Within the framework of the Individual Project 2 integrated in the Coordinated SecurHome Project (hereinafter PI2-SecurHome), this Deliverable aims to systematize the state of the art in relation to the topic under study: "the realization of a mobile application for the monitoring of domestic activity through television". Starting from the fact that the mission of the project focuses on the monitoring of elderly people in the home, with a focus on monitoring their activity that does not involve changes in the domestic ecosystem, the document collects a study of the state of the art of several technological solutions that approach this design. The study of these technological solutions is structured in two types of solutions: IOT approaches associated with complementary devices and approaches focused on television.
After this, a systematic presentation of the iNeighbour television system is made, with the perspective that it will serve as a technological base for the development of a mobile application that is the object of this project.
According to the National Statistics Institute (INS), by 2015 some 2.1 million Portuguese (approximately 21% of the total population) were over 65, and the forecast  indicates that this figure will increase to 2.8 million by 2050 (approximately 30% of the total population). Also according to the INS, the working age population (between 15 and 64 years) living in Portugal will decrease significantly, from 6.7 million in 2015 (about 67% of the population) to 3.8 million in 2050. In addition to this widespread ageing of the population, it can also be observed that in Portugal, the number of elderly people living alone doubled between 2012 and 2018. In 2018, the Republican National Guard (GNR) noted that more than 28,000 older people live alone and more than 5,000 live in isolation .
With advancing age, people can acquire a broad spectrum of sensory, physical and cognitive limitations, which tend to appear combined, increasing their impact.
In this context, the support and follow-up of older people, preferably discreet and non-invasive, has the potential to automatically identify accidents (such as falls or sudden illnesses) or, more importantly, to warn of potentially dangerous situations that allow caregivers to take timely action to avoid serious accidents (problems arising from lack of medication, physical disorientation, aggressions, etc.). This subject of monitoring is related to the concepts of tele-care, tele-assistance and telemedicine, which include various aspects associated with health care and support for people's lives when they are at home. These competencies are guaranteed by technological means that allow the transfer, between the community (in the broadest sense) and the patient, of information related to diagnostic, therapy and monitoring services .
The growing importance of telecare systems, in the perspective that they allow people to remain independent in their own homes, is corroborated by a study conducted by Cisco . This study, which included 6,000 people from around the world, aimed to understand people's perception of the usefulness of telecare systems. The results show that 70% of people feel comfortable with the possibility of communicating with doctors through technological means instead of personal contact and that 30% seek medical and diagnostic information on the Internet. It should also be noted that telecare services, which are not a substitute for face-to-face care, are assuming an integrating and complementary role in order to increase the quality of the services provided. From the technological point of view, telecare systems are usually supported by various devices and tailor-made solutions, including vital signs, drop and presence sensors and fixed and mobile terminals.
In addition, there is an interesting window of opportunity to include television, in its interactive aspect, in this list of devices. The relevance of this opportunity stems from the fact that most telecare solutions, in order to ensure wider functionalities, require the introduction of new devices in people's homes. This may condition, on the one hand, the installation and availability of the systems and, on the other, the motivation and acceptance on the part of future users. This situation is even more sensitive for the older public, which is generally less available to integrate new technological devices into their daily routines. In this sense, remote monitoring and telecare solutions supported by television, a device already available in the vast majority of homes and substantially used by the elderly1 ), present advantages that may be decisive for the generalization of these systems. Moreover, this approach, if applied correctly, can have a double advantage:
1 It should be noted that, in Portugal, average daily TV consumption is 4h44 minutes - one of the highest values in Europe - and that people over 64 years of age account for more than a quarter of the national audience profile.
- on the one hand, can contribute directly to the design of this project: support the monitoring of older people in the home in a discreet and non-invasive way, based on monitoring their daily activity, without the need for changes in the domestic ecosystem;
- On the other hand, it can automatically alert carers to potentially risky situations, such as deviations from the daily pattern of watching television and taking medication, as a result of problems caused by sudden illness, physical disorientation, theft or any other incident that modifies typical activity, allowing carers to take timely action to avoid serious accidents.
After this introduction, this report begins with an approach to the remote monitoring and telecare solutions available in the Portuguese market (presented in section 2.1). Following this, and taking into account the document's orientations for TV-based systems, a detailed analysis of the solutions focused on this device (presented in section 2.2) is carried out. Section 3 of the document presents a teleassistance system developed at the University of Aveiro, iNeighbour TV, which adopts an interactive television platform and, consequently, television as a technological mediation equipment. The areas of the system are described below with special attention to the functionalities most directly related to health. Finally, the current approach is presented with a view to redefining the functionalities of the ecosystem of support for the elderly, in order to make them more agile and efficient in relation to the objectives of the project.
