C-TOC - Cross-Cultural Review Panel

First Iteration: May 27, 2010

Introduction

• Setup of C-TOC prototype on Douglas College computer lab: no security/admin issues - macros working successfully
• refer to literacy education for seniors / immigrants - largely computer-based
• refer to UBC learning exchange w/ DT east side (apparently 40yo = senior)
• Claudia's introductory presentation
• cultural advisory coordinators: Kymberley Bontinen, Patricia Juvik, Sai Roshni (Priya) Raju; CHCP (centre for health and community partnerships) project manager: Marina Niks
• cultural advisory panel members (5, one missing)
  • Chinese, Japanese, South Asian, Southeast Asian, Latin American communities represented
  • Vivian Lam, Sayuri Sugawara, Kamaljit Kaur, Lam Dang, Karla Maranhao
  • recruited from community groups that interact w/ seniors in their respective communities
  • representative of health-care / extended care related positions, nursing, counselling
  • all members of the panel are immigrants

Interactive Prototype Session Notes

• users: 5 panel members, M. Niks, R. Hsiung, S. Raju, K. Bontinen, P. Juvik (10 total)
• difficulty realising what is a mockup and what is interactive (i.e. drop-down menus in introductory slides) - distinction may not be clear;
  • suggestion: use a warning label in the future?
• red prompts for referring to questionnaire not obvious enough - centre on screen rather than top-left?
  • suggestion: include pictures representative of each test on the questionnaire as reminders / in case they have skipped ahead and forgotten the questionnaire
• drag-and-drop habit hard to shake - everyone had difficulty with click-and-release moving of objects - some skipped the intro slide "move the blue circle into the square"; difficulty arose in sentence comprehension, which depended on this interaction; by this point many had developed an understanding of this interaction
  • will older users be similarly biased / used to traditional drag-and-drop? it requires constant motor pressure - did the panel understand this rationale for using click-and-release?
  • suggestion: try out traditional drag-and-drop in next prototype version and ask what is preferred
• pattern construction instructions not well understood by some users; dragging to other areas of the screen aside from the target zone; for instance, covering the source shape;
  • one user puts all the component shapes back into the source area after completing the target shape; not sure why?
• clicking on trails test not required but done by most users
  • suggestion: state that it is not necessary, provide animated instruction sequence
• click+drag on a shape misaligns the cursor, decoupling it from the shape causing confusion and the possibility for the shape to be dropped off-screen, or being unable to click-to-release shape unless the cursor is clicked on top of the shape;
  • not much to be done - a fault of the PPT macro
• square puzzles not fully interactive - some lines are still missing the drag/drop macro (#7 in particular)
• "stack on top" instruction in sentence comprehension has potential for multiple interpretations: some users layer shapes, some place shapes above one another on screen
• some go/no-go slides not advancing / hyperlink is broken and leads to an erroneous place in the slide deck
• sentence production instructions are still missing the additional instruction to "use as many words as possible"
• computers low on memory after opening 16 slide decks (will be resolved in non-ppt version)
• most participants finished session in 1h20min; final participant in 1h30min ("too long!")

Focus Group Notes

• Could handwriting be used as a diagnostic tool?
• general consensus: this test will work well for well-educated, high-income, well-integrated people
• problem w/ mouse drag-and-drop were vocalised
  • suggestion: avoid this by using touch-screens
• request for audio instructions as optional feature for all test instructions; other instruction formats could include a flow diagram / animated step-by-step instructions
• more practice sessions requested
• language throughout the tests needs to be overhauled, cultural-specific terms discarded; possible to translate into other languages?
  • Similarities test especially sensitive to language norms
  • cultural-specific names in item recognition test misleading (i.e. "stationery item")
  • suggestion: allow family members to translate, but not help with task
• provide an "I don't understand" option, a flag to de-validate a single test if necessary
• community centre use case scenario: group members help one another take the test rather than family/caregivers (peer support)
  • identified shame in cognitive illness, acknowledging it in the household, esp. in South Asian community
• suggestion: provide feedback on each test: descriptive time elapsed, # items correct, where you scored comparatively to pop. norms, past times taken
  • how to deliver potentially bad news over the net? instead direct to community resources regardless of test performance

