Persuasive Design: Enable Bystanders to Get Access to the Nearest AED When OHCAs Happen
Yiran Chen
Yiran.Chen.6651@student.uu.seCity, Uppsala University
Uppsala, Sweden
ABSTRACT
Out-of-hospital cardiac arrest (OHCA) has become a leading cause of death in Sweden, while the useful tool external defibrillator (AED), which enables the heart to restart to beat, is not fully used. Prior studies have worked out various solutions to promote the use of AEDs.
However, those studies only delved into the situation in certain areas but barely fit the conditions in Sweden. In addition, few of the studies explored the cause of low use of AEDs from the perspective of users. This work investigated the drawbacks in the current situation in Sweden and users’
thoughts towards using AEDs. As a result, this thesis presented a persuasive design, a group of embedded functions in Google Maps. The main effects of the design are: 1. Endowing bystanders with knowledge of where AEDs are located and how to manage the device 2.
Facilitating the process of seeking and retrieving the devices and creating a channel for bystanders to sought help. The prototype was further evaluated through Heuristic Evaluation. The study results showed the design successfully made a persuasive impact on bystanders to change their attitudes by offering instruction for them to seek and control AEDs. The design also remedied deficiencies in the current situation of using AEDs in Sweden. Lastly, the study concluded persuasive design can play a role to facilitate the use of AEDs, thus improving the survival rate of OHCAs.
Author Keywords
OHCA; AEDs; Persuasive Design; Smartphone Application; Heuristic Evaluation; Usability CSS Concepts
• Human-centered computing~Human computer interaction (HCI)~ Interaction design theory, concepts and paradigms
• Human-centered computing~Human computer interaction (HCI)~HCI design and evaluation methods
INTRODUCTION
Out-of-hospital cardiac arrest (OHCA), with a low survival rate, has become a leading cause of death in the western world [1]. On the other hand, automated external defibrillators (AEDs) (coupled with CPR), which enables the heart to restart effective beats and provides audible cardiopulmonary resuscitation (CPR) instructions, has been approved to significantly improve the survival rate of cardiac arrest “from <2% to >50%” [3]. Furthermore, laypeople can easily and safely use it. In short, AEDs play an essential role in emergent life-saving treatments for victims of OHCA [2.3].
However, according to a study from Fredman [4] at five emergency dispatch centers in Sweden, although AEDs are widely installed, and the installation is still increasing, the use of the device stays low instead of rising as expected.
What’s more, the study described that bystanders tend to call emergency first and be directed to get an AED to use.
The typical process of bystanders being distributed to an AED has distinct disadvantages. The process is stated that bystanders call emergency dispatch centers when encountering an OHCA and the dispatchers instruct them to nearby AEDs. During this process, the statement of callers about the case might influence the dispatcher’s decision- making, also, there is always a geographic gap between the location of the OHCA case and AEDs, it’s very likely that the timing for an AED to play its best role has been missed when the device is retrieved. Finally, another notable situation is that in many cases the callers can’t go to retrieve AEDs since they were alone on the scene, and leaving would interrupt Cardiopulmonary Resuscitation (CPR). The study revealed that the status of the usage of AEDs in Sweden still has much to improve. Firstly, as it’s known, the current process of dispatching bystanders to the nearest AEDs has drawbacks, more importantly, it takes a long time while the defibrillation coupled with CPR needs to be operated as short as possible to improve the chance of survival [5, 6, 7]. Secondly, bystanders’ being alone on the scene is an obstacle that prevents nearby AEDs from being utilized.
The insufficient use of AEDs has gained a lot of attention, many studies in the field of Human-Computer Interaction explored the problems behind and proposed various solutions. Among them, smartphone applications are playing an increasing role. For example, a mobile app
This work was submitted in partial fulfilment for the master of science degree in Human – Computer Interaction at Uppsala University, Sweden. Permission to make digital or hard copies of all or part of this work for personal or classroom use is granted without fee provided that copies are not made or distributed for profit or commercial advantage and that copies bear this notice and the full citation on the first page. Copyrights for components of this work owned by others than the author(s) must be honored.
