Applying user-centred research design and evidence to develop and guide the use of technologies, including robots, in aged care

Many developed countries face the pressure of rapid growth in the ageing of the population. Alongside this challenge is the projected increase in the number of people requiring aged care services or home support. However, where there is an ageing of the population, the resultant outcome is the shortage of young people to provide informal care. Conventionally, care has been provided by families and in recent decades by paid workers, of which in some countries, these workers are often migrants. As a ‘super-ageing’ society, Japan has been working on a solution to the problem of a rapidly ageing population for some decades. They initially tried to hire foreign workers but language and cultural challenges together with unethical dilemmas that result from employing carers from second world countries such as Indonesia, Philippines and Vietnam were noted. Furthermore, this was not found to advance care provision.

As one of the most technologically advanced countries in the world, effort was put into developing technologies to provide service and care so that older people in Japan can stay longer in their own home. However, in spite of advances being made in technologies, many people oppose the use of technology and specifically when used to provide companionship. Concerns continue to be raised about non-human forms, in particular the use of humanoid robots for what is regarded as ‘artificial’ companionship. This is in spite of overwhelming evidence that when older people are moved into a nursing home, there is a reduced likelihood that family and friends will continue to visit (Siniscarco, Love-Williams, & Burnett-Wolle, 2017). How then can we continue to offer companionship, social activities, cognitive stimulation and functional support to older people who are socially isolated? Technologies such as robotics may be a solution to functional support and helping older people stay at home for longer as they can offer services such as housecleaning, lifting and transfer of older people, hygiene care or the monitoring and management of symptoms and behaviours. Furthermore, robots can connect the older person to family and friends for companionship, and they can provide cognitive stimulation through games and entertainment.

However, the fear of replacing human caretakers with robots has also highlighted concerns about robots dehumanising care (Hebesberger, Koertner, Gisinger, & Pripfl, 2017). Such ‘head in the sand’ concerns have resulted in a situation where consumers (older people and health professionals) have had little involvement in the development or evaluation of technology. In addition, robots not specifically developed for aged care tasks are being promoted within aged care by marketing companies and developers hoping for a quick dollar, and often alongside the aged care CEO adopting the technology and broadcasting its use to demonstrate the advancement of their business. When robots are placed into environments for which they have not been developed for, this can perpetrate the negative views of robots. After all, how can a robot provide appropriate emotional responses or communicate as effectively as a human being? Technologies break down and their initial start-up cost is often quite high. Importantly, is it ethical to use robots as companions in place of human beings?

The poor quality of care in ageing services that is persistently reported in social media raises different questions and concerns for us. Robots can provide consistency in care and service provision. They do not suffer from burnout as experienced by staff. They do not neglect to communicate or look after a person if this is what they are programmed to do. Although robots are not human, this may help many of us to feel less concerned when a robot rather than some human assists us with intimate tasks such as toileting. Would you feel more comfortable with a robotic toilet or a human wiping your bottom?

There have been enormous technological advances in both healthcare and the home with the opportunity to improve quality of life of older people. It is imperative, however, that such technologies are developed through a user-centred approach. In the past, engineers have developed technologies for use with older people with no input from consumers. Consequently, those developed technologies were often either obsolete or impractical. More recently, engineers understand the need to invite consumers to test their products. However, there is still a reluctance to engage consumers in the conceptualisation phase. Our experiences have taught us that the best technologies, ones that are feasible and meet a purpose are those where a user-centred approach has been used in all phases of the product development and evaluation.

A social robotics team led by Professor Wendy Moyle at Griffith University, Brisbane, Australia, also using a user-centred approach, aims to create knowledge about products through research that initially focuses on feasibility. Product feasibility is usually undertaken within the Griffith University social robotic laboratory, and with a variety of end users. This process is followed by pilot testing of products in the ‘real world’, work that will inform the research design and the required sample size for the next stage of the research that will involve a large randomised controlled trial. An example of this work includes the development of social robot trials using PARO, a baby harp seal designed for a therapeutic purpose (Shibata, Kawaguchi, & Wada, 2012). Several years ago, PARO was introduced into aged care facilities and the Griffith University team (at that time Professor Wendy Moyle and Dr Cindy Jones) found that PARO was often kept in locked cupboards because of the cost and the limited understanding of when or how to use PARO. The Griffith University team purchased two PARO to investigate their feasibility. This preliminary work convinced the team that PARO does not pose a risk to older people (as long as maintenance is managed) and it is feasible to be used with a population of people with dementia. Although the team managed to procure funding for a pilot trial (Moyle et al., 2013), the research was met with criticism from those who developed an argument that PARO was unethical to use as it was not human. We still recall the ignorance of the journal editor who wrote “I would rather club a seal than hug a seal” when referring to PARO and the team’s research. What he neglected and failed to recognise was that PAROs were already in use. People were purchasing them in spite of the evidence for their use at that time being non-existent. The team’s research aimed to understand if they did have an effect. They were not advocating their use without the evidence. The pilot research (Moyle et al., 2013) found that PARO could potentially improve anxiety and quality of life of people with dementia. This was followed by a large cluster randomised controlled trial funded by the National Health and Medical Research Council (NHMRC) (Moyle et al., 2017) and undertaken with a larger team of interdisciplinary researchers from three national and two international universities. The trial with 415 people with dementia found PARO improved engagement and mood. Nevertheless, while PARO can have an impact on engagement, mood and agitation, there are still many unanswered questions that need further investigation, such as: “What is the appropriate dose?” (i.e. how long should PARO be left with people with dementia?) and “What people characteristics are required for Paro to have an impact?” Two current projects will work towards the quest to address such questions. These are an investigation of the effect of PARO on older people with depressed mood (Chen, in progress), a common problem in older age. The second is an investigation of the effect of PARO on pain in older people with dementia (Pu, in progress), another common problem for which to date this has not been able to be solved.

The world is rapidly ageing and as a result, there will be reduced availability of young people to provide care in the future. There is mounting evidence that in the immediate future, we will see greater use of technology providing services including entertainment, connection, diagnosis or treatment; and care provision such as lifting, hygiene and feeding. Robots and technologies can support older people to live independently but it is imperative that consumers are involved in the conceptualisation, development and testing of new products to ensure appropriateness and practicality. Importantly, there should be strong evidence for their use and impact before recommendations are made for its uptake in service and care provision.