1.       Background

Women continue to be burdened with heart disease despite the overall decrease in Cardiovascular Disease (CVD) mortality rates over the last six decades [1]. Recently, Heart and Stroke [2] reported that CVD in women is “under-researched, under-diagnosed, under-supported” and women are “under-aware” of their CVD risk. To help bridge these gaps, more research is needed to predict the possible development of CVD in women. The Framingham Risk Score is accepted (with modifications) as the ‘gold standard’ for predicting CVD risk [3-7]. The tool was developed over 60 years ago at a time when women’s cardiovascular health was of less concern relative to men’s. Moreover, physical activity which has been well documented to attenuate CVD risk, remains absent from most risk scoring [8,9].

Women’s CVD risk may be reduced by providing them with a way to better understand their personal risk and supporting them to attenuate modifiable risk factors. Thus, we undertook a prospective study to determine if women would engage with an online platform (Vivametrica^TM) to estimate their CVD risk. To benefit from Vivametrica^TM, women were required to wear a sensor-based activity tracker (in this case, the Garmin Vivosmart^® HR (GVWT), which can stream an individuals’ physical activity to Vivametrica^TM. Vivametrica^TM was able to provide a personalized CVD risk score when individuals signed onto the web-based program (Vivametrica^TM) and provided individual physical activity information, in conjunction with certain personal health information.

In the context of this study, we were also interested in women’s opinions about Vivametrica^TM and how this technology might be used in future studies. We thus took the opportunity to ask participants about their experience with using this technology. Here, we report the qualitative descriptive findings from those interviews.

2.       Method

We undertook a qualitative descriptive approach to this phase of study. This method is useful for obtaining answers to questions when little is known about a particular topic and the intention is to describe, but not to theorize [10,11].

2.1    Sample and Data Collection

This study was approved by the Conjoint Health Research Ethics Board. Following informed consent, 36 women were interviewed, after they had worn a GVWT for 12 weeks, and had access to Vivametrica^TM. The semi-structured interviews were guided by four major questions aimed at garnering participants’ opinions about using Vivametrica^TM. These questions were: (1) Did you like using the GWVT and Vivametrica^TM? (2) Tell me why (not)?; (3) Tell me more about your experience using this technology?; and 4) Is there anything else you would have liked to have gleaned from Vivametrica^TM?. Field notes were taken during and following the interviews to augment the narrative from each participant.

2.2    Data Analysis

Conventional content analysis was used to analyze the text data [12]. Two categories from the adapted Technology Acceptance Model (TAM) [13,14]; (‘perceived ease of use’ and ‘perceived usefulness’) and ‘other’ were used as a beginning framework to code the text data. Venkatesh and Bala [14] describe a person’s ‘perceived ease of use’ and ‘perceived usefulness’ of technology as key determinants that will affect an individual’s intention to adopt new technology.

Each participant’s interview was analyzed in its entirety and not limited to their responses to the guiding questions. The researcher (KH) listened carefully to each interview several times to enable understanding of the participants’ narrative/description. By using the TAM to guide the analysis and moving the actual texts from heading to heading, it became clear what comments (codes) belonged together. If the codes did not belong under either TAM heading (‘ease of use’ or ‘perceived usefulness’) the comment (code) was placed in the ‘other’ category. The themes became clear and were identified with supporting sub-categories.

2.3    Findings

As seen in (Table 1), a sample of 38 women was recruited over approximately 6 week period. Two women were excluded after enrollment, as their electronic devices would not connect to Vivametrica^TM. Thirty-six women who varied in age from 45 to 63 years ultimately participated in this study (Table 1). Most women had post-secondary education and over half (58%) of the participants indicated that they had previous experience with activity monitoring devices. There was great variability in the range of participants’ body mass index (BMI), and the sample’s mean BMI suggested overweight [15].

Participants seemed at ease when expressing their opinions about the GVWT but tended to need prompting to provide their opinions about Vivametrica^TM. The themes fit well into the ‘ease of use’ (confusion, convenience) and ‘perceived usefulness’ (measurement, sleep) categories of the TAM14 (see (Table 2-5) for exemplar quotes). 

2.4    Confusion

Despite having had an explanation about the purpose of the study, a thorough 30-minute orientation at the outset of the study (which included the participant demonstrating use of the technology, and receipt of an instruction pamphlet), some of the participants (n=8) did not appreciate the intended use for the Vivametrica^TM platform. They did not understand the need to use their computer to access the Vivametrica^TM platform and check on their cardiovascular health scores. The introduction of two types of technology, the GVWT and Vivametrica^TM, at the same time caused confusion for these participants and may have resulted in this omission. Some participants said they would have appreciated a tutorial and/or more education about Vivametrica^TM. Other participants who accessed and used Vivametrica^TM, found the additional health scores offered within the platform (e.g., back/lung health) were distracting and confusing, and they did not find them helpful. This was interesting because several of the participants did seek out the additional information offered by the GVWT such as duration and quality of sleep. Lastly, participants talked about ‘losing interest’ when they did not have enough knowledge/information about the      technology.

