr.it (A.M.); giovanna.rizzo@itb.cnr.it (G.R.) 5 Technological Unit of Nutrition and Health, Eurecat, Centre Tecnològic de Catalunya, 43204 Reus, Spain; noemi.boque@eurecat.org (N.B.); josep.delbas@eurecat.org (J.M.d.B.) 6 CNR-Institute of Information Science and Technologies (ISTI-CNR), 56127 Pisa, Italy; filippo.palumbo@isti.cnr.it (F.P.); michele.girolami@isti.cnr.it (M.G.); antonino.crivello@isti.cnr.it (A.C.)  7  Research Center Innovations in Care, Rotterdam University of Applied Sciences, 3015 GG Rotterdam, The Netherlands; c.ziylan@hr.nl Citation: Angelini, L.; El Kamali, M.; 8 Digital Health Unit, Eurecat, Centre Tecnològic de Catalunya, 08005 Barcelona, Spain; Mugellini, E.; Abou Khaled, O.; paula.subias@eurecat.org (P.S.-B.); silvia.orte@eurecat.org (S.O.) Röcke, C.; Porcelli, S.; Mastropietro, 9 Department of Design, Politecnico di Milano, 20158 Milan, Italy; carloemilio.standoli@polimi.it (C.E.S.); A.; Rizzo, G.; Boqué, N.; del Bas, J.M.; giuseppe.andreoni@polimi.it (G.A.) et al. The NESTORE e-Coach: 10 Fundació Salut i Envelliment UAB, 08041 Barcelona, Spain; laura.fernandezm@uab.cat 11 School of Business and Economics (SBE), Loughborough University, Loughborough LE11 3TU, UK; Designing a Multi-Domain Pathway to Well-Being in Older Age. m.d.sykora@lboro.ac.uk (M.S.); s.elayan2@lboro.ac.uk (S.E.) 12 F. Hoffmann-La Roche Ltd., 4070 Basel, Switzerland; sabrina.guye@roche.com Technologies 2022, 10, 50. https://doi.org/10.3390/ * Correspondence: leonardo.angelini@hes-so.ch † This paper is an extended version of our paper published in Proceedings of the 12th ACM International technologies10020050 Conference on PErvasive Technologies Related to Assistive Environments, Rhodes, Greece, 5–7 June 2019. Academic Editor: Mario Munoz-Organero Abstract: This article describes the coaching strategies of the NESTORE e-coach, a virtual coach for Received: 14 January 2022 promoting healthier lifestyles in older age. The novelty of the NESTORE project is the definition of a Accepted: 25 March 2022 multi-domain personalized pathway where the e-coach accompanies the user throughout different Published: 1 April 2022 structured and non-structured coaching activities and recommendations. The article also presents the design process of the coaching strategies, carried out including older adults from four European Publisher’s Note: MDPI stays neutral countries and experts from the different health domains, and the results of the tests carried out with with regard to jurisdictional claims in 60 older adults in Italy, Spain and The Netherlands. published maps and institutional affil- iations. Keywords: older adults; virtual coach; healthy lifestyles; pathway; well-being Copyright: © 2022 by the authors. Licensee MDPI, Basel, Switzerland. 1. Introduction This article is an open access article Nowadays, designing and deploying effective and reliable systems and services for distributed under the terms and preventing health decline or for supporting wellbeing in older age is a major target for our conditions of the Creative Commons silvering society. The European Commission (EC) has invested in this topic with dedicated Attribution (CC BY) license (https:// and funded research actions, such as the SC1-PM15-2017 call entitled “Personalised coach- creativecommons.org/licenses/by/ ing for well-being and care of people as they age” [1]. “Novel Empowering Solutions and 4.0/). Technologies 2022, 10, 50. https://doi.org/10.3390/technologies10020050 https://www.mdpi.com/journal/technologies Technologies 2022, 10, 50 2 of 28 Technologies for Older people to Retain Everyday life activities” (NESTORE) [2] is one of these initiatives aimed at designing a virtual coach for ageing well. Based on cloud, mobile and IoT embedded solutions, it provides everyday suggestions for staying healthy through distributed and ubiquitous interactions [2]. In particular, the goal of NESTORE is to assist older adults through an innovative, multi-dimensional, personalized coaching system to support healthy ageing in four well-being domains: physical and physiological function- ing, nutrition, cognitive functioning, as well as social interactions. The emotional/mental domain is also monitored in NESTORE, but no coaching is provided in such a domain. In this paper, we chose to use the term “well-being” to describe a wide range of functional domains relevant for health and well-being. The NESTORE system is constituted by different components: a cloud platform, two apps (a coaching app and a serious game), a tangible device acting as a voice assistant, a wearable device and environmental sensors to collect users’ data. Data collected through these components are sent to a smart Decision Support System (DSS) [3], hosted in the cloud platform. The DSS measures the status of people in the aforementioned domains, assesses their interests and provides through a mobile app and a tangible interface a personalized coaching strategy based on their status and interests. The role of the virtual coach is to motivate older adults to take care of their health and to provide personalized and data-driven strategies for healthy ageing. For instance, the NESTORE coach will suggest a personalized healthy diet and/or a customized physical, cognitive and/or social activity as a support to daily behaviours that could improve the performances and preserve well-being or, on the other hand, as a countermeasure to unhealthy behaviours that could lead to a cognitive/physical decline. Two key points in this strategy is users’ engagement and motivation: in order to sustain these factors, the NESTORE e-coach was designed as a friendly life-like companion that guides the users to improve their well-being. The pathways to well-being are a key innovation element in NESTORE. In our project, the pathways have been designed to ensure that overall well-being and health status is maximised, prompting personalized suggestions and well-being services according to the users’ interests. As such, NESTORE provides an innovative multi-domain intervention, bridging domain experts’ recommendations through interfaces that have been co-designed with users in order to support long-term use and self-reflection. During the 3.5-year project, first, the project consortium bridged the needs of older adults, elicited through different co-design activities, and the recommendations of experts. This activity led to the definition of the NESTORE multi-domain coaching pathway that was then implemented into the NESTORE system. Finally, the system was tested in three pilot sites to assess the user experience of the NESTORE coach and the adherence to the proposed coaching activities. In this paper, we reflect on the users’ and expert requirements that led to the definition of the multidomain pathway, on the different strategies implemented in the NESTORE system to make such a pathway effective and on the feedback collected during the pilot studies. The insights collected in this project aim at helping future research towards more effective digital health interventions for older adults. The paper is structured as follows: Section 2 presents previous e-coaching interven- tions that support healthy lifestyles in older age; Section 3 describes the objectives and the challenges of the NESTORE project, detailing the domains tackled by the NESTORE e-coach; Section 4 describes the co-design process carried out to conceive a pathway to well-being that could at once be beneficial for and appreciated by the end-users; Section 5 details the coaching strategy of the NESTORE system, explaining in particular the underly- ing behaviour change model, the concept of pathway to well-being (and its differentiation with the concept of a clinical pathway), a subset of the proposed coaching activity plans and other design aspects of the interventions; Section 6 describes the system architecture and the main components of the system; Section 7 presents the pilot studies conducted Technologies 2022, 10, 50 3 of 28 with the NESTORE system and the insights collected in these tests; Section 8 discusses the lessons learnt and Section 9 concludes the paper. 2. Related Work This article is an extended version of the conference paper presented at the PETRA’19 conference [4]. In this article, in addition to the previous paper, we present the co-design process carried out to design the well-being pathway and we present the results of the pilot studies carried out in the NESTORE project, providing further insights and design recommendations for accessible e-coaching systems. Several interventions have been carried out to improve the well-being of older adults, both for prevention [5] and rehabilitation [6]. In the past, most interventions were carried out by healthcare professionals who delivered appropriate coaching and guided the user towards healthier lifestyles. These interventions required face-to-face meetings or were mediated via phone calls, emails or SMS. Modern technologies offer the potential to automatize most of this process, allowing to reach a larger population with a limited need for personnel formed to deliver the intervention. Digital coaching, as recently defined by Banos and Nugent [7], implied “frequently, but not continuously, observe, listen to, question, understand, reason with, teach, and/or advise the users in order to change their behaviour and to improve their health”. Digital coaches are also known in the literature as virtual coaches or e-coaches. In NESTORE, we used the e-coach term to emphasize our goal of materializing the digital system into a tangible companion that blends unobtrusively in the users’ life (see Section 6.3). Since e-coaches aim at acting as substitutes of human coaches, they must exhibit advanced features and intelligent behaviours. Kamphorst [8] summarized the following key features for e-coaching systems: • Social ability: The coach has the ability to converse with the user. • Credibility: The system has to be trustworthy and should be perceived as having an expertise of the coached domains. • Context-awareness: The system needs to be aware of user context to propose ideas and actions that are relevant for the user. • Learning abilities: The system needs the ability to ask questions, give feedback, and offer advice that is tailored to the individual user, building up and maintaining a personalized user model. • Data gathering: The system should be able to gather information from different data streams (e.g., direct user input, but potentially also measurements of physical activities, mood self-reports, sleeping patterns) and take advantage of these data to personalize the coaching intervention. • Proactivity: The system should not only be responsive to user interactions, but it should also initiate interactions with the aim of stimulating action or users’ reflection on their behaviours. • Behaviour Change Model (BCM) integration: The system needs to know what a behaviour change trajectory looks like in order to provide successful coaching. • Planning support: To support users in setting themselves up for behaviour change success, the system should guide the user through the intention formation with appropriate planning strategies. As discussed in the following sections, NESTORE integrated all these aspects through the e-coaching strategy (described in Section 5) and system architecture (described in Section 6). To understand how NESTORE relates to previous e-coaching interventions, we con- ducted a systematic review of virtual coaches for promoting healthier lifestyles in older age [9]. The systematic review showed that about half of the previous coaching systems adopted a multidomain approach, but only four systems tackled four or more domains. The well-being domains addressed by previous systems are physical activity (with most of the interventions tackling this domain), nutrition, cognitive, social, and emotional/mental well- Technologies 2022, 10, 50 4 of 28 being. In this respect, few insights were found on how to conceive a holistic multidomain framework for promoting healthier lifestyles. NESTORE aims at providing a holistic framework to promote well-being in older age, delivering tailored coaching in physical activity, nutrition, cognitive and social domains. Additionally, it addresses the emotional/mental domain for monitoring and building empathy with the user (see Section 5.5). In particular, the multi-domain approach is designed using a novel integrated coaching strategy that is described in depth in this paper: a multi-domain pathway to well-being (see Section 5.2). In order to improve or maintain well-being in older age, new behaviours should be introduced in the everyday activities. To this purpose, behaviour change models can help to motivate users in taking such decisions. As discussed in Section 5.1, NESTORE e-Coach is underpinned by the Health Action Process Approach (HAPA) behaviour change model, which is specifically conceived for health interventions. In our systematic review [9], only 18 of the 56 explicitly adopted or discussed a conceptual behaviour change model (BCM) guiding the design of the intervention. Only one study [10] in our systematic review adopted the HAPA model to design the e-coaching intervention strategy, but outside of e-coaching, in the health psychological behaviour change literature, it is a very prominent framework as it is specifically designed to support behaviour change in various health domains and one of the only models specifying the intention-behaviour transition [11]. Therefore, it was chosen in NESTORE as a highly appropriate and established underlying framework for designing the intervention pathways. Transforming recommendations of BCMs into successful implementations of the e-coaching intervention is particularly challenging. In a scoping review on 27 studies, Lentferink et al. [12] analysed the key components that can significantly affect a variety of health outcomes, the adherence and the usability of an e-coaching intervention. The following Behaviour Change Techniques (BCTs) were found to positively affect both health outcomes and usability in the studies reviewed: • Setting short-term goals to eventually reach long-term goals; • Personalization of goals; • Praise messages; • Reminders to input self-tracking data into the technology; • Use of validity-tested devices; • Integration of self-tracking and persuasive e-Coaching; • Provision of face-to-face instructions during implementation, as key components for influencing both health outcomes and usability in a positive way. Moreover, the provision of personalized content was beneficial for both adherence and usability. These 8 key elements were often adopted in previous studies, although, from our analysis [9], no study adopted them all or the authors did not report it. The most frequent BCTs applied in the studies were the personalization of goals and content, followed by using validity-tested devices and combining self-tracking and e-coaching. Praise messages and reminders were present in about a third of the studies, while the reduction in long-term goals to short-term goals and face-to face instructions was present in 9 and 15 studies, respectively. In NESTORE, we paid particular attention to these 8 key elements, as explained in the following sections. 