2. Technological solutions to support the elderly
Older people and people with special needs are the main target group of telemonitoring and telecare systems, i.e. the most recent to integrate IOT (Internet of Things) approaches through various devices and sensors . In this segment, which deserves all the contribution of the scientific2, business and institutional community, in Portugal, as in many other countries, a growing penetration of these systems in Portuguese households is observed.
2.1 IOT approaches associated with complementary devices
To reflect the international reality in this area, with emphasis on the Portuguese situation, we present below some typologies of integrated telecare services essentially associated with bracelets and pendants with fall detectors , surveillance cameras, special mobile phones, presence sensors (pressure and opening), drug dispensers, with or without integration to medical alert systems, which have as basic components sensors and devices such as those presented in Figure 1.
2 See, for example, research in MIT's AgeLab (http://agelab.mit.edu).
3 Vodafone V-SOS Band©, https://shop.v.vodafone.com/pt/v-sosband
4 Active Guardian©, https://www.medicalguardian.com/products/active-guardian
5 V-Camera© by Vodafone, https://shop.v.vodafone.com/pt/V-Camera
6 ZTC SP4©, http://www.ztc.pt/item.php?i=109
7 CordLess mat©, http://smartcaregiver.com/cordless-floor-mats/
8 Hero©, https://herohealth.com
In Portugal, several initiatives have been developed with a view to developing integrated support systems for older people, such as the Portuguese Red Cross (CVP) telecare service to ensure assistance to older people. This system includes a bracelet or necklace, connected to a fixed telephone terminal, with an alarm button that when pressed by the user, anywhere in the house, establishes immediate telephone contact with the CVP Contact Centre (Figure 2), which guarantees support in situations of emergency/urgency, security and loneliness, 24 hours a day and 365 days a year. This system can also be interconnected to a set of sensors (fall, smoke, gas leak, safety zone delimiter) . Based on the information gathered by the different sensors and the integrating platform, the CVP can also provide home management services. In addition, with the help of a mobile device (adapted to the characteristics of the elderly), the service offered is improved with the possibility of georeferencing the user, adding new monitoring capabilities.
In addition to this integrated CVP solution, there are others in Portugal that use similar technologies, such as Comfort Keepers , the Vodafone V-SOS Band , which includes, in addition to a bracelet with fall detection and GPS, a communication module that sends notifications to a mobile application for use by the caregiver. True-Kare  also developed a more comprehensive solution for the elderly and people with special monitoring needs. This solution is divided into two components: a True-Kare mobile phone, used by users as if it were a normal mobile phone, but with design adaptations that make it easier for older people to use; and a web application called 'Service Portal', which is managed by a person (a caregiver) to support the user of the True-Kare mobile phone. In this portal, the caregiver can, among other things: obtain information about the health of his dependent; schedule medical appointments; schedule medication; consult the location; configure the emergency button of the phone. Sensors can also be added to the mobile phone, such as: i) blood pressure meter that automatically sends the data to the portal; ii) glucose meter adapter that also sends the automatically read data to the portal; iii) Clock, with actions that can be programmed in the portal; iv) Key ring, with actions that can be programmed in the portal.
The different systems described above imply the need for a set of equipment that, in the most simplified version, is limited to a "collar", with communication capacity via GSM, but can be completed with a mini communications center and the range of sensors identified in Figure 1.
However, this type of approach always implies that one or more sensors are transported or manipulated by elderly people, which besides involving the acquisition (sometimes expensive) of hardware, does not always represent an efficient and convenient solution.
2.2 TV-centred approaches
As mentioned in the introduction, television, in its interactive aspect, allows it, and all the dynamics that surround it, to be presented as an alternative to support remote monitoring and telecare systems, minimizing the installation of any additional sensor and approaching the underlying mission of this project:
"detection of elderly domestic accidents without making any changes".
It is in this context that this section exposes the current state of the art of these systems.
Of the various existing interactive television solutions (commercials or prototypes), those that have most potentially contributed to television being considered as a central device in a telecare system are those that incorporate functionalities related to social interaction , within the domain of Social iTV. There are several examples of these applications: ConnecTV, Collabora TV, Amigo TV, Telebuddies or WeOn TV. A common feature of these applications, which is important in the context of older users, is related to presence information (which allows the identification of other people who are also watching television) and the ability to communicate through television (possibly to comment on what is being watched, thus conveying a sense of shared vision and companionship).