2.5 Convenience

The participants emphasized the need for convenience. Participants expected that the technology would be effortless. One must access a website to use Vivametrica^TM and the GVWT requires changing modes to capture different levels of activity. The participants identified that they were busy with their families, lives, and employment and did not want to have to access websites or adjust settings to be able to obtain a cardiovascular health score. Participants were willing to interact with the technology, but ease of use was essential. The majority of women who participated in this study identified that it was inconvenient to gain access to Vivametrica^TM from a computer and wondered why this platform was not available as a smart phone application, similar to GVWT.

When considering the functions and modes, the women both embraced and tolerated them. Some participants found altering the mode, settings, and navigating the technology was helpful but others found it caused angst and frustration. Several participants appreciated the notifications, time keeping, and visibility of the GVWT.

2.6    Measurement

Most participants described how Vivametrica^TM provided interesting information about their overall health. Indeed, all participants identified they were eager to understand their CVD risk numbers when entering the study. However, measurement of this risk and its elements meant different things to different participants. Some participants looked at measurement as the step/activity count that motivated them to do more. Other participants found measurement illuminated the level of activity in their daily lives (e.g., created awareness). This was evident when participants would be reminded to move (GVWT buzzing), or that their step count was under the recommended amount (5000/day). This information coupled with the CVD risk information from Vivametrica^TM identified a need for change in the participant’s level of activity and some participants found this to be very helpful. Activity became very important to participants over the course of the study and some participants found it challenging to achieve certain activity metrics because the measurement was not calculated (e.g., they did not have their GVWT on or they did not have the correct mode/setting).

2.7    Sleep

An unexpected finding of this study was that the participants often spoke about sleep. The GVWT, provided information about the participants’ sleep creating an awareness of their sleep patterns (hours of sleep per night, lengths of time they were in deep sleep, and number of awakes times). Additionally, some women learned adjusting their sleep routine (e.g., limiting computer, television, etc. screen-time prior to retiring) [16,17] created an opportunity for change that was not realized prior to this study. The participants also learned that stress had an impact on their sleep. One participant described the decrease in ‘deep’ sleep she would experience if she had her grandchildren staying with her. Several of the participants commented about the value of learning about sleep.

3.       Discussion

Overall, the study participants appreciated the notion of having a resource such as Vivametrica^TM particularly with regard to having cardiovascular/health risk scores. However, some participants felt disappointed that they could not navigate or understand the platform or the scores, and thus, the potential realized benefits were reduced.

The TAM forms the foundation for this study describing the importance of ‘perceived ease of use’ and ‘perceived usefulness’ as key components when individuals are considering adoption of new technology [13]. Perceived confidence in one’s ability to use technology has a positive effect on an individual’s perception of usefulness of the technology [18]. How the information is received (what data are available) and the individual’s motives are factors when considering engagement, suggesting if an individual’s perceived needs are not addressed, engagement may not be successful [19].

 In this study, some participants described not having enough information to understand the various components of the GVWT and Vivametrica^TM. Some participants would have liked the option of having more tutorials and training. Also, accessing the computer to realize their health scores was described as not convenient by most participants. When considering technology, it is imperative to realize the importance of an individual’s personal preferences [20]. Women were wanting Vivametrica^TM to be available on their smart phones, similar to GVWT. Additionally, the introduction of two forms of technology created confusion. Participants expressed they forgot they could/should access Vivametrica^TM to access cardiovascular risk information and tended to use only the information within the GVWT application on their phones.

Findings from this qualitative descriptive phase of study are somewhat congruent with other study findings. Duus and Corray[21] studied 200 women, who identified activity monitoring devices as an active tool in the construction of their everyday lives and the benefits created such feelings as self-satisfaction, happiness, and motivation. The participants, in this study, expressed varying opinions about the benefits of the technology used (GVWT and Vivametrica^TM). However, participants were motivated to make changes such as awareness about their activity level and motivation to change sleep patterns. Most participants appreciated knowing their level of activity, sleep, and cardiovascular health scores. It is clear that women needed more resources (e.g., tutorials, ongoing support) to address their questions regarding this technology to receive the greatest benefit.

4.       Limitations

This was an observational study aimed at examining how and if women would access particular technology for monitoring cardiovascular health. Additionally, this is a small descriptive study and is not generalizable to the population. However, this study provides information about how women describe interacting with technology. Lastly, the women may have benefitted from having a more anonymous means to provide feedback about the technology.

5.       Implications for Practice

Women need ongoing access to resources when using this kind of technology whether to troubleshoot issues with the software/hardware or to access and understand advanced elements of the technology. As technology is accessed by patients’ nursing will need to be familiar with and understand the nuances of types of technology that can assist patients to achieve maximum health benefits.

6.       Conclusion

Women’s opinions related to Vivametrica^TM and GVWT were explored in this study. They were interested in the technology and the potential of the technology to motivate them towards increased activity and understanding of their personal cardiovascular health risk. However, some participants found the usefulness of the technology did not meet their needs. Additionally, participants were confused by the introduction of two forms of technology at the same time. This innovative technology has great potential for supporting women to understand their personal cardiovascular risk. However, people who use this technology need to be trained and supportive resources to enable them to use this technology to its capacity.

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