3. NESTORE Challenges and Objectives With advancing age, structural and functional impairment occurs in most physiological systems, even in the absence of discernible disease. These age-related physiological changes affect a broad range of tissues, organ systems, and functions, which, cumulatively, can affect activities of daily living and the preservation of physical independence in older adults. Counteracting the physiological decline occurring with ageing can be achieved by improving or maintaining the well-being of older adult users through a dedicated coaching system. In NESTORE, the target population are healthy older adults, with a good perception of their quality of life or lifestyle level, with potential subjective feeling Technologies 2022, 10, 50 5 of 28 of decline in one or multiple health domains but without severe chronic pathologies. The main challenge of NESTORE is thus to provide a coaching system which is both effective in maintaining the user’s health, and, at the same time, affective and non-obtrusive to sustain its use in the long term. In order to be effective, the coaching system should consider all main coaching do- mains related to healthy aging, in particular: physical activity, nutrition, cognition and social interaction. Moreover, the proposed coaching activities must be inspired by solid ap- proved guidelines whose efficacy has been already verified. Based on these considerations, the NESTORE e-coach deals with different intervention areas and provides a complete set of coaching plans, built on domain experts’ evidence-based recommendations. An additional challenge raised by the domain experts was to address all the well-being domains at the same time, to provide a holistic approach to well-being. At the same time, health recommendations adopted in NESTORE for tackling all the different well-being domains are various and complex (see Section 3.1). Therefore, the second challenge of the NESTORE project was to shape such recommendations into a user-friendly and user-tailored format to ensure sustained use of the e-coaching system. In this respect, on the one hand, health recommendations had to be tailored to the user to make it more appealing and effective. This required additional data collection and user interactions and further algorithm complexity for the tailoring of recommendations. On the other hand, simplicity of the interaction was the first requirement elicited from the co-design activities. Conciliating these two challenges was the main difficulty faced in NESTORE. 3.1. NESTORE Domains The proposed approach is based on a holistic well-being model tailored to healthy older people [13,14]. This model is aimed at providing a structured knowledge, built on expertise of the NESTORE experts (exercise physiologists, nutritionists, psychologists, geriatricians) able to characterize the person in terms of both status and behaviour; the model adopts a multi-domain classification, which includes three main dimensions related to well-being: Physical/Physiological, Nutritional, Cognitive/Mental/Social. Each of these dimensions tackles different aspects of wellbeing, which are detailed in the following subsections. As discussed in Section 5, these aspects (or-subdomains) will allow users to personalize their pathway in each domain, choosing to work on a particular aspect (coaching plan) for each domain. Table 1 presents an overview of the possible activities for each domain. Table 2 shows an overview of the possible pathways to well-being as they were initially designed for the NESTORE e-coach. Table 1. List of 5 most popular activities that participants already do and would do in NESTORE domain, ranked from the most popular to the least popular. Already Do Would Do in NESTORE Physical activity Walking Walking Climb stairs Climb stairs Walk with shopping bags Doing Stretching Doing Stretching Walk with shopping bags Go hiking Go hiking Technologies 2022, 10, 50 6 of 28 Table 1. Cont. Already Do Would Do in NESTORE Cognitive activity Write Write Engage in commercial brain Engage in digital photography training application Attend senior university lessons Attend senior university lessons Play video games Engage in digital photography Work on my own website Work on my own website Nutrition Choose seasonal fruits and vegetables Eat 5 portions of fruit and vegetables every day Limit the consumption of industrial pastries Increase vegetable consumption Try to drink 2 more glasses of water every day Increase fruit consumption Eat legumes (chickpeas, lentils, beans) at least Include legumes regularly in your diet 2 times per week Remove visible fat from meats and skin from Choose lean meat without visible fat like: poultry before cooking chicken, turkey, veal, rabbit, beef or pork sirloin Social activity Spend time with friends and neighbours Volunteer with others in your community Volunteer with others in your community Spend time with friends and neighbours Be part of a special senior citizen activity group Join a special senior citizen activity group Be part of a Reading Club Attend a class to improve conversational skills Attend a class about Be part of a Cineforum/movie or theatre club nonverbal communication methods Table 2. List of the preferred pathway to well-being for each domain, from the most popular to the least popular. Physical Cognitive Nutrition Social Improve or Improve or maintain Decrease or maintain Improve or maintain maintain everyday body flexibility body weight social integration mental skills Improve or maintain Improve or Achieve or maintain a Improve or maintain aerobic fitness maintain memory healthy diet social abilities Improve or Improve or maintain Increase or maintain maintain broader body strength muscle mass thinking skills Improve or maintain Increase body weight body balance 3.1.1. Physical/Physiological Domain Since deconditioning, reduced muscle mass, and/or low functional capacity contribute to poor health outcomes and low quality of life, the American College of Sports Medicine’s (ACSM) recommends that older adults engage in a combination of aerobic, resistance, flexibility, and balance training to promote and maintain health [15,16]. In this perspective, the NESTORE system aims to modify users’ behaviour in the physical activity domain, by proposing personalized coaching plans targeting four subdomains: (1) aerobic training, consisting of structured activities, such as walking, running or cycling to improve cardiores- piratory fitness; (2) strength exercises, such as chair squats or knee push-up to improve Technologies 2022, 10, 50 7 of 28 upper and lower limbs strength and power; (3) flexibility training, using stretching exercises for upper and lower limbs to improve the joint range of movement and posture; (4) balance exercises, such as one-leg-stand or toe-to-line to improve the overall body stability. Furthermore, in extension to the coaching paths, the NESTORE project also introduced a sensor-based approach to assess nocturnal sleep activity via unobtrusive sleep monitoring. In fact, sleep is a fundamental daily activity of human beings. A night of good sleep is strictly correlated to good conditions in both physical and cognitive domains. Furthermore, accurate sleep detection could be enabled to detect early signs of sleep deprivation and insomnia and, as a consequence, to implement mechanisms and systems for preventing these problems. Especially older people exhibit sleep fragmentation or difficulty falling asleep. Assessing sleep quality is a challenging task from a technological point of view [17] and, in this context, the NESTORE system identifies different sleep stages through the deployment of research-grade devices based on ballistocardiography (muRata SCA11H). 3.1.2. Nutritional Domain Older adults are at higher risk of undernutrition than younger adults due to different factors, including age-associated physiological changes, cognitive impairment or socioeco- nomic aspects. Simultaneously, the incidence of overweight and obesity typically augments with age, as seen in most of the European countries [18,19]. Both undernutrition and obesity critically affect quality of life and increase mortality risks [20,21]. Ageing is also related to significant changes in body composition that are characterized by: (i) the progressive reduction of muscle mass; (ii) the increase in body fat mass accompanied by slow organs metabolic rates; and (iii) the decrease in metabolic flexibility and in the basal metabolic rate. Opportune and efficient nutritional interventions for this population are considered as a key strategy for improving health outcomes and, therefore, achieving healthy ageing [22]. Following this line, the coaching plans for the nutrition domain are addressed to: (1) body weight management, focused to increase or decrease body weight, and consisting of tailored dietary activities, as well as energy balance monitoring, (2) body composition management, focused to increase muscle mass or decrease body fat, and consisting as well of tailored dietary activities and energy balance monitoring, and (3) the achievement of a healthy diet, focused to improve their dietary habits by targeting macronutrients and micronutrients intake through both diet monitoring (based on automated food image recognition) and nutrition coaching. 