© 2020 Copyright is held by Yiran Chen.
named PulsePoint Respond was developed and distributed in hundreds of communities in the USA. It actively notifies people nearby a suspected cardiac arrest and encourages bystanders to operate CPR and use AEDs [8]. Also, another study attempted to design a mobile game that educates laypersons on the location of AEDs in Singapore and motivates them to check the devices onsite [9]. These studies show the similarity that they all focused only on local situations. The resemblance reveals that exploiting those applications is limited by the geographic location of the AED devices and the local resource of AEDs to a great extent. On the other side, none of the studies mentioned above solved the problem of bystanders’ being alone on the scene.
Above all, this project aimed to promote the rate of using AEDs when OHCAs happen by enabling bystanders to approach and use the nearest AEDs in Sweden. To achieve the goal, 2 research questions were inspected: “why bystanders don’t use AEDs enough?” and “how to enable bystanders to get access to AEDs?”. Differed from previous researches, this study inquired about the cause of inadequate use of AEDs from the perspective of bystanders.
The research delved into people’s thoughts towards using AEDs and reviewed theories in order to generate an approach to change their thoughts, thus enhancing the probability for them to use AEDs when encountering an OHCA case. In addition, the study aimed to figure out a solution that fits the conditions in Sweden. As mentioned above, there are still barriers that prevent bystanders from fully making use of AEDs in the local context, therefore, the final design also contributed to eliminating the obstacles. As a result, this project worked out a set of features embedded in Google Maps using persuasive technologies.
RELATED WORK Persuasive Technology
Persuasive technology, as a sub-discipline of Human- Computer Interaction, was firstly emerged at CHI 97. Fogg defined the core of persuasive technology as producing, allocating, or applying computing products to make a social influence on their human users, thus changing their attitudes or behaviors [10]. From Fogg’s perspective, persuasive technology is strongly rooted in social contexts.
Fogg’s achievements [10,11] addressed the social attribute of computing products, and regarded the computing products as a kind of social actor, which generates social cues to affect humans to change user’s attitude or behavior changes; the change itself is deemed an elicited social response.
One of Fogg’s studies [11] proposed five social cues that are significantly implicated in persuasion: “Physical, Psychological, Language, Social dynamics and Social roles” [11]. These 5 types of social cues constitute a framework that structure the persuading movement of persuasive technologies:
• Physical: It reveals that computing technologies exist as a social actor with physical features, which means they can use the physical attributes to convey physical cues to persuade. Also, the physical cue is strongly impacted by physical attractiveness.
• Psychological: From this perspective, computing products are able to convey psychological cues to users during the interaction; after a while, users will unconsciously consider the technology to have personalities or emotions. It’s also noted in this area that people tend to be persuaded by others who are more like themselves.
• Language: Computing technologies are proved to use both spoken and written language to bring out social influence on users, both positive and negative, to persuasion.
• Social dynamics: Cue of social dynamics addresses that the social rituals such as reciprocity can be applied by computing products on users to convey social presence and persuasion.
• Social roles: This view regards computing products as functional roles in society like other human roles.
Furthermore, the study [10] not only demonstrated how social cues play a role in persuasive technologies, but also put forward principles for designers to adopt the concept properly to map out persuasive inventions:
• Principle of Attractiveness: Computing products with higher physical attractiveness probably are more persuasive to users.
• Principle of Similarity: Users tend to be persuaded by computing products that are more similar to themselves to some extent.
• Principle of Praise: Praise (in various forms) has a positive impact on users for persuasion.
• Principle of Reciprocity: Users will feel necessary to pay it back when they receive favor from computing products.
• Principle of Authority: Computing technologies can act as authority roles to leverage powerful influence on users to persuade.
The social cues theory exposes the social attribute of computing products and illustrates how they convey the social impact on users to achieve persuasion. It provides designers approaches the essence of persuasive technologies. To better adopt social cues, designers should thoroughly understand every single cue and determine the quality and reiteration sensibly when applying them in the product’s constructions.
Behavior Model for Persuasive Design
From the perspective of users, to better apply persuasive techniques on them, it’s necessary to understand the internal evoke of changes of behaviors or attitudes. To
achieve the goal, a Behavior Model (FBM) proposed by Fogg [12, 13] is widely used for understanding human behavior. It deconstructed the inner mechanism of formation of human’s behavior in 3 dimensions: ability, motivation and trigger, in other words, for a person to perform an aimed action, the three factors must take place at the same time.
