Problem Statement and Background

Older age is associated with many changes to the body whether it be due to the aging process or the development of diseases commonly seen in older adults, such as Parkinson’s disease and arthritis (Carmeli, Patish & Coleman, 2003). The body is impacted across a variety of systems, from the muscular, skeletal, and nervous systems, to changes in sensation, coordination, vision, and auditory processes (Hackel, Wolfe, Bang & Canfield, 1992). As a result of these changes, an individual’s independence and ability to perform activities of daily living (ADLs) may be greatly impacted. Some older adults have difficulties with hand function, which has been demonstrated to decline steadily after 65 years of age (Carmeli et al, 2003). The older population presents with a variety of declines in hand function: hand and finger strength, precision dexterity, tactile sensation (Carmeli et al., 2003), voluntary fine motor control (Krampe, 2002), and bimanual coordination (Carmeli et al., 2003; Seidler et al., 2010), to name a few. It is important to note that difficulties in vision, such as color differentiation, depth perception, and hand-eye coordination (Hackel et al., 1992), will also affect hand performance.

In recognition of the significant role that hand function plays in independence and the designers’ clinical experiences with older adults who had difficulty donning shoes, the proposed device is a footwear that aims to reduce the following: (1) reliance on fine motor control, (2) the need for strong hand grip (required for a shoehorn) and (3) the need for pristine vision. It aims to reduce the necessity of these skills, all the while maintaining safety, reducing falls risk, and being aesthetically pleasing for consumers.

Problem Statement. Develop a shoe that will minimize the use of finger and hand grip strength and accommodate visual impairments, making shoes easier to don for older adults.

Methods/Approach/Solutions Considered

Analysis Approach

An in-depth analysis of factors surrounding the user, the task’s needs, and the demands of the context was completed through a front end analysis (FEA) (Yuen, 2015). The FEA occurs before the design, development, and selection of a product and uses human factor tools and techniques to answer the who, what, when, where, why, and how questions (W5H) of the analysis (Yuen, 2015). It aims to verify problems and identify solutions by either collecting new data or analyzing existing information. In order to answer the W5H of the FEA, four types of analyses were completed.

Person/User Analysis

An analysis of the product users will identify the user’s characteristics, capabilities, and preferences (How, 2015). To gain insight into older adults who have difficulties donning shoes due to hand and visual impairments, both subjective and dynamic anthropometric analyses were conducted.

Subjective Analysis. A subjective analysis was completed in order to gather information on consumers’ preferences regarding shoes and difficulties they may experience when donning shoes. This analysis ensured that the design process was user-centered. An informal semi-structured interview was conducted with 10 inpatient older adults at Victoria Hospital, in London, Ontario. Responses were focused around clients experiencing difficulty donning shoes, especially with manipulation of shoelaces and pushing heels into the shoes, therefore often opting for slip-on type shoes.  

Dynamic Anthropometric Analysis. Dynamic “functional” anthropometrics focus on the physical characteristics of a person when the body is engaged in physical activity (Rogers et al., 1996). This analysis identified the difficulties and capabilities of the older adult population, illuminating the product requirements that will accommodate current hand function of this population. Research has indicated that grip strength decreases 20%-60% in older adults (Yuen, 2015). Taking into consideration the various methods individuals use in tying their shoelaces, the normative data of different types of pinch and hand grips were examined.

Occupation/Task Needs Analysis

Task Analysis. A task analysis allows for a systematic description of an ordinary user’s (person) basic actions to perform a task and achieve their intended goals. Analysis of the activities and actions of the task identified constraints or areas of difficulties.

Visual Perceptual Analysis. Older adults with visual perceptual impairments have difficulties distinguishing between similar colour contrasts. Depending on the footwear, they may have problems identifying the laces from the shoe, viewing these features as one collective figure. At certain distances, older adults need three times as much colour contrast to see patterns as clearly as younger adults (Kavanaugh & Tate, 1996). It is recommended that visual contrast between two objects be greater than 70% (Hoy, 2004).

Environment/Context Analysis

An environmental analysis was completed to determine the context for occupational performance in the areas of socio-economic environment, institutional environment, physical environment and social environment. That is, to determine when and where the product will be used, as well as to rationalize why users would use this product. Additionally, it assessed both the facilitators and barriers that impact one’s occupational performance.