3.1.3. Cognitive/Mental/Social Domain Cognitive and social well-being tend to show distinct age-related trajectories. Whereas many cognitive domains show reliable decline with age, particularly in the biology-driven fluid intelligence, the number of emotionally close others in people’s networks tends to remain stable. Nonetheless, loneliness is one important risk factor for diminished well- being in later life. To address these age-related changes, we designed three different coaching plans in the cognitive domain that are intended to support the improvement and maintenance of fundamental cognitive processes and broader cognitive functioning (see also [23]). In line with traditional standardized cognitive training interventions, the first coaching plan involves a computer-based working memory task (e.g., [24,25], the second coaching plan has a multi-domain focus and involves a serious game adapted from a previously developed training game [26] that requires simultaneous involvement of multiple cognitive domains so that broader thinking skills are trained. The third and final coaching plan includes unstructured daily life activities and thus represents a productive intellectual engagement intervention, in which people are asked to engage in cognitively challenging and stimulating activities that are particularly relevant to daily life cognitive functioning [27]. Coaching plans in the social domain were selected based on the limited evidence on impactful interventions that can be implemented in daily life and address non-clinical groups of older adults. The first coaching plan encourages people to seek out opportunities Technologies 2022, 10, 50 8 of 28 for new social contacts, aiming to improve a person’s social integration (e.g., [28]). The sec- ond coaching plan in this area was a social abilities intervention, targeting a person’s ability to adequately function in various social contexts and interactions (e.g., [29]). Furthermore, in extension to the two previous coaching plans, the NESTORE project also introduced a sensor-based approach to monitor social interaction of involved users, helping them to reflect on the quality and quantity of face-to-face interactions with family and/or friends. Indeed, exploiting a commercial and widely diffused sensing technology, namely Bluetooth LE, NESTORE enabled users tracing contacts between the NESTORE users and their family or friends who accepted to bring a NESTORE beacon with them. 4. Co-Design of the NESTORE Pathways A co-design approach has been adopted to conceive the components and services offered by NESTORE and to adapt them to the desires, needs and expectations of the users [30]. The representatives of users and stakeholders become active participants in all phases of the design process. The design process has been organised according to the Double Diamond, a framework proposed by the British Council of Design [31]. This framework identifies and alternates between research and discovery phases (divergent) and practical phases focused on the concretisation of the project (convergent). A first phase of exploring the boundaries of the project topic (discover) is followed by a step to define the design problem and the users’ needs (define). After that, there is a phase of development and exploration of the project possibilities (develop), followed by a phase of making the project idea concrete (deliver). Users and stakeholders from different countries (UK, Italy, Spain, The Netherlands) were actively involved in each phase. In the first two phases (discover and define), workshops were held to understand users’ needs and attitudes towards technology products. In the discover phase, a tool named Exhibition in a Box [32] (Figure 1) was used to facilitate the stage of discussion and exploration, involving 80 participants in the UK. The activity was then replicated in the other countries (Italy, Spain, The Netherlands) with smaller groups to validate the insights collected in the UK or to acknowledge cultural differences. Thanks to the Exhibition in the Box method, through a series of everyday objects, older adults started conversation about their wishes and desires for their everyday life. Relevant insights were collected regarding the different well-being domains, which were particularly useful to design the NESTORE pathways. Concerning physical activity, participants acknowledged the benefits of exercising not only in terms of physical well- being but also in terms of mental and social well-being. Indeed, physical exercise could be an opportunity to go outside, relax and stay with other people. On this aspect, users highlighted the importance of the social dimension of activities for their mental well-being. Spending time with family and friends was also driver for being motivated in doing such activities. Being able to learn something new also perceived as an important driver for motivation, but also as a possible barrier, when such expectations are disappointed. Another barrier for engaging in activities was the lack of time, especially for the “sandwich generation”, i.e., older adults having to care for both grand-children and older parents. Barriers for adopting technology were also discussed within this activity frame. The main difficulties were mainly linked to the cognitive demand required (a typical example being the difficulty to remember all the passwords). Technological factors were further discussed in the define phase. Eight people partici- pated to a digital probe activity, tacking photos of good and bad examples of technology, to inspire requirement with the NESTORE system (Figure 2). Such requirements where further discussed together with technologists in order to ensure the transferability into the final requirements. Among the negative aspects highlighted by the participants, the following remarks are worth noting, such as too high number of inputs required to ac- complish an operation, too small interfaces or numbers, poor cable management, intrusive audio notifications. Portability of some technology, their ability to provide easy access to information and voice control were considered as positive aspects of technology. , x FOR PEER REVIEW 9 of 29 Technologies 2022, 10, 50 9 of 28 Figure 1. Exhibition in a box co-design tool. Technological factors were further discussed in the define phase. Eight people participated to a digital probe activity, tacking photos of good and bad examples of technology, to inspire requirement with the NESTORE system (Figure 2). Such requirements where further discussed together with technologists in order to ensure the transferability into the final requirements. Among the negative aspects highlighted by the participants, the following remarks are worth noting, such as too high number of inputs required to accomplish an operation, too small interfaces or numbers, poor cable management, intrusive audio notifications. Portability of some technology, their ability to provide easy access to information and voice control were considered as positive aspects ofFigure technology. 1. Exhibition Figure in a box co-designintool. 1. Exhibition a box co-design tool. Technological factors were further discussed in the define phase. Eight people participated to a digital probe activity, tacking photos of good and bad examples of technology, to inspire requirement with the NESTORE system (Figure 2). Such requirements where further discussed together with technologists in order to ensure the transferability into the final requirements. 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The scope to test the pathway selection process and the explication of each domain provided by the of this tool was toexpert. co-design The list different of activitiesscenarios was developed of usetakingof inspiration the NESTORE from thesystem and insights collected investigate users’ attitude during thetoward co-design each scenario. activities of the One resultand first phase example was an was validated e-coach by the domain who experts, would want to know to ensure thatgender first the the proposed of theactivities user and couldtheactually statusbeofbeneficial for theirorwell-being. living (alone couple). The survey was Next, the system would need implemented to understand as a responsive the users’ webgoals application in termsand was translated in four of well-being. For lan- guages, in order to collect data from UK, Spain, Italy and The Netherlands; 11 participants instance, the user can be asked if a decrease in weight or increase in weight is their first goal to achieve for now. Then, the system would ask the users in which activities they would like to engage in order to improve their well-being. The workshop provided an opportunity to envision a methodological approach to mapping and creating different Technologies 2022, 10, 50 10 of 28 from Spain, 7 participants from the United Kingdom, 6 participants from The Netherlands, and 2 participants from Italy completed the survey. Based on the users’ feedback, we prioritized the development of the preferred coaching activities and goals. The main result of the survey was that the preferred coaching activities that participants would like to do are those that they were already doing. For example, for the physical activity domain, walking was the most common activity that participants already engaged in to stay fit, but also the one they reported to preferentially do to improve their well-being. Thus, an e-coach should suggest the users to walk-faster to train in the cardiovascular domain or to walk with heavy shopping bags to train their strength. Provided that survey participants could do activities they already engaged in to improve their well-being, they reported they would spend an average of 4.38 h per day doing NESTORE coaching activities. Table 1 Technologies 2022, 10, x FOR PEER REVIEW 10 of 29 presents the 5 most popular activities that participants already reported doing, compared to those that they said they would like to do, ranked by decreasing popularity. Figure 3. (left) Figure Picture 3. (left) Picturefrom theworkshop, from the workshop, using using both both pre-printed pre-printed and empty and empty design design cards.ex-(right) cards. (right) example ample of of a pathwaychoice a pathway choiceprocess. process. AsTable 2 presents a further the pathways co-design to well-being activity, preferred in the define by participants phase in each domain. we conducted a survey to Participants received a short description of each sub-domain understand the type of activities that users usually do to stay fit and those and of the activities that that they would would be carried out in each pathway, as described in Section 3. like to carry out in order to improve users’ well-being in the different domains. In the subsequent phase (develop), users and stakeholders were involved through Participants were also asked to rank the goals that they would select in each domain and focus groups and questionnaires to evaluate and choose between the different opportunities to rate theby offered activities that In the project. they would carry particular, out in each an embodied vocaldomain assistanttowas stayco-designed fit. The survey and was alsotested an opportunity to test the pathway selection process and the explication within a focus group in the UK. Through a survey conducted in the four countries, of each domain provided older adults by the preferred expert. design a physical The list ofaactivities with geometricwas developed shape, taking such as Google inspiration Home or from the insights Amazon collected Echo, rather during[33] than a life-like the(animal co-design activities or plant) device. of the first Through phasegroup, the focus and was we identified validated by thethe conversations domain experts,expected to ensureby older adults that the from such proposed embodied activities e-coach. could In be actually particular, older adults would like to ask which are the activities they beneficial for their well-being. The survey was implemented as a responsive web should do during the day and how they are progressing in the different domains. The final system is described application and was translated in four languages, in order to collect data from UK, Spain, in Section 6. Italy and The Netherlands; 11 participants from Spain, 7 participants from the United Then, in the deliver phase, 60 older adults took part in a pilot study, to test the complete Kingdom, system in6 their participants from the Netherlands, home environment. The main resultsandof2 the participants pilot studyfrom Italy completed are presented in theSection survey.7. Based on the users’ feedback, we prioritized the development of the preferred coaching activities and goals. The main result of the survey was that the preferred 5. NESTORE coaching Coaching activities Strategy that participants would like to do are those that they were already doing. Promoting behaviour For example, change for the requires physical considering activity several domain, aspects,was walking suchthe as understand- most common ing psychological activity processes that participants that can already foster in engaged motivation, to stay fit,recommendations but also the onefrom theydomain reported to experts for providing an effective intervention and user needs and preferences preferentially do to improve their well-being. Thus, an e-coach should suggest the to obtain anusers to walk-faster to train in the cardiovascular domain or to walk with heavy shopping bags to train their strength. Provided that survey participants could do activities they already engaged in to improve their well-being, they reported they would spend an average of 4.38 h per day doing NESTORE coaching activities. Table 1 presents the 5 most popular Technologies 2022, 10, 50 11 of 28 enjoyable and sustainable experience. To this purpose, Section 5.1 details the Behaviour Change Model (BCM) adopted in NESTORE and the related Behaviour Change Tech- niques (BCTs) that were implemented. Section 5.2 presents the concept of pathway to well-being, explaining how this was implemented in NESTORE. Section 5.3 discusses examples of coaching activity plans for the different domains presented in Section 3.1. Finally, Sections 5.4 and 5.5 show how NESTORE tries to increase the user experience and eventually the intervention effectiveness through a high level of personalization and a sense of companionship between the e-coach, physicalized in a tangible device, and the user. 5.1. BCM and BCTs To guide the NESTORE coaching implementation, we used the Health Action Process Approach (HAPA) [11] as the theoretical framework of behaviour change (see also [34]). The advantage of the HAPA framework over alternative models of behaviour change is that it specifically focuses on two distinct phases (i.e., motivational and volitional phase) and consequently on phase-specific factors underlying the success or failure of the formation of an intention and eventually change in behaviour. In contrast to alternative models, it thereby also addresses the often-neglected intention-behaviour gap, meaning that some individuals may develop an intention to change their behaviour, but they might not act upon this intention. There are six key variables, which