• next panel meeting (late October 15/28/29?)
  • suggestion: provide a shorter evaluation version of the test for cultural advisory panel (i.e. less trials per test), provide web-accessible version of next prototype version in October, allow them to take + fill out survey from home - likely not in PPT, but in interactive programmed version (Flex?)
  • longer focus group next time, allow discussion on interactivity of each test
  • more focus group members to be recruited

Second Iteration: October, 2010

Introduction

• Setup of C-TOC prototype on Douglas College computer lab: no security/admin issues - macros working successfully
• refer to literacy education for seniors / immigrants - largely computer-based
• Claudia's introductory presentation
• cultural advisory coordinators: Kymberley Bontinen, Patricia Juvik, Sai Roshni (Priya) Raju; CHCP (centre for health and community partnerships) project manager: Marina Niks
• cultural advisory panel members (5, one missing)
  • Chinese, Japanese, South Asian, Southeast Asian, Latin American communities represented
  • Vivian Lam, Sayuri Sugawara, Kamaljit Kaur, Norma Sanchez, Gita Rafiee
  • recruited from community groups that interact w/ seniors in their respective communities
  • representative of health-care / extended care related positions, nursing, counselling

Interactive Prototype Session Notes

• users: 6 panel members, M. Niks, S. Raju, K. Bontinen, P. Juvik (10 total)
• observers: MB, HL, CJ, CT
• session started ~40 min late, finished ~45 min behind schedule (longest participant session 1h15min, shortest around 45min)

• intro/help menu/throughout CTOC
  • tooltips on buttons and links may be confusing
  • help menu has no exit button (must click on 'help' again to exit
  • by moving "back" from slide 2 to intro screen, you are unable to move forwards again;
  • too much text in help dialogs
  • pull-down menus not yet interactive
  • red questionnaire response cues are being missed - not obvious enough
  • "Click" here to proceed to next screen on page 1 - ambiguous as to where to click
  • yellow dot to click on unresponsive for some users
  • "are you still there?" prompt premature, timeout too soon

• PWP - after clicking on stimulus once, there is a long pause before feedback is given - potential source of spurious clicking or confusion
  • inform user of pause? mouse-over the name - only require 1 click?
  • on "correct" screen - show PWP before next trial?

• SDM - stopwatch image confusing - small clicking target - long pauses here

• SC - inconsistency in feedback given after practice problems: "correct" vs. "good"
  • "overlapping" vs. "on top"
  • obvious drag/drop issue

• SIM - no pictures for "fame" and "money" stimuli

• WR - no dedicated questionnaire page - tied to PWP

• MOS - need to click twice on misplaced object
  • would "click on object that doesn't belong" work?
  • contrast problem - potential need for hiring a graphic designer to design scenes and stimuli
  • bigger objects required

• TRA - automatic generation of lines on mouse-over confusing and likely invalid - people will click anyways; * numbers and letters culturally dependent

• SqP - one trial has impossible instruction
  • obviously difficult (for healthy adults)

• PC - wording instructions too small
  • reconstruction: "... like these" : instead of "."

• SP - dra/drop macro missing for some stimuli

• GNG - instructions too lengthy, not being re-read while they are subtly different

Focus Group Notes

• demographics: acceptability of CTOC in 80+ - computer literacy issues
• children will bring CTOC home to parents - dependent on culture and living situations - others will prefer company of peers in public spaces - knowledgeable peers or nurses
  • high trust and confidentiality among peers in some communities, others among family
• knowledge of English still an issue; more graphical instructions needed to address language issue;
  • provide a limited version w/ no language used, full version w/ language?
• high level of education, computer literacy, cultural knowledge required - can cultural content be more general?
• test could agitate depression or severe anxiety; can people break at will? a clear way to pause the test needed; test takes a lot of energy, very fatiguing
• consider a practice version of the test to be taken before undertaking the full version?
• adjusting test difficulty dynamically dependent on early performance - increasing difficulty may conflict w/ fatigue - confounding variables
  • "sorry try again" discontinuation rules after consecutive failures
• multiple clicks and pauses a hassle, spurious clicking - must strike a balance b/w always needing to click and not clicking
• moving objects very difficult
• variable scoring based on location of test-taking and current anxiety score?