Physical Environment	Social Environment	Institutional Environment	Socio-economic Environment
-> Occurs in various environments: front halls, mud rooms, garage, varying weather conditions -> Availability of assistive equipment -> Seating areas to assist in donning and reducing strain	-> Lives alone -> No supports -> Family members -> Inconveniences others and self with time required -> Energy conservation to further enhance active participation	-> Inpatients at a rehabilitation hospital, often need to wear shoes to attend therapy sessions, requiring the ability to done shoes quickly in an efficient manner to maximize therapy time -> Home supports	-> With any population, personal finances and the cost of products may have an impact on appropriate footwear selection, and subsequently participation in meaningful activities

 

Design Criteria

Criterion	Objectives	Constraints
Convenience	User is able to independently don shoes (without assistance or assistive device) Able to quickly don shoes User should be able to wear the shoes with ease Able to visually see fastening mechanism	Should not take more than one minute to don shoes The process of donning shoes should only involve one user
Patient Comfort and Safety	Minimize shear on users Shoes are comfortable Slip resistant	Must not contribute to skin integrity issues Must not cause discomfort Shoes must not contribute to a fall hazard
Consumer Preference	Aesthetically pleasing to users The product should look similar to other typical shoes	The shoes should not cause stigmatization due to impairments related to aging
Cost	Minimize cost
Hygiene Factor	Material of the shoes should allow for sufficient air flow	Product should allow for breathability of material
Durability	The shoes should be sturdy	The shoes must last at least one year under normal use

 

Design Alternatives and Selection Process

	Criterion	Objective Weighting	Design 1	Design 2	Design 3	Design 4
			Zipper Shoes	Button Shoes	Drawstring Shoes	Backless Velcro Shoes
Convenience	Ease of Use	30%	4	3	6	9
	Speed of Use
	Independent Use
Patient Comfort and Safety	Slip-Resistant	30%	8	8	8	10
	Cushioning
Consumer Preference	Aesthetic	20%	2	4	1	9
Cost	Affordability	10%	6	7	7	9
Hygiene Factor	Breathable Material	5%	10	10	10	10
Durability	Water-Resistant	5%	6	6	5	5
	Quality of Material
Total Score		100%	5.4	5.6	5.85	9.15

 Several design alternatives were brainstormed in order to address our occupational performance issue of older adults struggling with donning shoes due to hand and visual impairments. As older adults with hand dexterity issues have difficulties manipulating shoelaces, we decided to eliminate this feature in our design. The first design incorporated a pair of shoes with zippers on the front. The shoes would be slip-resistant, cushioned, and comfortable. However, there were several weaknesses that arose from such a design. Although zipper shoes would be easier to manipulate than shoelaces, zippers are not the easiest mechanism to grasp, grip, and stabilize. This would be especially difficult for older adults with deficits in hand and finger strength and voluntary fine motor movements. Zippers are prone to defects and are difficult to see, which was another drawback to consider. Additionally, zippers would not guarantee the absence of a shoehorn as older adults may continue to encounter challenges around pushing in their heels into the shoes.

Snap buttons replaced the zippers in the second design. Although snap buttons are easier to detach when doffing shoes, older adults with dexterity issues may continue to encounter challenges when fastening the footwear. The shoes would still incorporate slip-resistant and comfortable cushioning properties, and the cost of snap button is generally lower than zippers (Fabricland, 2014). Again, buttons do not guarantee the absence of a shoehorn when pushing the heels into the shoes, hindering full independence. Buttons would be a better alternative to shoelaces but will not particularly perform the most efficiently in the convenience factor of ease, speed, and independent use. 

Our third design considered a drawstring to fasten the shoe. It would be easier to grasp as the mechanism is immobilized and would require less strength to grasp, pull, and fasten/unfasten. The drawstring scored the highest in the convenience factor but did not eliminate the absence of a shoehorn to assist with pushing heels into the shoes. Moreover, drawstrings scored low in consumer preference factor, as the design is aesthetically unpleasing.    

Based on the weighted decision matrix, our final design, a pair of backless Velcro shoes, was chosen as the most suitable to explore and develop. From our prior design alternatives, our main focus was to ease the process of donning shoes. Through the task analysis, we recognized that shoelaces were the hardest fastening mechanism to manipulate. Based on literature evidence, it was found that older adults with hand dexterity impairments benefitted from using Velcro (Scott, 2009). Furthermore, we wanted to eliminate the use of external aids to enable maximal independence. Based on the subjective analysis, many problems for consumers stemmed from difficulties pushing in the heel, thus needing a shoehorn for assistance. However, since they continued to encounter challenges with grasping the shoehorn, we decided to create a removable, backless shoe with Velcro as the fastening apparatus. The heel collar and backing will secure the heels, which is safer and reduces the risk of falls. Ultimately, the design will ease and speed the process of donning shoes, facilitate full independence, provide the consumer with safety and comfort, and be made durable.   