predict intention formation and change in behaviour. In the motivational phase, three variables predict if someone will form an intention to change their health behaviour: risk awareness, which starts a process of critical reflexion, positive outcome expectancies and self-efficacy, which jointly operate to form the intention to change behaviour [35]. In the volitional phase, another set of three variables predicts how effectively the actual behaviour will be implemented by the individual. First, self-efficacy, as an indicator to overcome the intention-behaviour gap, which is also linked to how easily a person can get back on track after a relapse [36]. Second, action and coping planning, which denotes the when, where and how a target behaviour will be performed and how an individual will deal with potential problems arising when changing their health behaviour. Finally, action control, which subsumes self-monitoring and self-regulatory efforts when pursuing a target behaviour. In orchestration, these six key variables determine whether or not a health behaviour change is successfully initiated by any given person. The NESTORE e-coach is a multi-domain coaching system, meaning that it offers older adults multiple coaching activities from various health domains (described in Section 3.1). The NESTORE intervention is particularly challenging in terms of pursuing a behaviour change, as it may recommend the user to change more than one behaviour at once by engaging in multiple coaching plans simultaneously. Thus, it is crucial to implement a variety of BCTs to sustain the motivation of the user and promote the overall effectiveness of the intervention (e.g., [37]). Based on a literature search identifying the most effective BCTs in the NESTORE domains, we implemented a variety of BCTs in the NESTORE coaching, including providing general educational information, providing information of health consequences, prompting intention formation, providing instructions, prompting specific goal setting and reviewing these behavioural goals, providing detailed feedback on health behaviours and many more. These messages were personalized based on contextual and other person-specific information so that the BCT messages come at the time and in the form needed by each individual (see also [38]). 5.2. Pathways to Well-Being The overall goal of NESTORE is to accompany older adults towards a healthier lifestyle. This is not possible without considering all the domains presented in Section 3.1. Identifying the optimal pathway for each individual is not trivial, and the role of the NESTORE e-coach is to guide the user in the choice of the appropriate pathway to well-being based on their status and interests. We note that our concept of a pathway is slightly different from the term “clinical pathway” found in the literature (e.g., [39]). Within NESTORE, a pathway Identifying the optimal pathway for each individual is not trivial, and the role of the NESTORE e-coach is to guide the user in the choice of the appropriate pathway to well- being based on their status and interests. We note that our concept of a pathway is slightly different from the term “clinical pathway” found in the literature (e.g., [39]). Within Technologies 2022, 10, 50 NESTORE, a pathway encompasses the different components a user travels through in 12 of 28 the process of finding and pursuing their individually suited behaviour change process. While in its core this resembles the essential steps recommended in clinical care settings encompasses to address a specific disease, theourdifferent focus goes components beyond acircumscribed user travels through in the diseases individual process of finding and involves the person-specific fine-tuning rather than a more normative approach.inAs and pursuing their individually suited behaviour change process. While its core this resembles the essential steps recommended in clinical care settings to address a specific informing the user in an intuitive manner on the goals and outcome of the intervention is disease, our focus goes beyond circumscribed individual diseases and involves the person- crucial for adherence andfine-tuning specific engagement, ratherwethan chose the normative a more metaphor approach. of a pathway to represent As informing the user in an the journey that each usermanner intuitive should onregularly the goalsgoandthrough, outcomeintroducing healthy activities of the intervention is crucial and for adherence behaviours into and theirengagement, daily routines. we chose As the well-being metaphor is of aintrinsically multi-domain, pathway to represent we that each the journey represented a pathway as inregularly user should Figure 4,goencompassing the 4 domains through, introducing presented healthy activities and in Section into their behaviours 3.1. Nevertheless,daily routines. as every domainAs well-being is intrinsically is also multifaceted and multi-domain, training in all weaspects represented a pathway as of well- being at once would be overwhelming for the user, we identified for each domain as every in Figure 4, encompassing the 4 domains presented in Section 3.1. Nevertheless, different coachingdomain plans is alsothe that multifaceted and training user can choose from into all aspects build theirofown well-being pathwayat once and would be overwhelming for the user, we identified for each domain different coaching plans that ultimately reach the goal of improving their well-being. These coaching plans mainly the user can choose from to build their own pathway and ultimately reach the goal of correspond to theimproving different their sub-domains well-being. elicited in Section These coaching 3.1 and plans assessed mainly withtousers correspond in the different sub- the co-design phase (Section domains 2), with elicited the exception in Section of the physical 3.1 and assessed with usersactivity domain phase in the co-design where(Section 2), flexibility and balance with theexercises exception areof integrated the physicalin both coaching activity domain where plansflexibility for aerobic and fitness balance exercises and muscle strength. are integrated in both coaching plans for aerobic fitness and muscle strength. Figure 4. SummaryFigure of the4. possible Summarypathways for a pathways of the possible NESTORE foruser. In parenthesis a NESTORE user. In are noted the parenthesis are noted the alternatives for each coaching for alternatives plan, which each will be coaching personalized plan, according which will be to theaccording personalized user needs in the to the user needs in specific sub-domain.theFor example, specific a user with sub-domain. good level For example, of aerobic a user fitness with good leveland poor level of aerobic ofand fitness body poor level of strength will be able to choose between “Maintaining aerobic fitness” and “improving body body strength will be able to choose between “Maintaining aerobic fitness” and “improving body strength”. The userstrength”. is asked to choose The user isone coaching asked to chooseplan onein each domain, coaching training plan in each at the domain, same at training time the same time all the dimensions of well-being. Only the cognitive domain can be skipped if there is no need for improvement. In bold, highlighted with the dashed line, a possible pathway choice. After a period of two weeks in which the system monitors the user’s habits, objective functioning and subjective feelings, the NESTORE e-coach asks each user to build their own pathway to well-being, selecting for each domain one of the available coaching plans. Coaching plans are presented to the user as high-level long-term goals, to which the user should commit through specific activities. Indeed, the choice of the pathway at the end of the second week influences the type of coaching activities (shorter-term goals) that are proposed to the user in the following 12 weeks. These activities are proposed in specific coaching activity plans (CAPs), described in Section 5.3. Splitting longer-term goals in smaller shorter-term goals should help support behaviour change, as shown by Lentferink should commit through specific activities. Indeed, the choice of the pathway at the end of the second week influences the type of coaching activities (shorter-term goals) that are proposed to the user in the following 12 weeks. These activities are proposed in specific coaching activity plans (CAPs), described in Section 5.3. Splitting longer-term goals in Technologies 2022, 10, 50 smaller shorter-term goals should help support behaviour change, as shown by Lentferink 13 of 28 et al.[12]. It is worth noting that the user is informed about the kind of activities they have to engage in for each coaching plan before committing to the chosen pathway. In order to increase et al. [12].their motivation, It is worth notingjust thatafter choosing the user the different is informed about the subdomains, the user kind of activities theyhas haveto confirm the goals they committed to in each domain, signing to engage in for each coaching plan before committing to the chosen pathway. In order a sort of behavioural contract. to increase their motivation, just after choosing the different subdomains, the user has to In building confirm the goalsthe they personalized committed to pathway in each to well-being domain, thearole signing sortofofthe e-coach iscontract. behavioural crucial, sinceIn it building guides the choice of the user towards a pathway that will likely the personalized pathway to well-being the role of the e-coach is crucial, most effectively lead it since toguides an improvement the choice of the in well-being. user towardsFor this purpose, a pathway that willbased on the likely most information effectively lead to an improvement in well-being. For this purpose, based on the information collectedthe collected in the first two weeks, the e-coach recommends the coaching plans where in userfirst the needs more training two weeks, the e-coachto meet the domain recommends recommendations the coaching plans where elicited the user by needsexperts. more Therefore, training to the meet pathway the domainis customized recommendationsfor each user, including elicited a recommendation by experts. Therefore, the pathwaywhether an improvement is needed or whether maintaining the is customized for each user, including a recommendation whether an improvement current level is sufficient. The is presentation needed order maintaining or whether of the coaching plans depends the current on the urgency level is sufficient. of trainingorder The presentation in each of of the them. coaching plans depends on the urgency of training in each of them. Finally, totolimit Finally, limitthethe user-burden user-burden to train to train concurrently concurrently in multiple in multiple domains, domains, the systemthe system allows the user to skip the domains that do not need allows the user to skip the domains that do not need particular changes in behaviour to particular changes in behaviour to maintain the current level. As users were maintain the current level. As users were mainly interacting with the NESTORE e-coachmainly interacting with the NESTORE through e-coachapp, a mobile through a mobile app,of the representation thethe representation whole pathway of the whole pathway to well-being to well- as illustrated being in Figureas illustrated 4 could notinfitFigure 4 could the vertical, not size small fit the vertical, of the small size smartphone of the screen. smartphone Therefore, the screen. Therefore, pathway choice process the pathway was rather choice split inprocess was different rather tabs, withsplit in review a final different tabs,different of the with a choices as depicted final review in Figurechoices of the different 5. as depicted in Figure 5. Figure 5. Pathway choice interface in the NESTORE Mobile app. Figure 5. Pathway choice interface in the NESTORE Mobile app. 5.3. Coaching Plans A three-layer coaching strategy [3] is proposed in NESTORE to better adjust to users’ needs and likings. This layered approach allows users to (1) select a pathway to follow (as described in Section 5.2), which is composed by a coaching plan (goal) for each domain; (2) choose how they want to achieve that goal, henceforth referred to as coaching activity plans (CAPs); and (3) accomplish their goal by executing specific coaching activities sched- uled by the system, named coaching events (CEs). Here, we can see as the overall goal of improving the well-being is first reduced to specific goals in each domain (the pathways) and then to elementary activities that users should carry out during their daily routines. These three layers are consecutively dependent on each other: a pathway contains many CAPs, and a CAP is formed by many CEs. Technologies 2022, 10, 50 14 of 28 5.3.1. Example of a Coaching Activity Plan for Physical Activity If users decide to improve aerobic fitness they can choose among three different sched- ules (CAPs): three, five or seven sessions per week; moreover, they can select exercise intensity (light, moderate or vigorous). Based on these choices, the system provides a personalized physical activity training plan (75–300 min per week depending on the se- lected intensity), asking the user