Starting from the knowledge that academia, and also industry, has been drawing not only from the applications identified above, but also from other successful cases of a more commercial nature, some solutions have been emerging which, due to their objectives, fall within the scope of telecare. Below are four European and four national examples resulting from research projects aimed at promoting health care and user autonomy:
eCAALYX - this project was one of the first to be supported by the AAL (Ageing Well in the Digital World)9 programme, with the aim of creating solutions to prevent and manage chronic situations associated with the elderly. Together with a set of remote monitoring tools, the eCAALYX system incorporated a television-based interface that allows patients to monitor and evaluate their clinical evolution. This interface also allows older people to interact with their network of caregivers, such as children, doctors, nurses, among others. Prototypes of the eCAALYX system were tested in a day centre in order to optimise them using a participatory design methodology.
BL Healthcare - BL Healthcare provides a set of telemedicine functionalities through a special digital multimedia receiver (STB), which is capable of collecting data from wireless devices and sending it to medical professionals. The supplied STB and Smart TV sets are only used for BL Healthcare functions and do not allow decoding of the TV signal.
T-Asisto - the T-Asisto project integrates teleassistance services with television using DTT (Digital Terrestrial Television) broadcasting technology. This system, of Spanish origin, integrates the Set Top Boxes (STB) used in DTT with a telecare terminal that receives alerts from various sensors (Gas, Smoke, Fire, Movement, among others) distributed throughout the user's home. The terminal also allowed the detection of emergency events activated by the user and the display of written messages (SMS) and user appointments on the television;
CogKnow - aimed at people with dementia, the project aimed to help users live their days better. To achieve this goal, it sought to understand the needs of patients by identifying how portable and configurable technological solutions should be to help these people. It was supported by cognitive capacity building prototypes to help patients:
- Remember events;
- Maintain social contact;
- Live daily life and enjoy recreational activities;
- Improve the sense of security.
IDTV Health - The main objective of this project was to evaluate the potential of interactive digital television (iDTV) to promote original services, formats and content that may be relevant to support the health care and well-being of people over 55 in the Portuguese territory.
Saúde.come - this project focuses essentially on a teaching and motivation program for the promotion of healthy lifestyles, using an interactive television application for its diffusion.
AAL@MEO - as part of the AAL4ALL (Ambient Assisted Living for All) funding programme, the AAL@MEO interactive television application was developed. It allows diverse information to be displayed on television, such as vital sign measurements (e.g. blood pressure), weight measurements or informative videos, based on a dashboard with a summary of all the information made available to the user.
+TV4E - is an interactive television application developed by the SocialiTV research group at the University of Aveiro, which allows the inclusion of videos on public and social services of interest to the elderly in normal television broadcasts. The generation of the videos is totally automatic and they are sent to the users through a specific personalization service.
In addition to the projects mentioned above, Blackburn, Brownsell and Hawley present a systematic review of other projects developed for interactive television platforms. In this review, which is contemporary with the conceptualization phase of the iNeighbour television system (see section 3), the authors classify the projects into 7 groups: i) E-commerce; ii) Health consultations; iii) Health information and education; iv) Infotainment; v) Local services and events; vi) Social interaction; and; vii) Vital signs monitoring.
An analysis of this review shows that 68% of the projects described are part of groups with functionalities related to: monitoring of people (vital signs, for example); provision of health and information services; and remote medical consultation. In percentage, this high quota of projects, with concerns at the level of tele-care, confirms the importance that the scientific community places on this area.
As for the functionalities, of the set of projects related to remote care, we highlight the communication functionalities between users, present in all the studies analyzed. These are essentially supported by voice calls. However, of the 17 projects analysed, 40% also include video call communication. The review also reveals a tendency for systems to rely on additional sensors to provide vital sign monitoring services and improve, for example, the response times of emergency care networks. Another perceived trend is that 30% of the work reviewed by Blackburn, Brownsell and Hawley includes additional devices to facilitate interaction with applications, especially for people with some form of physical limitation.
These interaction mechanisms are especially suitable for specific audiences, such as the elderly. According to this study, the problems of the projects studied focus, on the one hand, on the fact that only 30% of them are implemented on platforms for commercial use and, on the other hand, on the fact that only 50% of the projects report the existence of usability tests with users.
It is in this context that, due to the transversal approach of the iNeighbour television system (associated with the fact that it was supported by a commercial IPTV infrastructure and was subject to longitudinal evaluation in a field test environment, in which two Portuguese cities participated), this project is different from the others identified by Blackburn, Brownsell and Hawley.