The Graph (see Figure 1) [13] demonstrates how FBM works. Firstly, it contains two axes: the vertical one indicates Motivation (also defined as Core Motivators), the higher position on the axis, the higher motivation for a person to perform an aimed behavior while the same the other way around; another axis indicates the Ability( also defined as Simplicity Factors) a person has to perform a behavior, it keeps increasing as it’s pinpointed from left to right on the axis. Secondly, the third factor shown on the chart is Triggers (Prompts), the text Prompts, together with the formula B=MAP, indicates that Motivation and Ability cooperate at the same time in the context of Prompts to arise actions.
Besides, the action line shows the boundary of successful and failed actions, which means the minimal level of motivation and ability is required to arise an action.
Suppose the effect of motivation and ability is under the action line. In that case, the actions are failed to arise, as they are increasing, the probability of performing an action for a person is going up. When exceeding the green line, motivation and ability collaborate to succeed in initiating a target behavior once it’s triggered. The action line also signifies that “motivation and ability can be trade-off.
People with low motivation may operate an action if it’s simple enough while they are very likely to perform a difficult behavior if the motivation is high enough as well”
[12].
In addition, coupled with the visualized model, the study put out a notion named Kairos, which addresses the timing to persuade. Fogg claimed that “opportune moment for behavior performance is any time motivation and ability put people above the behavior activation threshold.” [12].
In reality, generally, people have a moderate level of motivation and ability. Designers need to deploy the two factors to adjust every single persuasion case to make the persuasive techniques play a most effective role.
Figure 1. Fogg Behavior Model
Persuasive System Design
Apart from research in the field of Social Psychology, a new trend of the system design is arising that applies persuasive technologies in the system to “reinforce, change or shape attitudes or behaviors or both without using coercion or deception” [14]. The successful outcomes of these systems are summarized into the following 3 points representatively: “1. Strengthening current attitudes or behaviors to resist changes; 2. Changing a person’s reactions to target objects; 3. Formulate a pattern for upcoming situations” [15]. In this area, Social Cues Schema established a guideline for producers to understand and merge persuasive technologies into products. However, it seems to be too limited to work as a framework that can be referred to determine functions, contents of persuasive computing systems [16].
To better accomplish successful persuasive systems, Harri Oinas-Kukkonen& Marja Harjumaa [15] devised a Persuasive Systems Design (PSD) model to illustrate the development process. The model suggests 3 phases:
“understanding the essential issues behind, analyzing the persuasion context, shaping the main functions and features” [15]. The three steps guide designers to clarify the critical factors in the context that influence the intention of performing a specific behavior. Moreover, by following the model, designers are supposed to choose a method to approach to users and create the system to produce an impact on the intention of users to perform the action.
Furthermore, to help shaping persuasive functions for a system, the study brought out dozens of design principles for designers to refer to, grouping in primary task, dialogue, system credibility, and social support. Among them, this project highlighted the following principles that are incorporated in the system design:
• Reduction: Cutting the complexity of tasks to make it more likely to perform target behaviors.
• Reminders: Users are more likely to perform a task if being reminded to do so.
• Suggestion: Offering useful suggestions to users is an effective persuasion.
• Trustworthiness: A system that is regarded as trustworthy will have enhanced powers of persuasion.
• Social learning: Enabling users to look at others' performing a target behavior will motivate them to act the same.
• Social facilitation: Making users discern that others are doing the same thing with them will improve the probability for them to target behaviors.
Persuasive Nature of Map
As a frequently used navigating instrument in daily life, Map has strong persuasive quality. A study from Sara Stidstone Gronim [17] investigated the evolution of maps in British Colonial New York, analyzed the geographic feature
and the role of Map in cultural and political activities, hence pointing out that Map naturally became a useful tool of persuasion. Firstly, Map displays information in terms of specific cartographic language, such as longitude and latitude, cartographic semiotics, and direction pointers.
These conventions make Map a trustworthy representation of natural and civilizing phenomena on the earth, compared with the literal word, this representation is more decipherable. Furthermore, those displayed geographic appearances stay immutable, which enhances the credibility Map. When put into practice, historically Map always played an important part in culture and policy deployment.
For example, Map kept acting as a reference in cadastral recording, navigating in the military, commercial activities and so on. By actively supporting political and cultural activities of countries, Map built up an impression of authority imperceptibly.