to put the training sessions (CEs) into the weekly calendar and encouraging them to adhere to the plan. Each training session is monitored using a wearable device able to estimate physiological effort and provide prompt feedbacks to the user. In order to reduce the workload from carrying out structured training sessions, the NESTORE system also measures through the wearable device the activities performed by the users during their everyday life and adapts the physical activity training plan (CAP) accordingly, reducing the time to be dedicated to the structured training sessions. In NE- STORE, users’ physical activities are classified into non-structured and structured activities. Non-structured activities include activities taken during the day such as walking or doing housework. On the other hand, structured activities are defined by the aforementioned specific training plan. 5.3.2. Example of a Coaching Activity Plan for Nutrition If users decide to increase muscle mass, the system provides them with personalized dietary plans (CAPs) based on personal food preferences and especially designed to favour muscle mass increase by targeting mainly protein and total energy intake. Some CEs’ examples are “Add pumpkin seeds to salads” or “Choose nuts as a snack”. Moreover, users are asked to monitor their dietary intake during at least 3 days per week (including one weekend day) by taking pictures of all their meals with the mobile phone. The system returns their daily and weekly energy and nutrient intake, and shows them whether they are within, below or above the recommended ranges. Energy expenditure is monitored by using a wearable device and displayed to users in order to help them to obtain a positive energy balance, essential to achieve an increase in muscle mass. 5.3.3. Example of a Coaching Activity Plan for Cognition If users decide to exercise their broader thinking skills, they will be asked to engage in the serious game activity 5 times per week for approximately 30 min, resulting in 2.5 h of cognitive engagement per week. The CE consists of manually navigating a boat along a memorized path through a natural reservoir, while reacting to certain stimuli and inhibiting their reaction to other stimuli. Thus, three cognitive abilities are incorporated in the serious game task: inhibition, spatial memory, and visuo-spatial coordination (adapted from [26]). The serious game is also adaptive in nature, meaning that the difficulty level increases (or decreases) if the performance of the user increases (or decreases). Adherence is monitored and data is stored in the system. 5.3.4. Example of a Coaching Activity Plan for Social Activity If users, for example, choose the social integration intervention, they will be asked to engage in this activity approximately once per week for 1–2 h (as most group-based leisure activities take place on a weekly basis). The user may choose from a variety of provided suggestions on how to engage in social opportunities (CEs), such as joining a theatre club, orchestra, choir, group sport, or senior citizen activity. The NESTORE system will provide information on where to find these activities in the area of the user. Some of these activities may also involve cognitive or physical elements and thus can facilitate cross-domain pathways. After four weeks of participating in the same social activity, users will be asked to evaluate their enjoyment and, in case of dissatisfaction, the NESTORE system will suggest new social CEs tailored to their profile. Technologies 2022, 10, 50 15 of 28 5.4. Personalization NESTORE deploys several tools towards fostering the adoption of well-being of older people. However, the success of the mechanisms designed throughout the different modules of the system greatly depends on the users’ engagement with the platform and, more specifically, with the degree of personalization of those mechanisms. Thus, it is clear that regardless of having a good design of BCTs, NESTORE will not be able to trigger any effect on users’ health and behaviours if they do not feel engaged or feel a sense of real support from the system. In this regard, what should be avoided is user burnout and immunization to the interactions, which could be caused by either non- personalised recommendations or out-of-context interventions. Therefore, what NESTORE aims to achieve is an emotional link between users and the platform, making the users feel supported by the e-coach whenever they need it, in an appropriate format, and in a personalised manner. For such purpose, knowledge processing algorithms and reasoning techniques are included so that, for instance, coaching plans can be personalised in terms of which kind of CEs are proposed, when they are sent—frequency, time of day, etc.—the total amount of recommendations to administer, and their priority. For example, the status of users on the different target domains, their enjoyment and likings, and the weather are items that will have an impact on the coaching plan proposal and its personalization. Users have multiple possibilities for choice, starting from the choice of the pathway, as described in Section 5.2, which will affect the sub-domains that they will train and the types of coaching activities they can engage on. Depending on the domain, the user will also have the possibility to choose among different coaching activities for achieving the same goal. In general, the system has also been tailored for older adults of the four different countries that participated in the co-design process, as described in Section 3. This resulted not only in an interface translated in the four respective languages, but also in an attempt to have conversations tailored to the local habits and traditions, in dishes and food recipes typical of each country, as well in social activities that were linked to the local facilities and events. In particular, the CEs that are implemented in the system reflect the interest of the users, collected in the four countries, first through co-design workshops and then through a survey. Whenever possible and within the terms agreed by domain experts, user feed- back is also employed to adapt the amount of training that the e-coach should propose, according to how much time the users think that they can reasonably spend to engage in coaching activities. 5.5. NESTORE e-Coach as a Companion As anticipated in Section 5.4, a key goal of the NESTORE e-Coach is also to build an empathic relationship with the user in order to increase trust in the system and to foster adherence to the proposed intervention. In order to avoid a distant e-coach that is perceived as a mere virtual entity, the e-coach was embodied in a tangible artefact [40]. The tangible coach allows users to interact with an embodied e-coach, constituting a daily companion that might encourage people to engage in the NESTORE intervention. This tangible artefact also helps building an emotional relationship with the user and, to this purpose, one of its goals is understanding users’ emotions. Indeed, in order to build empathy with the user, the system asks the user to report about her day and a semantic analysis [41] of its corresponding response allows the e-coach to detect the emotions experienced by the user and to respond accordingly. Nevertheless, as mentioned already in Section 3, it is worth noting that no specific e-coaching intervention was provided directly for the emotional and mental well-being. Physical interactions were also implemented, such as changing the position and orientation of the tangible coach to activate the possibility to speak with the coach. This should further foster the emotional bonding between the e-coach and the user and also ensure higher trust in the system, as the users could be sure that the system was not listening to them all the time. experienced by the user and to respond accordingly. Nevertheless, as mentioned already in Section 3, it is worth noting that no specific e-coaching intervention was provided directly for the emotional and mental well-being. Physical interactions were also implemented, such as changing the position and orientation of the tangible coach to Technologies 2022, 10, 50 activate the possibility to speak with the coach. This should further foster the emotional 16 of 28 bonding between the e-coach and the user and also ensure higher trust in the system, as the users could be sure that the system was not listening to them all the time. As the interface of the tangible coach may be limited in terms of type of content that As the interface of the tangible coach may be limited in terms of type of content that can be delivered and not adequate for all situations, different interfaces were available to can be delivered and not adequate for all situations, different interfaces were available to ensure a proper communication between the user and the e-coach, typically available on ensure a proper communication between the user and the e-coach, typically available on the user’s smartphone. The e-coach then continued interacting with the user in a more the user’s smartphone. The e-coach then continued interacting with the user in a more virtualized manner through the different interfaces, namely, an app with integrated virtualized manner through the different interfaces, namely, an app with integrated chatbot, chatbot, a game and a wearable. These interfaces are detailed in Section 6. a game and a wearable. These interfaces are detailed in Section 6. 6. 6. e-Coaching e-Coaching System System Architecture Architecture Ochoa Ochoa and Gutierrez [19] and Gutierrez [19] identified identified aa typical typical architecture architecture for for e-coaching e-coaching systems. systems. TheThe key key elements of the proposed architecture can be categorized in (1) data gathering, (2) elements of the proposed architecture can be categorized in (1) data gathering, (2) data data processing processing (which (which includes includes sensor sensor data data analysis analysis andand decision decision making making for for adapting adapting thethe intervention intervention toto the the context) context) and and (3) (3) actuation actuation ofof the intervention through the intervention through the the delivery delivery ofof the coaching action to the user. Data Data analysis analysis includes includes both both the understanding understanding of user variables and characteristics (i.e., monitoring unit)unit) and and user user actions actions (i.e., (i.e., diagnosing diagnosing unit). unit). In particular, particular, the intelligence of the system (i.e., learning unit) should able the intelligence of the system (i.e., learning unit) should be to adapt be able the to adapt intervention according the intervention accordingto different contexts: to different contexts:thethe state stateofofusers’ users’characteristics, characteristics,thethe user model (including users’ preferences), the coaching plan and the progress throughout the coaching coaching plan. Figure Figure 66 depicts depicts the e-coaching architecture of the NESTORE system. In the following subsections, we detail each part of the e-coaching system. A more detailed description of the system can be found in [42]. Figure 6. NESTORE e-coaching architecture. 6.1. Data Gathering and Sensing Architecture The NESTORE architecture comprises a set of wearable/portable sensing units and back-end Cloud for storing and processing the collected data. It is worth noting that most domains also require self-reporting in order to accurately monitor user status, which is important for providing tailored coaching, as described in previous sections. Figure 7 shows the main components of the sensing architecture. Data is collected mainly through the wearable device and the NESTORE app on smartphones. Some sensors, such as the smart scale and the sleep sensors, are able to directly send the data retrieved to the NESTORE cloud infrastructure using dedicated endpoints of the NESTORE API. A wearable device is worn by the user during their daily activities. Environmental sensors, including BLE back-end Cloud for storing and processing the collected data. It is worth noting that most domains also require self-reporting in order to accurately monitor user status, which is important for providing tailored coaching, as described in previous sections. Figure 7 shows the main components of the sensing architecture. Data is collected mainly through the wearable device and the NESTORE app on smartphones. Some sensors, such as the Technologies 2022, 10, 50 smart scale and the sleep sensors, are able to directly send the data retrieved17toof the 28 NESTORE cloud infrastructure using dedicated endpoints of the NESTORE API. A wearable device is worn by the user during their daily activities. Environmental sensors, Beacons, Smart including BLE Scale and aSmart Beacons, sleep Scale sensorand based on Ballistocardiography a sleep (BCG), have been sensor based on Ballistocardiography deployed in the (BCG), have user’s been vital space. deployed in the user’s vital space. Figure7.7.The Figure Thedata datagathering gatheringand andsensing sensingArchitecture. Architecture. For Forthe thepurpose of this purpose work, of this we briefly work, summarize we briefly the strategies summarize adoptedadopted the strategies for collect- for ing data belonging collecting to the NESTORE data belonging domainsdomains to the NESTORE described in Section described 3.1. in Section 3.1. 