Description of Final Approach and Design

We recognized the importance of aesthetics in footwear selection and decided to create a versatile design that is non-bulky and lightweight. We chose canvas as the surrounding material to enhance breathability and to reduce irritation (Scott, 2009). Canvas footwear was found to reduce the risk for falls in older adults, which became an advantageous feature of our prototype (Koepsell et al., 2004). We immediately recognized that the heel would be visible when walking due to the absence of the collar heel on the edge of the inner sole. Thus we decided to raise the collar to create space for the Velcro to attach, which would fully cover the heel and secure non-slippage. However, we ensured that the collar remained short enough to mimic a pair of backless shoes for easier access when undone. The removable Velcro backing would ensure reduced risk for falls when fastened. After multiple testing, we decided to secure the fastening in the inner aspect, as opposed to the outer aspect of the shoes, as it is easier to attach medially. To avoid further heel slippage and to enhance comfort, a gel-insert on the inner back of the shoe was added to the final prototype. The heel height remained relatively low (< 1’’) and we added textured slip-resistant outsoles to reduce risk for falls (Tencer et al., 2004). We avoided excessive cushioning to minimize destabilization of feet and maintain balance. We decided to add an elastic band in-between the lateral attachment to allow users to tighten the backing if necessary. A loop pull was sewn to the end of the flap to allow for easier grip and Velcro pull. Finally, we chose an orange Velcro rather than black to enhance the color contrast for individuals with visual impairments.

Prototype Evaluation

The prototype was tested and evaluated using a sample size of five individuals with hand impairments (members from The Arthritis Society and a retirement home). A task analysis was repeated with each individual to see if problems arose with the prototype usage. Semi-structured interviews (subjective analysis) were then conducted to elicit information on user experiences and preferences. Visual perceptual analysis was recalculated based on the color contrast, reflecting a value of 84.8% (Black Light Reflectance Value = 5%, Orange Light Reflectance Value = 33%; [(33-5)/33] * 100% = 84.8%).

Based on the task analysis, four participants were able to independently don Peel Heel without the need of external aids. One participant required the use of a reacher (for all shoes in general) to assist with donning shoes as she has difficulty bending at the hips. Participants found Peel Heel easier and faster to don than regular laced footwear. Each participant completed the task in a varying amount of time but all were successful in donning Peel Heel within the one minute criteria (mean: 27 seconds). In terms of doffing, all participants found it easy to pull the Velcro strap due to the loop attached to the end of strap. A theme that consistently appeared across all participants was the design of the shoes. All participants found Peel Heel aesthetically pleasing, particularly appreciating the invisible nature of the Velcro once donned.

The subjective analyses revealed several improvements that can be made. Most of the participants suggested adapting the prototype to accommodate orthotics, which can be incorporated in our future design (e.g. widening the shoe to accommodate orthotics). They also suggested raising the heel collar higher to avoid heel slippage and to ensure more foot support. For future direction, magnets as opposed to Velcro can be tested and evaluated as they tend to have greater durability and would eliminate the need for consumers to keep the strap clean.

Cost and Significance

The overall cost to produce our low-fidelity prototype was approximately $5 CAN. However, the projected cost of our finalized product while incorporating all the proposed design criteria and elements is $25-$100 based on research and market findings. The cost will vary depending on numerous factors such as number of production (in bulk vs. individualized), type of manufacturer (wholesaler vs. custom designer), and location of production (China vs. Canada).

Our proposed device addresses a common occupational performance issue that many older adults encounter: donning shoes as a result of deficits in hand dexterity. Peel Heel will be a valuable product in the future with a projected increase in the older adult population with hand impairments due to rising conditions like arthritis (Widdifield et al., 2013).

Through the various analyses conducted, we were able to identify the gap in existing market and determine the associated problems while incorporating consumer preferences. Peel Heel offers consumers with a safe footwear that facilitates their independence when donning shoes, enabling their participation in ADLs. Consequently, it is of value to consumers and their caregivers alike, as it decreases the reliance on caregivers in completing this everyday task. Those who own a pair of Peel Heel shoes will be satisfied and reassured knowing that not only are their shoes easy to use, but that they are also equally safe and fashionable.