METHODOLOGY AND METHODS
As mentioned above, this study aimed to improve the usage rate of AEDs in Sweden by enabling bystanders to use them more. Among all the cities in Sweden, Uppsala is the forth- large, which means the population in the city is big and diverse enough to represent Sweden. More importantly, as there are 2 universities located in Uppsala, a large number of residents in the city is student, who is assumed to be more accessible for carrying out user researches and open- minded to try new technologies. Therefore, the study was conducted in Uppsala. To achieve the research goal, the first thing needed to do was digging up the reasons why they don't use AEDs from the perspective of themselves.
Then, the second stage was to implement proper technologies to change the current situation. Such changes could be accomplished by reshaping their attitudes towards AEDs or altering how they react when meeting OHCA cases. Under the premise, persuasive technologies, that were created to change humans' attitudes and behaviors, well fit the requirements. Therefore, the study was mainly guided by several theories in this branch.
The first stage of the study was exploring bystanders' notions towards using AEDs under the framework of the Fogg Behavior Model, in order to answer the question:
“why bystanders don’t use AEDs enough?”. In the beginning, a group of "Epistolary Interviews" [18] via E- mail were carried out to gather residents' in-depth insights about AEDs. The method was selected because it allows participants to read, digest, and prepare their responses at leisure. Also, it reduces the negative feeling such as fatigue, being monitored in the interview; on the other side, it helps reduce the workload of recording and transcription for the interviewer [18]. Next, "Thematical Analysis" [20] was used for basically processing the data. "Thematic analysis"
[20] is a widely used qualitative research method that directs the classification of patterns and entitles themes for qualitative data. It's very effective for researchers to summarize and interpret data characteristics, thus understanding an issue [19, 20]. In this study, the analysis
was referred to a step by step guideline [21]. At the end of this stage, the result was examined by the Fogg Behavior Model to uncover the cause of bystander's few AEDs usage.
Secondly, knowing the internal cause of low use of AEDs in users’ mind, the next step was generating approaches to solve the problem: “how to enable bystanders to get access to AEDs?”. In this project, persuasive technologies were applied to change bystanders’ attitudes towards using AEDs in OHCAs. The smartphone application was selected as the carrier of persuasion, since it is flexible and playing a significant role in people’s daily life and it is assumed to be easily approached when OHCAs happen. Besides, the solution design was supported by “persuasive technologies” [10, 11] theories. Among them, the principles proposed above were referred to as determining persuasive features. Meanwhile, several UX design methods were used to structure the design process.
Finally, to gain a view of how users would interact with the design, a “heuristic evaluation” [22] was conducted. This method is widely used by designers and researchers for its advantages that efficient and low-cost [23]. The evaluation centered on the research goal that promotes the utilization of AEDs in Sweden, which means its content was designed to measure the effectiveness of the design to make users apply AEDs more OHCA cases. Besides, the evaluation also discovered some usability issues for future improvement. The whole evaluation process was conducted remotely via online tools since participants are located separately in different countries. In this case, this method allows researchers to approach them beyond the limits of location and time and reduce the high costs of traveling to remote positions for both researchers and participants [24, 25]. The practical implementation of the methods mentioned is described in the system design part.
SYSTEM DESIGN User Study
First of all, the user study aimed to collect qualitative data about in-depth insights about applying AEDs from residents in Uppsala and identify the internal causes of not using AEDs within those insights. Considering the feasibility, the sample size was not big (N=7), the small sample made the
“research can be conducted quickly and also avoid spending too many resources, e.g. time and financial costs”
[26]. Although the sample size was limited, the diversity augmented the reliability of the result. The participants were recruited among students with different backgrounds (such as nationality, major, and so on) in Uppsala, for the reason that they are all potential bystanders in accidental OHCA cases. Another reason was that as students, they tend to be more open-minded in new things, which means the technology will probably be more likely applied among them. The participants were recruited directly by the author via online chatting, phone call, and in person. In view of data protection, all the interviewees were fully imparted the content of the interview and the data (not concerning
sensitive information e.g. name, gender, age) were used with consent.
The data collection was operated via a set of “Epistolary Interviews” [18] by emails. In each interview case, firstly an invitation was sent to every recruited interviewee after it was accepted. Next, every single question was sent to the interviewee, and he/she was asked to reply to it whenever the answer is ready. As long as the question was answered, the next question was sent, and so on. The interview contained eleven items, mainly concerning the following issues: if the respondents have the experience of encountering OHCA/using AEDs; would they like to use them to help OHCA victims; the reason why they don’t do it; their opinions about the current status of AEDs in Uppsala and suggestions to improve. Finally, seven out of nine participants finished the interview.