6.1.1. 6.1.1.Physical/Physiological Physical/Physiological Domain Domain The The monitoring of the dailyphysical monitoring of the daily physicalactivity activityisisperformed performedthrough throughaawearable wearabledevice device worn by the user. This device is able both to gather data sent from worn by the user. This device is able both to gather data sent from the BLE the BLE beacons andand beacons to monitor the structured activity during the exercise session. Furthermore, to monitor the structured activity during the exercise session. Furthermore, it providesit provides the user feedback the user through feedback a vibration. through When a vibration. When a user ends a user thethe ends exercise, the exercise, thesystem systemevaluates evaluates the the adherence with the prescribed plan. Finally, to find the appropriate trainingplan, adherence with the prescribed plan. Finally, to find the appropriate training plan,after after each each session the system asks the user to provide the Borg Scale and the Total Qualityofof session the system asks the user to provide the Borg Scale and the Total Quality Recovery Recoveryscalescaleasasindicators indicatorsofofperceived perceivedfatigue fatigueand andrecovery. recovery.Thanks Thankstotothese thesesubjective subjective indicators, NESTORE is able to adjust intensity and duration of the next activity session, indicators, NESTORE is able to adjust intensity and duration of the next activity session, maintaining an adherence to the weekly prescriptions conducted by the domain experts. maintaining an adherence to the weekly prescriptions conducted by the domain experts. The user can also self-report specific daily activities that can be beneficial for the aerobic The user can also self-report specific daily activities that can be beneficial for the aerobic fitness or body strength coaching plans. fitness or body strength coaching plans. In relation to the physical well-being of the user, physiological parameters have been In relation to the physical well-being of the user, physiological parameters have been col sleep indicators have also been gathered. NESTORE uses a ballistocardiography sensor col sleep indicators have also been gathered. NESTORE uses a ballistocardiography (muRata SCA11H), which reports multiple parameters at 1 Hz frequency. In particular, this sensor (muRata SCA11H), which reports multiple parameters at 1 Hz frequency. In sensor is able to collect heart rate, respiratory rate, relative cardiac stroke volume, heart rate particular, this sensor is able to collect heart rate, respiratory rate, relative cardiac stroke variability, signal strength, bed occupancy status and beat-to-beat intervals. Evaluating the volume, heart rate variability, signal strength, bed occupancy status and beat-to-beat raw data collected from the sleep sensor, NESTORE algorithm is able to evaluate perceived calm sleep, awakenings, time in bed, sleep stages, calm sleep, total sleep time, sleep onset, sleep onset latency, sleep offset, wake after sleep onset. Finally, by combining these high level and objective indicators, NESTORE showed to the user a sleep quality index. It is worth noting that some indicators are useful from a long-term perspective. In particular, perceived calm sleep, time in bed, sleep stages, total sleep time, and sleep quality index can guarantee a posteriori trend analysis, identifying significant differences in terms of sleep behaviour. 6.1.2. Nutritional Domain Food intake can be monitored both through an app and through a conversational agent. The Logmeal food recognition API [43] is used to support the user in food tracking, allowing the user to track food by simply sending a photo (or the name of the dish) to Technologies 2022, 10, 50 18 of 28 the e-coach, through the chatbot or through the app. NESTORE calculates the nutritional information of the food entered by the user: besides calories and macronutrients (proteins, fat and carbohydrates), the app keeps track of important nutrients such us Vitamin B12, Calcium, Omega-3, etc. Moreover, physiological parameters are collected through a smart scale (Withings Body+), which allows keeping track of the user weight, fat-free mass, total body water, muscle mass, bone mass and body mass index (BMI). These parameters are particularly useful for the coaching plans for increasing, maintaining, or decreasing weight and for the coaching plan for increasing muscle mass. 6.1.3. Cognitive/Mental/Social Domain The NESTORE project adopted commercial sensing technologies to demonstrate the possibility of automatically tracing contacts between the NESTORE users. To this purpose, the adopted hardware consists of Bluetooth tags to be carried as keyrings and the NE- STORE app paired with the NESTORE wristband. Tags have been designed to periodically broadcast Bluetooth messages, namely beacons [9]. In turn, the NESTORE app and the NESTORE wristband record and store such messages to the Cloud for a periodical analytic process. Such a process identifies the time periods during which two users are in proximity, i.e., co-located for a time period. In particular, the implemented analytics compute for each user the following three metrics: • The starting and ending time of each contact with a monitored user; • The number of detected contacts over a time period; • The cumulative duration of contacts over a time period. Such metrics are computed on a daily basis and uploaded on the personal user’s profile Technologies 2022, 10, x FOR PEER REVIEW 19 of 29 of the NESTORE dashboard. We report in Figure 8 on the right the adopted hardware and on the left a detail of the computed analytics available from the NESTORE mobile app. Figure 8. Figure 8. (right) (right)The The Bluetooth Bluetooth tagstags andand the NESTORE the NESTORE wristband. wristband. (left)ofDetail (left) Detail of the computed the computed analytics. analytics. The same technology has also been adopted to possibly detect the indoor locations The visited bysame users technology has to and eventually also been adopted identify to possibly the location detect the of an interaction indoortwo between locations users. visitedspecifically, More by users and eventually a limited number to identify the location of Bluetooth tags have ofalso an interaction been deployed between two by users users. in theirMore specifically, private houses to amonitor limited target number of Bluetoothe.g., environments, tagskitchen, have also beenroom living deployed or main by users in their private houses to monitor target environments, e.g., kitchen, living room or entrance (the exact target locations strictly depend on the house’s layout). Such fixed tags mainperiodically entrance (theemit Bluetooth exact beaconsstrictly target locations with adepend specificonmessage identifier. the house’s layout).InSuch turn,fixed the NESTORE wristband tags periodically emitcan collect them Bluetooth andwith beacons record on the Cloud. a specific messageSuch information identifier. allows In turn, the us to infer two NESTORE information: wristband (i) thethem can collect user’s andvisited recordlocations and (ii)Such on the Cloud. the location of a contact information allows between two us to infer twousers. information: (i) the user’s visited locations and (ii) the location of a contact between two users. and exercises integrated in the app allow monitoring user’s memory Cognitive games and broader Cognitive cognitive games functioning. and exercisesThe e-coach in integrated alsothe periodically app allowasks questionnaires monitoring user’s memory and broader cognitive functioning. The e-coach also periodically asks questionnaires about daily social engagement, perceived loneliness and cognitive behaviours in daily routines. These standardized questionnaires are presented through the chatbot or the app in order to speed up the process and improve the user experience and engagement with the coach. Emotions and stress are tracked both through Technologies 2022, 10, 50 19 of 28 about daily social engagement, perceived loneliness and cognitive behaviours in daily routines. These standardized questionnaires are presented through the chatbot or the app in order to speed up the process and improve the user experience and engagement with the coach. Emotions and stress are tracked both through questionnaires and through semantic analysis of user’s answers to selected questions with the conversational agent. The analysis is performed through an adapted version of the EMOTIVE ontological model [44]. 6.2. Processing NESTORE personalization techniques are encompassed inside a Decision Support System (DSS), which is the core component that provides intelligence to NESTORE modules and adequate the interactions to users’ preferences, status and context. A DSS can be defined as a “computerized information system used to support decision- making in which the characteristics of an individual are matched to a computerized knowl- edge base” [45]. A DSS allows to peruse large amounts of data and easily systematise the information to properly tackle complex problems and make tailored decisions. In NESTORE, the data collected through the data gathering stage (Section 6.1) is treated by the DSS in order to provide tailored recommendations to the user. The NESTORE DSS compiles information about the lifestyle and preferences of older adults with the final goal of identifying their strengths and weaknesses (areas in need for improvement) with respect to the NESTORE domains and, ultimately, select the most appropriate decisions that will help them to improve or maintain a healthy life. To ensure the adequateness of the proposed NESTORE journeys for the users, multiple validation points are set to evaluate the representativeness of the data used for the assessments of the NESTORE domains. In order to achieve this, data mining algorithms are used for modelling the user behaviour in a short-term timespan and then providing support to the user to decide the most convenient coaching activities based on the implementation of a tagging system and other reasoning techniques. NESTORE data processing is based on various techniques used to model and personalize the recommendations. First, a dynamic user profile is built, including either sensed, inferred or manually inputted data and user context. Then, different reasoning systems are applied to make personalised recommendations on the pathway to well-being and coaching activity plans [3]. In particular, the DSS is responsible to generate the list of tailored coaching plans based on the data collected on the first two week, and to continuously monitor and adapt the coaching activity plans (CAPs) proposed to reach the chosen goal in each domain. 6.3. Intervention Delivery Following the recommendation of the decision support system, coaching is provided to the user through different interfaces, implementing each different BCTs. The different interfaces can also be used in different interaction contexts. The intervention is provided mainly through a smartphone app, developed with the Ionic cross-platform framework and implementing the different BCTs described in Section 5.1. The app allows the user to monitor progress in the different domains, providing thresholds for optimal ranges and recommendations in the different domains. The app allows also to schedule the activities proposed by the coach in a calendar view, keeping track of all the activities carried out (including all the photos of the dishes entered in the system) and of the activities to be conducted. In order to support a multidomain intervention, each section of the app (the calendar, the chart, the menu for adding new activities or dishes) has specific sections for each domain. The users can rapidly switch across the different domains through intuitive icons for the physical, nutritional, cognitive, and social domains. Following the HAPA model, the calendar has been designed to help people planning their coaching activities and coping with daily hurdles that can prevent them from doing the suggested activities. Rescheduling the planned coaching activities is therefore also possible. Many charts presenting the data collected by the system, aggregated by day, week and Technologies 2022, 10, 50 20 of 28 month, and the users’ data positioning in relation to expert recommendations support the users’ self-reflection. A specific part of the app is shown after the first two weeks, for guiding the user in the pathway choice (see Figure 5). Through the same app, users can also chat with the e-coach, which provides educational content, instructions for coaching activities, reminders, praise messages and ask questions to the users, for self-monitoring purposes (as discussed in Section 5.2). The chatbot has been developed with RASA NLU, which enables intent recognition and context management [46]. The smartphone can further be used to play games, which target the physical, and cognitive domain. As support for physical activity, the wearable device also provides specific feedback on physical activity intensity level and duration. Moreover, a social platform allows participation at local events (in relation to different domains). Finally, a tangible device embodies the e-coach, allowing users to ask about their scheduled and recommended activities and a summary of their score for each domain. The tangible coach provides them with constructive feedback to keep users motivated. Figure 9 below depicts a scenario of the different way of interaction between the NESTORE coach and the user in Technologies 2022, 10, x FOR PEER REVIEW 21 of 29 order to choose their personalized pathways, coaching activities and then to review them and obtain personalized feedback. Figure 9. Intervention delivery trough the main coaching interfaces. Figure 9. Intervention delivery trough the main coaching interfaces. 