3. The iNeighbour TV system
The system "iNeighbour TV - Interactive television in the promotion of comfort and sociability among the elderly" reflects the result of a research project of the University of Aveiro, concluded in 2012, with funding from FCT and the participation of Portugal Telecom. As its name indicates, the system, whose central component is an interactive television application (iTV), has the dual objective of, on the one hand, promoting social interaction among older people (a dynamic that often tends to decrease with age with an impact on the level of isolation) and, on the other, supporting activities in the field of telecare.
With regard to functionalities aimed at promoting social interaction, a component with potential at company level, surveillance and communication between individuals, its dynamic focuses on mechanisms for identification and interaction between people based on: i) common interests; ii) geographical proximity; and iii) kinship relationships. Despite the welfare importance of this component, this section focuses mainly on the inherent aspect of teleassistance provided by iNeighbour TV. In this area, the system includes several functionalities, such as: medication management, consultations and medical examinations (with the respective reminders appearing at the appropriate time in the television image or, if the elderly person is not watching television, via SMS or e-mail); continuous monitoring system of deviations from the daily routine of the elderly person (with the issuance of alerts to the caregiver) and panic button (with which the elderly person, through a remote control button, can immediately ask for help to his caregiver).
As reflected in this brief description, television becomes the central element of the entire action of iNeighbour TV, designed to coexist harmoniously with normal television reception. It should be clarified that the approach of television as a telematic terminal is related to the fact that, on the one hand, it is the device that supposes a greater penetration and use among the greater population and, on the other hand, the familiarity with the respective interaction becomes a facilitating factor for the integration of interactive functionalities, such as those mentioned above, in the daily routines of the elderly.
In addition to the iTV application, specially designed to be easy to use for the older audience (described in more detail in the following sections), the iNeighbour television system is complemented by two other platforms (see Figure 3): a web portal and an application for mobile terminals, usually aimed at carers and, possibly, health professionals. While the web portal allows advanced system customization and faster information entry, the mobile application allows caregivers to constantly monitor the activities of their dependents (these functionalities are described in section 3.3).
It should be noted that the iTV application, in addition to having been implemented in commercial Set-Top Boxes (STB) (from Altice's IPTV system - MEO), was evaluated longitudinally, along with the other platforms, in a field study with the participation of residential users from the cities of Aveiro and Porto. This field trial allowed not only to evaluate the usability and user experience (UX) issues inherent to the system, but also to collect data related to the potential impact of the system on the quality of life of older people.
3.1 System functionalities
After this brief overview of the iNeighbour TV system, the inherent features of the TV application are described below. Its identification was the result, firstly, of a detailed study of the needs of the target audience that could be supported by the application and, secondly, of a user-centred design approach, adopted throughout the development of the project, which allowed the various functionalities to be adjusted according to the information obtained through senior users. This identification of functionalities led to a structuring of the iTV application in six main areas: i) community; ii) health (the main area addressed in this document); iii) leisure; iv) information; v) mural and vi) communication.
However, the most important area in the context of this document is health (see section 3.2), it is relevant to describe, albeit briefly, the role of the remaining areas which, directly or indirectly, can also contribute to the well-being of older people (both physically and socially).
The community space was designed with the aim of contributing to the fight against social isolation and loneliness. Thus, its objective is to facilitate the establishment of new relationships (as well as the strengthening of existing ones) through social interactions mediated by television. It is relevant to verify that this approach, typical of applications in the area of Social iTV, began to be applied by other researchers, with the same purpose as that of the iNeighbour TV system. This area allows, therefore, to create and manage a list of friends (see Figure 1), to consult friends who are watching television, as well as to know the programs that are being watched by them at that moment. At the same time, it allows the management of a personal profile, with information that includes location, age, interests and abilities, and also to make changes of state (connected; busy; sick). It is also possible to search and add friends (searching by name, interest or aptitude), and the results are returned based on geographical proximity, facilitating the process of searching for "neighbors".
As mentioned above, older people spend a lot of time watching television. However, paradoxically, television can act as a tool to promote healthier lifestyles.
To this end, the leisure area (see Figure 6) includes features designed to encourage older people not to watch as much television and to leave home by making them socialize and exercise outdoors. The user has the possibility of creating an activity by sending invitations to anyone. They can also consult all the events created by third parties and manage their participation. A subtle way to speed up the creation of these activities/events is that the application has the ability to give contextualized suggestions to the user. This is the situation in which, if the user is consulting the weather information (and the weather is good), the application automatically displays a message such as: Today is good weather! How about scheduling a walk with your friends?