• practice problems / instructions:
  • buttons top small throughout
  • use audio for instructions and feedback but not for test content - may be a distraction - optional audio
  • graphical sequence requested - demonstrating low level mouse clicks - accessible via help menu
  • graphical instructions well received, increased confidence and reduced stress - clear pictures
  • could instructions affect test validity? biases?
  • provide multiple options for different kinds of learners
  • itemise instructions to encourage re-reading of instructions with subtle differences (i.e. Go/No-Go)

• interruptions / distractions
  • physical noise - preventative, doctor's office scenario? use of sound-cancelling headphones? could still need to shut out loud conversation
  • resumption cues: could provide an automated summary, recap illustrations, one-step back
  • strategy: resume scoring on next trial - several cutoffs for "are you still there?" several restart points dependent on length of interruption
  • bathroom breaks should be considered

Third Iteration: February, 2011

Introduction

• Setup of C-TOC prototype on Douglas College computer lab: no security/admin issues - macros working successfully
• UBC attendees: MB, RH, HL, CL, WW (CJ ill)
• Robins's introductory presentation
• cultural advisory coordinators: Kymberley Bontinen, Patricia Juvik, Sai Roshni (Priya) Raju, Marjory Ditmars; CHCP (centre for health and community partnerships) project manager: Marina Niks
• cultural advisory panel members (4, one missing)
  • South Asian, Southeast Asian, Persian, Latin American communities represented
  • Kamaljit Kaur, Norma Sanchez, Gita Rafiee, Fariyal Dhirani
  • recruited from community groups that interact w/ seniors in their respective communities
  • representative of health-care / extended care related positions, nursing, counselling
• next panel meeting likely in May-June

Interactive Prototype Session Notes

• users: 4 panel members, CHCP coordinators (6 total)
• observers: MB, HL, CL, RH, WW
• longest participant session around 75 min, shortest around 60 min
• delayed start (surveys, headphones needed to be distributed)

• General / Navigation
  • button affordances are required throughout (mouseOver, mouseDown, disabled feedback, an audible click on mouseDown);
    • ppt hyperlink mouseOver modal frames are shown currently (confusing, meaningless hyperlink text is shown)
  • consistent button UI needed throughout: colour, text colour, gradients, border, font, font size, bevel, etc.
    • many nav. buttons have poor-contrast: black text on blue background.
    • help buttons are currently different from nav. buttons (colour, shape);
    • I suggest a permanent control bar with small set of icons for help and navigation, visible throughout the test; pause button, progress bar visible between tests; consistent button UI and affordances, redundant coding of button meaning (text and icons); selected help menu items could be enabled/disabled depending on where the user is in CTOC (between tests, during tests, etc.)
  • click to pick up, drag, and click to drop instructions still insufficient; default drag-drop behaviour overrides; this will be eliminated in programmed version;
  • computer-literate-biased terminology used throughout: "Back", "Icon", potentially more?
  • "Click "Next" to continue" should be added to all introductory test screens (currently just the title of the test and the "Next" button are shown); "Next" button could be enlarged;

• Introduction
  • drop-down menus still not implemented (explained by small note - it is difficult to differentiate between limited interactivity notes and genuine test materials);
  • shortest completion time of the introduction was about 12 min