7. 7. Pilot PilotStudy Study At Atthetheend endofof thethe development, development, the the NESTORE NESTORE system and its system andcomponents its componentswere tested were by finalby tested users finalinusers a real-life context.context. in a real-life The main Theobjective of the testing main objective of thephase was testing to study phase was both the use and the impact of the e-coaching system and of its to study both the use and the impact of the e-coaching system and of its components in components in the daily life the of thelife daily target of theusers. targetMoreover, it was anit opportunity users. Moreover, to understand was an opportunity possiblepossible to understand issues related to functionality, issues related usability, to functionality, acceptability, usability, acceptability,andand user userexperience, experience,totoimprove improve the the system. After system. Afterthethefirst first phase phase of of recruitment recruitment and and evaluation evaluation of of the the users’ users’ characteristics characteristics (physical, cognitive, (physical, cognitive, familiarity familiarity withwith electronic electronic devices, devices, etc.), etc.), the the NESTORE NESTORE system system andand its components its components were were presented presented to to the the users. users. The TheNESTORE NESTORE system system became becameeffective effective after after the installation, the installation, learning learning information information (either (either automatically automaticallyor or by by the the users) users) toto customise customise the intervention the interventioninindifferent different domains domains and based on their and based onpreferences, habits and their preferences, objectives. habits and Following Following objectives. these first weeks of learning, these first weeks ofthe intervention learning, period began, the intervention in which period began,thein system which is supposed the system is to suggest to supposed activities suggestand goals and activities to begoals achieved. Unfortunately, to be achieved. the outbreak Unfortunately, the of the COVID-19 outbreak pandemic forcibly of the COVID-19 pandemic modified the modified forcibly testing and theevaluation testing andactivities of the evaluation NESTOREofsystem, activities starting from the NESTORE system,the starting sample size fromtothethe sample durationsize of the pilotduration to the (in someofcases, the it was not possible to do a 12-week pilot), up to the possibility of pilot (in some cases, it was not possible to do a 12-week pilot), up to the possibility doing coaching activities of linked coaching doing to the NESTORE intervention activities linked to domains the NESTORE(the social domain, and intervention in many(the domains cases also social the outdoor domain, andactivities). in many cases The COVID-19 outbreakactivities). also the outdoor has partially Thelimited COVID-19the effective outbreak action has partially limited the effective action of the e-coaching system. For the management of the activities, the staff of the pilot sites constantly monitored and supported the users, when possible, in presence or using video call and/or chat systems. Technologies 2022, 10, 50 21 of 28 of the e-coaching system. For the management of the activities, the staff of the pilot sites constantly monitored and supported the users, when possible, in presence or using video call and/or chat systems. 7.1. Participants Initially, the pilot study was planned with at least 60 participants testing the NESTORE system, equally divided between Italy, Spain, and The Netherlands. All participants required to meet the eligibility criteria (see Figure 10); users affected by severe chronic conditions were excluded. In addition, there was a control group, to check the system impact on people’s health and well-being (evaluating the difference between those who used the system and those who did not). Participants were supposed to test the NESTORE system for about 12 weeks independently. Due to COVID-19 pandemic breakout, the pilot scheduling and the users’ sample suffered an adjustment according to the context situation and country restrictions. Around 72% of participants were allocated to the intervention Technologies 2022, 10, x FOR PEER REVIEW 22 of 29 group (43 individuals), and the remaining 28% to the control group (17 individuals). The aim of having a gender-balanced sample was achieved. Regarding the socio-demographic composition of the sample, the average age was 70 years old. The educational level was educational level was higher than expected in relation to the general population of this higher than expected in relation to the general population of this age range. A high age range. A high percentage of participants (81%) lived in a house of his/her partner’s percentage of participants (81%) lived in a house of his/her partner’s property. Around property. Around 19% reported living alone. It was decided to take the “time of use of the 19% reported living alone. It was decided to take the “time of use of the wearable” as a wearable” as a reference to calculate the approximate duration of the length of the reference to calculate the approximate duration of the length of the intervention, due to be intervention, due to be one of the first devices setup. As mentioned before, it is important one of the first devices setup. As mentioned before, it is important to note that few cases to note that few cases have reached the 12 weeks of intervention, initially established as have reached the 12 weeks of intervention, initially established as the standard period. 50% the standard period. 50% of the participants followed up for more than 9 weeks. This of the participants followed up for more than 9 weeks. This period was calculated based period was calculated based on the start-up of the wristband and first use. on the start-up of the wristband and first use. Figure Figure 10. Eligibility criteria. 10. Eligibility criteria. 7.2. Methods 7.2. Methods The study was designed as a prospective interventional study aimed to assess the Theofstudy validity was designed technological as a prospective procedures developed byinterventional the NESTORE study aimed partners fortothis assess the project, validity of technological procedures developed by the NESTORE partners evaluate the usability of the platform, including particular experience of the participants for this project, evaluate with the usability the system and itsofcomponents. the platform,Finally, including particular the goal was alsoexperience to assessof the the participants effect of using with the system and its components. Finally, the goal was also to assess the system on user status and behaviour based on standard measures between pre- and the effect of using post- the system on user status and behaviour based on standard measures between test changes in the control and intervention groups. Given the exploratory nature of the pilot pre- and post-test changes in the control and intervention groups. Given the exploratory study, the small sample size analysed, and the magnitude of missing data, the conclusions nature of the pilot study, the small sample size analysed, and the magnitude of missing derived are more explicative in the usability and acceptance part of the study. The methods data, the conclusions and tools forderived evaluating are the more explicative in functionality, the usability usability, and acceptance acceptability, and userpart of the study. experience were The methods selected among and tools forand qualitative evaluating the functionality, quantitative usability, to approaches, according acceptability, and user the various phases of experience the were pilot (e.g., selected among installation, qualitative mid-term, and quantitative final-term). Concerning approaches, qualitativeaccording methods, to the three various focus phases groups of the pilot (carried (e.g., installation, out remotely, mid-term, due to the final-term). COVID-19), Concerning and interviews qualitative (conducted by methods, three focus groups (carried out remotely, due to the COVID-19), phone) were used; these were mainly employed in the final phases to have direct and interviews feedback (conducted of by phone) were the user experience with used; these were the system. mainly employed Concerning quantitativein the final phases methods, to have standardised direct feedback were questionnaires of theused, user experience such as thewith the system.Usability SUS—System Concerning quantitative Scale [47,48], the methods, TAM— standardisedAcceptance Technology questionnaires Model were used,the [49–51], such as the SUS—System UEQ—User Experience Usability Scale [52–54], Questionnaire [47,48], the TAM—Technology Acceptance Model [49–51], the UEQ—User Experience Questionnaire [52–54], the Companionship Scale [55,56], and the Friendship Scale [57]. These questionnaires investigated the different dimensions of use, interaction, and experience of the system and its components. To ease users’ answering, the questionnaires Technologies 2022, 10, 50 22 of 28 the Companionship Scale [55,56], and the Friendship Scale [57]. These questionnaires investigated the different dimensions of use, interaction, and experience of the system and its components. To ease users’ answering, the questionnaires were changed into online forms, and sent by email. Users voluntarily answered after the first use of the system and at the end of the pilot. We added open-ended questions to these standardised questionnaires, to gain a more detailed insight into the users’ experience. 7.3. Results During the pilot, the use of the system was affected by several factors, both contextual (COVID-19 outbreak) and related to the state of development of the NESTORE system and its components (the system was a prototype). Nevertheless, the users’ response regarding acceptability and usability of the system and its components was moderately neutral to positive. The findings regarding the specific pathways of interest, collected in both qualitative and quantitative form, are presented here. Overall, the intervention explored did not show statistically significant nor clinically relevant differences for any of the measures assessed in the pre-post study. Although few participants were conscious of following a pathway spanning across each domain during the intervention, it is important to emphasize that due to the contributing factors and underlying circumstances of this pilot study, it was extremely difficult to identify all the mediating factors in their experience that could affect their pathway selection awareness. However, in relation to the selected pathway to well-being (Table 3) in the first stage of the intervention, generally, participants were more likely to prioritize those coaching plans aligned with their personal goals. Thus, in the physical domain they prioritized the improvement and retention of fitness activities (37% and 31%, respectively), in nutri- tion they prioritized achieving a healthy diet (76%), in the mental and cognitive domain they preferred to improve their memory (41%) and in the social interaction domain they prioritized almost equally in both routes (48% and 52%). Table 3. Pathway choices (coaching plans in each domain) for the 29 pilot users who started the intervention phase. Domain Coaching Plan Number of Users Percentage of Users Aerobic fitness 20 69% Physical activity Body strength 9 31% Achieve a healthy diet 22 76% Increase muscle mass 1 3% Nutrition Decrease body weight 6 21% Increase body weight 0 0% Social integration 14 48% Social Social abilities 15 52% Broader thinking skills 9 31% Cognitive Everyday mental skills 8 28% Memory 12 41% In relation to their performance perception of each of the coaching plans, one of the most valued coaching plans was in the physical domain (i.e., maintaining or improving aerobic fitness) because they could easily monitor their daily activity, as in the case of the nutritional domain (e.g., decrease body weight), thanks to the use of the scale. From the users’ insights it could be inferred that the mediation of a device generated a nexus that helped users to maintain the daily monitoring of their activities. If the device that mediated the activity monitoring failed, users’ motivation with respect to the coaching plan was affected. The tangibility of the devices acted as a reminder of the existence of a commitment Technologies 2022, 10, 50 23 of 28 to the pathways and the project. However, this affirmation could not be constrained