Next step, the data was analyzed under the framework of
“Thematic Analysis” [20]. Firstly, the collected data were carefully reviewed to extract meaningful segment related to the research questions; secondly, the extracted segments were coded and categorized according to their meanings;
after that, those codes were examined to identify broader themes that address specific points of the research questions; next, those themes were reviewed to clarify sub- themes and refine the phrase of each theme; finally, 3 broader themes with sub-themes were identified: Current cognition of AEDs with CPR, Current cognition of OHCAs, Practical insights. In each theme, the codes were summarized into findings that reflected several aspects of the research question: “why bystanders don’t use AEDs enough?”. The initial findings were:
• Almost all the interviewees have no experience dealing with an OHCA case, only 1 of them has encountered a situation, but the responder didn’t think about to use an AED.
• Most of them tend to ask for input help such as call 112, turn to other people around, few of them take AED as the first choice.
• Some of them have trained for CPR, but none has experience operating AEDs. Over half of them do not know what it is or how to use it.
• Most of them have never noticed AED devices around
• All of them have no/vague knowledge about the location of AEDs in the city, which means they don’t know where to find one when needed.
• Most of them are heartily willing to use AEDs to save the life of victims of OHCA, but all of them have much concerns mainly focusing on: their capability to find and operate it, the effectiveness and efficiency of managing the device.
• Most of them expected education of AEDs.
In short, participants are all willing to use an AED to save the life of victims of OHCA, but due to lack of knowledge and experience of managing them, and where to find them, they neither used them nor felt competent to do it. In addition, they all looked forward to AEDs' education to gain the ability to operate the devices to save lives.
Computing the findings in the model (see in Figure 2), we can see that users have high motivation to use AEDs, but the ability to perform the action is low, making the effectiveness of the two elements lower than the threshold.
To succeed in exciting the behavior of using AED, there are two options, boosting the motivation and enhancing the ability. However, as shown on the chart, as the motivation increases, the increased utility of is getting less, which means improving the same value of ability will make a greater effect. Based on the result and taking users' expectations into account, enhancing users' ability to find and handle an AED is a sensible solution.
Figure 2. Analysis of the data collected in user study Abstract and Keywords.
Features Design
Based on deficiencies of implementing AEDs in Sweden, and the conclusion of user study, to achieve the project goal : enabling more bystanders to get access to nearest in OHCA cases, the system should fulfill purposes below:
• Shorten the process and time of bystanders being dispatched to an AED device.
• Provide instruction of where to find AEDs and how to use them.
• Enable bystanders to get AEDs to use when they are alone on an OHCA scene.
What’s more, as mentioned before, smartphone application was selected as an approach to convey persuasion to achieve the research goal. As a result, this study worked our final solution to the low-use of AEDs in OHCAs, a group of features merged in Google Maps mobile application. A prototype was created to present the design.
First of all, the design should not only acquaint bystanders with the location of places equipped AEDs, but also guide them to find it quickly in urgent OHCA cases, in this instance, a mobile map would fully meet the requirements.
Among all mobile map applications, Google Maps is one of
the most widely used ones, which means it enjoys high trustworthiness. Therefore, it was selected to work as a tool to locate AEDs and navigate bystanders to reach them. As stated above, maps naturally have persuasive quality, so the Google Maps application itself can also work as a persuasive instrument and a platform to carry other persuasive features to persuade bystanders to use AEDs in OHCAs.
Google Maps originally provides geographic information about the area and has a categorizing feature (see in Figure 3) that displays locations in different classes, such as hotels, groceries, and so on, for users to explore different functional places. When users click any of the classes listed on the interface, all the places collected in the group will be listed by distances default. In addition, users are free to select any location and follow Google Map’s navigation to get there.
Based on Google Map’s original functions, the places equipped with AEDs were marked with heart shapes. On the top of the pin icon of the location, all of the marks are in visible red color (see in Figure 3). In this way, the feature emphasizes those AEDs' existence and delivers the information about the locations of those devices in the city to all users. Besides, a new category of AEDs was added to the categorizes row to array the places equipped with AEDs, it can help users to find the nearest device when necessary.