• Help Menu
  • What does this test mean option elicits a "available with every test" dialog; this doesn't provide any context: it is two clicks away from the test, so context is difficult to recall without a visual reminder and/or additional text; consider embedding a screenshot of the current test screen in the help UI, to provide context;
  • Each option in help opens a modal window, which is unnecessary (requires a button click to close / return to the main help menu; the main help menu options should always be visible when the help menu is shown, as should the progress bar - these components could be grouped on the left of the screen; the right of the screen could be populated with help content, whenever an option on the left is selected;
  • In some help dialogs, the user is shown a screen of text, at most 7 lines of text in a single paragraph; consider breaking this up into smaller paragraphs with headings or re-arranged into a FAQ format, include visuals;
  • There is no indication of where "Back" takes you, nor what "Back" does; we cannot assume familiarity with the meaning of "Back" as used in web browsers or file tree navigation;
  • Animated transitions (revealing or closing modal windows) may be confusing for some users; eliminating the need for modal windows eliminates the need for distracting animations;
  • If a help menu option is available and selected during a test, there should be some indication given that the current test is paused;
  • all help menu options should not be available during time-sensitive components of trials (i.e. available during the encoding stage of a sentence comprehension trial, but not during the action phase);
  • progress bar needs to be more visible; panelists remarked that they would like to be shown progress during CTOC, perhaps between tests, without having to look for the progress bar; include on conclusion screen for each test? the progress bar must not be confused with performance;

• Picture-Word Pairs
  • "Click "Next" to continue" should be added to "Sorry, Try Again" screens;
  • 4 lines of text on practice problem

• Temporal Orientation
  • large block of text is given on demo screen: counted 6 lines;
  • button affordances needed for calendar grid buttons;

• Symbol-Digit Matching
  • button affordances needed to differentiate between icons and buttons;

• Similarities
  • 4 lines of text are given for practice problem; after practice problem, 5 lines of text are shown on a screen with no additional interaction required;
  • some trials without images - is this deliberate?
  • panelists found this very confusing, largely a language issue and familiarity with abstract/concrete representations in English

• Word Recognition
  • redundant navigation cues needed;
  • should the category word get more emphasis?
  • only the first 2 puzzles have images - is this deliberate?

• Pattern Construction
  • it is not clear that any interaction is possible or required on the example screen; this example interaction should be forced - the "Next" button should only be enabled after the correct interaction is completed;
  • 6 lines of text on example screen;
  • shapes can overlap bounding boxes; this problem will be eliminated when implemented programmatically;

• Sentence Comprehension
  • it is not clear that any interaction is possible or required on the example screens; this example interaction should be forced - the "Next" button should only be enabled after the correct interaction is completed;
  • 7 lines of text on first example screen (no interaction is required);
  • add instruction: "Read instructions carefully because you cannot go back"
  • very long instructions for some trials (no suggestions, this is the nature of the test)

• Trails
  • the click instruction is misinterpreted: one subject repeatedly attempted to click on 2 before realizing she had to start at 1; the instructions should be supplemented with this instruction;
  • an alternative approach could involve an elastic string metaphor: clicking on 1 could create a direct line segment between the 1 icon and the cursor, clicking on the next icon (A) in the sequence anchors the line segment at that icon, with another line segment generated from (A) to the cursor; in other words, a line segment connected to the cursor is always shown until the puzzle is completed or dismissed;
  • visual feedback that an icon has already been clicked should be given (i.e. border, text, or background colour change)
  • practice #2 has no further instruction other than "Practice";
  • are these trials not timed? there is no icon illustrating this; is this deliberate?