in all devices, as with the social beacons due to the confinement situation or the pandemic social restrictions. From the results of the surveys and the qualitative approach it become clear that the mechanisms for selecting, scheduling, monitoring and evaluating the coaching activities have a wide range for improvement, since NESTORE system presented usability issues typical of products and systems under development. From the qualitative approach, it can be concluded that the difficulties during the pilot modified users’ perception about the system. The participants’ effort to confront the technical issues far exceeded what they were getting out of it, and they developed two attitudes: abandoning the system or using it at a low minimum. Any action aimed at reducing the mismatch between the effort required to use the system and the benefit obtained will contribute to improving the final user experience. Some of the recommendations related to the system functioning pointed towards: extend the test period, especially in multi-domain systems, balancing the time required to complete tasks for all domains, making task management more flexible, introducing more engaging activities, reducing complexity and adding more support elements during system use and familiarization period that reinforce users’ digital literacy to facilitate the adoption process. Nevertheless, the integration of participants’ views during their performance and creation of mechanisms to evaluate their self-progress have been considered important factors to increase their satisfaction level with the coaching process. The participants showed a high level of commitment to develop the activities proposed by the system, even though they faced technical and functional barriers in carrying them out that affected the data collection and therefore the proposed coaching strategies. Despite this, they showed a high level of perseverance to do what they were supposedly expected to do. These circumstances were ultimately determinative of their final experience using the system. As an example, Table 4 presents the results from the quantitative analysis of the use of the NESTORE system and its components. Specifically, it gives the results of the questionnaire carried out based on the SUS and TAM questionnaires, in which the satisfaction (S) and acceptability (A) of the system are evaluated. The first nine questions investigate satisfaction of use, and the last three, acceptability of use; the tenth question covers both domains. The surveys were submitted to the participants in digital form, at the beginning and the end of the pilot; the participants could answer it voluntarily. We present the mean and the mode of the collected answers. The sample of answers demonstrates acceptable values for the satisfaction and acceptability of the system. Table 4. The results of the SUS/TAM surveys, answered by the users at the beginning and the end of the pilot. Beginning of the Pilot End of the Pilot NESTORE System 23 Answers 22 Answers Satisfaction (S) and Acceptance (A) Global Evaluation MEAN MODE MEAN MODE I think that I would like to use the system frequently 3.3 4 2.9 3 I found the system unnecessarily complex 3.4 4 3.4 3 I thought the system was easy to use. 3.1 3 2.7 3 I think that I would need the support of a technical person to 3.5 3 3.4 3 be able to use the system S I found the various functions in the system were 3.2 2 2.9 4 well-integrated I thought there was too much inconsistency in the system 2.9 2 3.5 3 I would imagine that most people would learn to use the 3.2 3 3.1 4 system very quickly I find the system very awkward to use 3.1 3 3.1 2 I feel very confident using the system 3.1 3 2.9 3 Technologies 2022, 10, 50 24 of 28 Table 4. Cont. Beginning of the Pilot End of the Pilot NESTORE System 23 Answers 22 Answers Satisfaction (S) and Acceptance (A) Global Evaluation MEAN MODE MEAN MODE I needed to learn a lot of things before I could get going with S&A 3.5 3 2.7 2 the system I find the system easy to use 3.1 4 2.8 3 Using the system to help me maintain and improve my 3.7 4 3.1 4 A mental well-being is a good idea Using the system is beneficial to improve my overall 3.7 4 3.4 4 well-being 8. Discussion 8.1. Discussion of Results The NESTORE project, through an iterative process that involved users and domain experts, allowed to conceive a novel multi-domain intervention aimed at improving well- being in older age. One of the main challenges in the project was to design an e-coach able to recommend effective healthy behaviours in multiple domains of well-being (physical, nutritional, cognitive and social) and, at the same time, to ensure the usability of such a complex system, requiring multiple devices and inputs from the user in order to provide tailored recommendations in each domain. The iterative co-design and testing process allowed us to discover important insights on users’ desires and needs. Although most healthy older adults who are interested in maintaining their well-being have already quite busy days, they are still interested in finding time for training in the four different domains tackled by NESTORE. The partic- ipants to the survey estimated that they could spend, on average, around one per day in each domain. From the answer to our survey, we also evidenced that they reported a preference for those activities that were already part of their daily routines. Based on expert recommendations, for example, walking fast enough or walking with heavy shopping bags could contribute to the user’s physical well-being, respectively for the aerobic fitness and body strength coaching plans. Still, some time should be dedicated to specific exercises that could not be integrated in daily routines. Monitoring progress in each domain is also technically challenging adding multiple devices and questionnaires to check user’s progress. Users are happy to spend time in such reporting activities if there is enough feedback on the monitored activities and on the overall progress. However, the uptake at once of several devices and apps (in our case, mostly prototypes, which were still prone to bugs) brought an important cognitive effort and time burden, which decreased the user experience of the user. Precisely, one of the suggested recommendations by users was to adding more support elements during system use and familiarization period that reinforce users’ digital literacy to facilitate the adoption process. This type of actions may initially require a significant resource investment to define, design and implement them. However, the impact of their implementation can be high impact as they can definitely contribute not only to increasing users’ awareness of the system’s performance and what to expect from it, but also to increasing success in future interactions. So, it can be an opportunity if the system embraces the user and offers contextual aid (always available and visible if user needs it) and welcome ‘step by step’ help. In the other hand, it is necessary that the system could be adapted to different levels of digital literacy (e.g., basic, moderate and advanced). In addition, it is useful if the system is permeable to the accumulation of usage experiences and has the capacity to adjust messages according to the learning detected, so that it can offer help depending on the user’s needs. Considering the time constraints imposed by the European funding for designing, implementing, and testing the system and the difficulties brought by COVID-19 pandemic the results of the study have limited scope and it is difficult to generalize findings on Technologies 2022, 10, 50 25 of 28 the efficacy of the NESTORE multidomain intervention. Nevertheless, the qualitative approach used during the co-design and evaluation of the system allowed to derive design recommendations for building future e-coaching systems and for the improvement of the NESTORE system. 8.2. Design Recommendations On one hand, participants considered that flexibility and freedom were important ingredients in their life. Therefore, they value having the chance to improvise and decide what activities they want to engage in and when without excessive planning; this recom- mendation, although not completely aligned to the HAPA model, can be considered in future studies and interventions. The pathway selection stage is a key moment in the well-being intervention, in which user needs to receive from the e-coach a greater follow-up and support and in a meaningful way, to become more aware of the importance of their choice. This phase should carefully manage the expectations of the users, so that they clearly understand the next steps to be taken. Participants suggested selecting the pathways in a more visible and structured way. Additionally, it will be useful if users can constantly check their progress in each pathway, also as a reminder of their choice and final goal. Such progress was nuanced in the app among various charts monitoring progress in each domain and clearly provided only as oral feedback in the tangible coach, which unfortunately encountered technical problems for some users. On the other hand, they also expressed the need that the pathway selection becomes a meaningful moment that generates an informed and conscious choice (i.e., clear intention formation). Participants considered that experiencing happiness and fun are important not only to increase the interaction with the system but also to maintain their engagement and to improve the app user experience. Therefore, participants suggested different strategies to enhance the user experience (e.g., improving the vocal interaction—in terms of languages and styles—and introducing a greater variability and diversity in the interaction modes and activities). Finally, participants in the study agreed that coaching styles could affect their accep- tance and receptiveness to the intervention. Because of this, if the communication style is considered as coercive, strict, rigid, or unfriendly that will not encourage them to interact more with the system and to be motivated and engaged. Considering the multidomain design of the intervention, there is scientific evi- dence [58,59] that the different domains are strictly intertwined, and a comprehensive e-coach should tackle the different domains at once. At the same time, the burden associated with adopting several devices and apps is not negligible. For a commercial e-coaching system, we would recommend exploiting the modularity of such e-coach, introducing additional domains one at a time, once the user is already acquainted with a part of the system and managed to integrate healthy behaviours in one domain in their daily routines. 9. Conclusions This paper presented NESTORE, an e-coaching intervention for promoting healthy lifestyles in older age. In the article, we highlighted the novel approach of providing simultaneous coaching activities in different domains, modelled as a personalized pathway to well-being. We showed how the design of the NESTORE e-coach was based on state- of-the-art recommendations for e-coaching systems, as well as on the HAPA model for behaviour change as conceptual underpinning. We highlighted the importance of designing an e-coach which is not only a tool for exercising but also a companion of the user during the process of behaviour change, providing support and knowledge for sustainable and long-term well-being improvement. Finally, we presented the results of the pilot study conducted with 60 older adults in three European countries. Technologies 2022, 10, 50 26 of 28 The overall process highlighted the many open challenges to design a multi-domain e-coaching system that is at the same time effective and easy to use. Personalization, simplicity, engagement and integration in daily life are the main aspects that older users highlighted as key features of such e-coaching system. Author Contributions: Conceptualization, G.A., G.R., E.M., M.C., F.P., S.O. and L.A.; methodology, L.F.M., C.E.S., G.A. and C.R.; software, M.E.K., M.G., M.S., S.E. and A.C.; formal analysis, L.F.M., C.E.S. and P.S.-B.; writing—original draft preparation, all; writing—review and editing, all; supervision, G.A., G.R., E.M., O.A.K., M.C., S.O. and L.A.; project administration, G.A.; funding acquisition, G.A., G.R., E.M., M.C., S.O. and L.A. All authors have read and agreed to the published version of the manuscript. Funding: This project is supported by the European Commission under the Horizon 2020 programme, SC1-PM-15-2017—Personalised Medicine topic, through the project grant No. 76964. The authors want to thank all the NESTORE Consortium. The opinions expressed in this paper are those of the authors and are not necessarily those of the project partners or the European Commission. Institutional Review Board Statement: Not applicable. Informed Consent Statement: Not applicable. Data Availability Statement: NESTORE data can be retrieved from the public deliverables available on https://nestore-coach.eu/deliverables (accessed on 4 March 2022). Conflicts of Interest: The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results. References 1. European-Commission. Personalised Coaching for Well-Being and Care of People as They Age. 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