Figure 3. Categorizing feature with heart-shapes marks to address the existence of AEDs and lead to navigation function.
By doing this, this project offers another channel for bystanders to approach to AEDs in the city. Compared with calling an emergency center and waiting for being distributed, it significantly reduces the procedure and needed time to get to an AED. From the perspective of persuasive design, it cuts the series of complex tasks into a simple action, from searching for input information about where to find, being dispatched, turn to navigation tool for guidance to arrive there, to clicking a place fixed up AED to follow the navigation to get there. According to the Reduction principle proposed above, users are more likely
to perform the behavior that goes to get an AED to use.
Most importantly, cutting down the waiting time before being applied AED will significantly improve the survival chance for a suffered OHCA patient.
Secondly, as concluded above, enhancing bystanders' ability to find and handle AEDs will effectively lead them to adopt it. Apart from enabling them to find them by guiding them to reach AEDs more efficiently, another mission of the design is offering instruction on how to handle an AED to make it play its role.
Referring to the principle of Suggestion, providing useful information is an effective persuasion. Hence, an instructional module (see in Figure 4) was embedded in the google map system. On the main map interface, an information panel was set to pop out automatically, and it leads to two interfaces that exhibit educational content, where users can learn what AED is and target patients it works on (see in Figure 4). In addition, it provides users with video tutorial together with detailed textual descriptions, by entirely going through them, users are supposed to attain basic knowledge of in what context an AED is using and how to operate it correctly on a patient.
The information panel will keep pop out periodically, and only if users finish the tutorial will stop appearing.
However, users can enter the educational pages, vie site- menu. Furthermore, under the video window, there is a link that connects to websites that provide onsite first-aid training courses for users to choose to gain practical AED and first-aid experiences.
Figure 4. The auto-pop-out information panel leads to content that educates users on what AED is and how to use it.
This feature aims to educate as much as bystanders how to apply AEDs to cardiac arrest patients. According to FBM, by strengthening their ability to handle the task, they are supposed to be more likely to perform it.
Next, another purpose of the design is to allow bystanders to get input help to gain AEDs when they are alone on an OHCA scene.
To achieve it, an SOS-alarm function (see in Figure 5) was merged in google map. A noticeable one-click button was placed on the screen. Once bystanders find a heart attack patient and click it to seek input help to get an AED, as long
as it is clicked, an SOS signal will start shining on the map.
In the meantime, the alert will be transmitted from the senders' location to other Google Maps users around (within 3 km). On the other side, the other bystanders with Google Maps installed on their phones will receive a notification, which contains a visible red title to address the urgency of the situation, as well as a brief description of the case and a request for help. Users who get informed are free to either ignore the notification or click to check the situation. If they click to enter Google Maps, they will see it is in SOS model and the SOS button is pressed-down, which means normal Google Maps’s functions (the functions of searching/navigating to places irrelated to AEDs are inactivated) not accessible. In the meantime, a location pin in the shape of the water drop is flashing on the screen, which means, in that position, there is a cardiac arrest happening, and the victim is in badly need of AEDs delivery. As the location of the OHCA case and AEDs around it have been marked on the interface, bystanders who get alerted can get a quick view of how far it is from the urgent situation to themselves and to the nearest AED, to think over the condition to offer proper help. They can either use the navigation function of Google Maps to get to the OHCA case or go to retrieve the nearest AED and deliver it. In the meantime, the person who first found out the cardiac arrest case can stay on the scene for applying CPR. Moreover, this alarm system may also inform persons with a medical background, and it created a chance for the patient to received professional medical treatment before an ambulance arrives.
Figure 5: One-click button to send alert to other Google Maps users around.
From the standpoint of persuasion, the SOS button makes the time-consuming process of seeking help a simple one- click action. Additionally, the alert plays the role of a reminder to help persuade users to perform a target behavior and a trigger to make a move happen.
Finally, according to principles of Social learning and Social facilitation, making users recognize that others are performing the target behavior will encourage them to learn from others and to perform the same. Therefore, a function that exposes the status of the transportation of AEDs (see in Figure 6).