• Arithmetic
  • number grid button affordances needed;
  • which part of the start timer icon is a button? is it all a button? if so, better affordances needed;

• Pattern Reconstruction
  • this version contains more puzzles than were originally in the PC encoding puzzle set (likely overlooked when new cultural advisory panel version was created)
  • shapes can overlap bounding boxes; this problem will be eliminated when implemented programmatically;

• Misplaced Object Search
  • button / background contrast needs improvement; full-screen images are unnecessary - the image could be placed in a frame, with a navigation bar along the screen edge;
  • there is no instruction as to what to do once the misplaced item is enlarged; some feedback (i.e. "Click to continue") should be provided;

• Sentence Production
  • 4-5 lines of explanatory text is given on each trial, with differing emphasis and size;
  • some sentences require more vertical space, using 2 lines of text;
  • when implemented programatically, word icons should snap to the sentence area, and allow for snapping between already-placed words; automatic re-arrangement of words when middle words added/removed;
  • Panelists remarked that the interaction here in this test needs re-thinking

• Square Puzzles
  • some explanation is needed to mention that lines cannot be rotated or twisted;
  • additional instruction is needed w.r.t. incomplete squares/ extra lines
  • each panel member experienced considerable difficulty with this task;
  • ability to place lines above one another should be disabled - lines should snap back to original position on attempted drop;

• Go No-Go
  • no interactivity on instruction screens; 4 lines of text on instruction screen; 5 lines of text on later instruction screen;

• Misplaced Object Recall
  • button affordances and contrast with background image need improvement; scene selection buttons need affordances (border highlights?);

• Conclusion
  • no interactivity on this screen;

Focus Group Notes

• acceptability
  • CTOC developers are English-speaking computer-literate students, out-of-touch with immigrant/refugee communities;
  • expected that only 10% of older refugee in Latin-American community could use the test, even if translated to Spanish;
  • willingness to take the test is not a problem; usability and language problems will be the barriers to adoption;
  • CTOC easier than MMSE, but assistance in administration still needed;
  • self-administered version difficult to imagine;
  • family, GP assistants or receptionist nurses, home nurses, research assistants, community facilitators would need to administer the test in its current form;
  • 5 years from now, more older adults will be ready to take the test;

• context of use
  • panelists to poll their communities wrt to computer use, context of computer use, types of computer programs used, frequency of computer use, willingness to take a computer test and what the desired context should be
    • older adults who use computers tend to use games, Skype (not universally), Internet, email, Word;
    • many older adults use cell phones, used primarily for voice conversation; many tend to avoid expensive communication (i.e. video chat)
  • 50/50 split on opinion wrt to use of CTOC at home: family settings may be distracting or not private enough for some communities;
  • also a risk associated with taking CTOC in a public setting;
  • potential venues: assisted living centres, recreational centres with computers, family doctor's office, over the web at home; community centres, adult day program centres;
  • home-care nurses with a laptop to administer test? time to administer test a barrier here;
  • long-term care assessors to administer test?

• language
  • some words a barrier, but panelists convinced that someone with a grade 7 education could take the test; variability between cultures still possible (apparently gr. 2 Iranian arithmetic skills = gr. 7 North American arithmetic skills)
  • trails test involves concepts that could be untranslatable;

• general usability
  • using the mouse, clicking, dragging difficult for older immigrants and refugees
  • additional graphics, illustrations would be helpful throughout (esp. illustrations for Arithmetic test)
  • help menu:
    • not useful in its current form; too much text, text too technical; help was unavailable when actually needed (i.e. Trails test);
    • "need to take a break" option in help menu not yet implemented;
    • sub-test-specific help material still absent;
    • "what does this test mean?" option needs to simplify and reduce the text, or eliminated altogether
    • progress bar went missed by many of the panelists, but would be desired; improved visibility required;
  • good consistency between sections wrt to navigation;
  • too much clicking throughout; users will be fatigued;

• audio
  • audio helps - audio should be either on (automatic) or off entirely, not toggled for each instruction (Manual audio); more control;
  • audio could deliver incorrect response prompts, supplementing visual information, potentially with graphics or animations;
  • CL's voice was found to be pleasant

• practice problems / instructions:
  • more practice is needed for the tests; could it be more like a game? practice on the games could help performance on later tests; games would not score or have any diagnostic/screening repercussions, aside from practice performing actions;
  • practice = readiness to take CTOC; must overcome lack of computer skills (potential for optional additional practice for those without computer experience);

• interruptions / distractions
  • depends largely on context;