It is also important to mention that, in addition to the more fun events, the application also allows the user to search for (and apply for) volunteer scholarships that match their interests and skills, as well as their work history. In the Information area (Figure 7), the user can, in addition to consulting meteorological information, be informed of alerts relating to civil protection and tidal conditions.
As for the Communication area (Figure 8), it allows you to send and receive text messages (SMS) from and to the televisions of other iNeighbour TV users or to any person's mobile phones. Due to problems related to the lesser visual acuity of the elderly and, eventually, the difficulty of using mobile phones, this is an interesting way of, for example, allowing communication between grandparents and grandchildren.
3.2 Health area
This area of iNeigbour TV is one of the most important and relevant in the context of this document, given its framework in the field of teleassistance supported by interactive television. Therefore, it is important to analyse each of the three subareas that make up it: i) my medication; ii) appointments (appointments/exams) and on-call pharmacies; and iii) prescription management.
In the subarea - my medication, the user can check which medications to take (see figure 9). To make it easier to view this information, the application provides a list of medications for: same day; next day; and expired doses. In addition, in order to avoid the memory problems that are often exacerbated in this age group, when it comes time to take a certain medication, if the user is watching TV (even if the application is not open), a reminder is automatically displayed (above the TV picture), as shown in Figure 10.
The options available for the reminder are: mark as taken or postpone the reminder until later. There is also the possibility of connecting a physical medication dispenser that interacts with the system by inhibiting reminders if the user has already taken the respective medication. If the TV is not turned on, the reminders are redirected to the user's mobile phone. In addition (as described in section 3.3), if there is no notification that the medication has been taken, the appropriate caregiver is informed via the iNeighbour TV mobile application.
In the subarea - appointments and on-call pharmacies, you can check which appointments and medical examinations will need to be performed. These appointments can be scheduled via the web portal (by you, your caregiver or possibly your doctor), and 24 hours before each appointment the user will receive a notice similar to medication reminders. Also in this subarea, the user can consult the on-call pharmacies, which are automatically sorted by geographic proximity to home.
In the subarea-inserting medication, through a very simple tutorial, the user can inform the system of the medications to be taken, inserting, step by step, the following information: medication, quantity, periodicity, start date and duration of treatment. On the web portal, normally used by the caregiver and/or doctor, it is also possible to enter this information and add details about the dose, for example: do not take on an empty stomach.
3.3 Detection of emergency situations
One of the aspects taken into account in the design of the iNeighbour television system has been the fact that older people often need permanent assistance, or even supervision, from their carers to prevent or respond to potentially dangerous situations. Like other telecare systems (identified in section 2), the iNeighbour TV application also provides a system of panic buttons, although in this case it is not necessary to provide the wearer with any additional equipment (collar or bracelet), as the alarm is activated simply by pressing a button on the remote control. After pressing the button on the remote control, the user has 5 seconds to cancel sending the request for help, which sends an SMS to the mobile phone of the caregiver previously associated (through a web portal).
In addition, the system provides a permanent monitoring mechanism that, although transparent to the user, detects significant variations in their usual routines, alerting the caregiver in the most serious cases, via SMS and e-mail.
The algorithm, specially developed for this purpose, continuously crosses information on user status (online or offline), deviations from typical television consumption, lack of interaction with television, delayed drug consumption, consultations or examinations, and participation in events abroad (see Figure 11). To minimize false alerts, the algorithm also uses data from the senior's calendar to check whether he or she is expected to be home at that time.
The causes of alerts, available at 5 levels of severity (according to the National Security Advisory System and the civic protection scale), can be monitored by the caregiver from the mobile application (see Figure 11). The caregiver (who has been authorized by the user) can also control the following information about his or her dependent:
- time of the last interaction with the TV;
- the history of television consumption (programmes and channels);
- list of medicines (taken and not taken);
- dependent's diary.
Through the mobile application, the caregiver can also send short text messages to the television of the senior (his dependent).
4. Updating functionalities
Along with this state of the art study, the project team is stabilizing the operation of the entire iNeighbour television system infrastructure and considering the redefinition of its basic functions. As explained above, the mobile application depends on the functioning of the iTV application and its support portal. Thus, considering the results obtained in the field evaluation of the project, the maturation of the researchers on the crucial aspects to be taken into account and a fluid integration of the system in the television practices of the target users, the entire iNeighbour TV ecosystem will be restructured to make it more agile and efficient in relation to the objectives of the project.
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