The system was assumed to connect to all the AED containers in the city. Once an AED is picked, the change will be detected by the container and transmitted to Google Map, the state of the in-transit AED will be displayed on the map. The SOS mode will end automatically when the device arrives. Otherwise, it will end in 40mins. During the process, all users involved are free to click the SOS button again to exit SOS mode at any time. Users were set to enter SOS model when clicking the notification and the button is shown as pressed-down to turn off normal Google Maps’s functions for the reason that it the pressed-down button addresses that bystanders are involved in an urgent situation. What’s more, making normal functions inactive allows users to focus on ongoing OHCA case, thus enhancing the probability of them to offer help.
Figure 6. Exposing the status of others’ transportation AEDs to make users recognize and encourage them to perform the same.
This function was set up in case multiple people go to retrieve and convey available AED devices around. Most importantly, it succeeds in solving the problem of bystanders’ being alone on the scene.
EVALUATION
In the project, a Heuristic evaluation was conducted, the evaluation contained two parts. Nielsen and Molich’s heuristics were selected in the first part, discovering the usability issues, since they were developed based on a large amount of data and accepted widely among designers and researchers. Nielsen and Molich’s heuristics [27, 28, 29, 30]
offered a broad range of principles for evaluating a design.
Next, evaluators were asked to answer a series of questions to measure the design's effectiveness to provide useful information for them to handle AEDs, thus changing their attitude towards using them in sudden OHCA cases.
In this stage, three interviewees with an academic background in Human-Computer Interaction were recruited again to play a role as evaluators. They were selected since they have knowledge in usability evaluation rather than the system itself, so they are defined as novice evaluators [31, 32], and 3 to 5 novice evaluators are enough for heuristic evaluation [28]. What’s more, the three evaluators had proposed their insights about using AEDs before in user
research. By investigating their attitudes after using the design, the change can be revealed to measure the design's performance.
The evaluation was carried out via email and online chatting software-Wechat. In the beginning, the interactive prototype document and a text file containing a description of evaluating tasks and short questionnaires were sent to evaluators. Then, the author introduced the design ideas and functions of the prototype to them via a video call representative. After gaining a basic understanding of the evaluated object, the three evaluators were asked to test the prototype to discover usability issues referring to Nielsen and Molich’s heuristics. The framework worked as an assistant to identify problems but not as the format to describe found problems [33]. All evaluators had the freedom the finish the evaluation and submit their answers at any time. Finally, through the evaluation, several usability issues and a notable change of attitudes towards using AEDs to save lives of cardiac-arrest patients were revealed.
Firstly, the design still has usability problems to be improved:
• Showing users' mobility path who go to retrieve AEDs might concern exposing users’ privacy.
• The SOS button might cause misunderstanding that it can be used in any emergent situation, instead of only OHCAs.
• User don’t have enough freedom to turn on/off the AED function in settings if they do not want to be engaged in such kind of situation.
• The system doesn’t show the status of AED in certain locations, such as whether it is taken or not working; it causes time-wasting if bystanders failed to retrieve a working AED.
• The SOS button has two functions; it makes the item low- Fault tolerance if 2 cases happen simultaneously.
• The size of the font and the layout of the text in instruction pages are not readable.
On the other side, the questionnaire inquired the impact the design made on users’ insights about using AEDs. The findings showed:
• The app provides useful information about where AED devices are located in Uppsala and how to get access.
• Users gain awareness of the existence of AEDs around.
• Users are much more willing to use AEDs to save the life of victims of OHCA when encountering it.
• Users feel they are more able to find and handle AEDs.
• Embedded function in Google Maps is acceptable.
• Users still worry about using AEDs in the wrong way, so that bringing irreparable consequences.
CONCLUSION
The research goal of this project was to boost the usage of AEDs in out-of-hospital cardiac arrests by enabling bystanders to get access to AEDs around. To achieve the goal, the study conducted user research using FBM [11,12]
to find out reasons why residents in Uppsala don’t use AEDs and generate a solution. The result of the user study uncovered that the internal causes of insufficient use of AEDs in users: lacking knowledge about AEDs prevents bystanders from performing or even considering doing it.
According to the findings of the user study, the key to making them play the target behavior that uses AEDs was endowing them with the ability to find and handle the devices, thus changing their attitudes toward using AEDs and enhancing the chance for them to do so.
In the end, the project worked out a new function embedded in Google Maps under the framework of Persuasive System Design [15]. The evaluation's findings showed that the design made them gain knowledge of the location and operation of AEDs. The acquisition further allowed them to realize that there are AEDs around can be used and enhanced their ability to apply AEDs to a heart-attack patient as well. As a result, the design transformed users’
attitudes from “feeling willing to use AEDs but uncapable of managing it” into “feeling more capable and also more willing to do it”. In conclusion, the design successfully made a persuasive impact on users to change their attitudes towards using AEDs to save lives of victims of OHCA, and such change can lead them to perform the target behavior that using AEDs to save the life of OHCA victims.
From another point, the design also effectively remedied the deficiencies in the usage of AEDs in Sweden by shortening the process of bystanders' getting access to AEDs and enabling them to have AEDs to use when they are alone on the scene.
In conclusion, persuasive design can be a method to facilitate the use of AEDs, thus improving the survival rate of OHCAs.
DISCUSSION Limitations
The proposed work is limited in several. Firstly, there are certain limitations of the proposed methods. As stated above, only 7 participants attended the user study, which means the sample size is not big and diverse enough to represent the whole population in Uppsala. Moreover, the evaluation was conducted by only three evaluators online and only examined the change of users’ attitudes. It failed to test how users will interact with the design and if it will enable them to apply AEDs in reality. From another point, one of the causes of low use of AEDs is the availability of those devices. With a large amount of AEDs being installed in public locations such as train stations, shopping malls, and school buildings, and so on, the accessibility of them primarily relied on the opening hours of those places, which
means they are likely inaccessible due to that these places are closed [1][2], the project didn’t delve into this problem.
Ethical Issues
Apart from the limitations, the study concerns several ethical issues. Firstly, as the final design is a group of functions merged into Google Maps, the issue of data privacy needed to be addressed. To fulfill the functions of the design, some private data of users such as location, mobility path will need to be obtained. Out of data protection, how to deal with these data should be taken into account. One basic rule is notifying them what will happen and getting permission before processing the data.
Secondly, it’s still controversial whether it’s safe to dispatch bystanders to OHCAs. As it’s known, there is still a high chance that the AED-treatment failed, and the irreversible consequence might make a great negative impact on bystanders. Thirdly, for now, the condition that users don’t want to be engaged in such kind of situation is not fully considered. The design should endow users with more freedom to choose wanted and unwanted functions, such as turning off the AED mode if they don’t want to be altered. Fourthly, apart from OHCA, there are plenty of other accidental emergencies happen at any time, the SOS button in the interface might cause misusing the function, quite apart from that, the SOS button has two functions: for users who found OHCAs to notify and for others being notified to exit SOS mode. The dual function makes the item low-fault tolerance if 2 cases happen simultaneously.
The potential problem of misusing the button is necessary to be explored and solved, to make users opt in (not opting out) of the SOS mode can be a reasonable solution. Most importantly, a notable finding is that although AED was designed for laypeople to use without pre-training, almost all the evaluators are still unsure if they can use the device properly. The gap between bystander’s cognition about AED and its real attribute deserves further research.
Future Work
First of all, to eliminate the limitations mentioned above, the user study and evaluation needed to be run in a broader range of potential users to gain more reliable and representative data. Additionally, it is better to operate an onsite usability test to examine the design's effect to enable bystanders to obtain and control AED devices. On the other side, the design still has a few usability issues to be improved. For example, the pages of introduction and tutorial of AED need to be optimized to be more readable according to design principles such as intimacy and information classification; the features needed to be modified to adapt to different kinds of users, such as qualified and unqualified. From another perspective, taking ethical issues into account, the design should also reduce the mental burden for bystanders to apply AED treatment to heart-attack patients; moreover, to enhance the freedom for users to control the system, a button used to turn on/off the AED mode can be added in Google Maps’ system; to reduce misusing of the alarming function and augment the
error tolerance for the whole AED mode, the alarming button should specify that it fits OHCA case instead of being marked with the confusing SOS text. Finally, the design provides a channel and resource for users to comprehensively study AEDs, however, it will take a long time and demand for further devotion to eliminate the knowledge gap in bystanders. Above all, future researches will concern educational system design and linking the design to the government’s educational policy to disseminate knowledge about AEDs in the whole population in Sweden.
ACKNOWLEDGMENTS
Thanks to all the volunteers, the supervisor, and the examiner for helpful feedback.
Thanks to B.J Fogg for offering permission to use the Fogg Behavior Model in this thesis.
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