A Person Centred Approach to Developing a Digital Tool (KOKU-Nut) to Improve Dietary Intake in Community-Dwelling Older Adults

A Person Centred Approach to Developing a Digital Tool (KOKU-Nut) to Improve Dietary Intake in Community-Dwelling Older Adults | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A Person Centred Approach to Developing a Digital Tool (KOKU-Nut) to Improve Dietary Intake in Community-Dwelling Older Adults Chloe French, Sorrel Burden, Emma Stanmore This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4212596/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 18 Nov, 2025 Read the published version in BMC Geriatrics → Version 1 posted 11 You are reading this latest preprint version Abstract Background Digital tools embedded with behaviour change theories can encourage the successful implementation and maintenance of positive lifestyle changes. Keep on Keep up (KOKU) is a wellbeing app offering strength and balance exercises and educational games to raise awareness of fall prevention. We aimed to further develop KOKU using a person-centred approach to support nutritional intake and align with the service users’ needs and priorities to maximise engagement and usability. Methods Initially, adults aged 65 and over were recruited from assisted living facilities across Greater Manchester. Five focus groups involving 33 older adults (aged 69–96 years) were conducted between October and December 2022. A topic guide was used flexibly to understand factors that influence the groups eating habits and explore their thoughts around a digital tool to support nutritional intake. Conversations were audio-recorded, transcribed verbatim and analysed using an inductive thematic approach. Researchers then collaborated with designers to develop a nutrition game based on UK dietary guidelines and findings from the focus groups. The nutrition game was tested with end users in January 2024 before making any necessary changes. Users provided feedback and completed the system usability scale (SUS). Results Four themes emerged from the dataset. The main determinants of food intake were personal preference, perceptions of foods and changes as a result of age-related decline. The ability, engagement and willingness to use digital technology varied among participants but the majority had a positive attitude towards the digital service. A matching pair’s card game was chosen and the educational content was produced by the research team. A prototype of the nutrition game (KOKU-Nut) was tested with 10 end users on an iPad provided by the research team. Feedback was generally positive and the median SUS was 87.5 (IQR: 65, 95) out of 100 indicating the nutrition game had excellent usability. Conclusions We anticipate this person-centred approach will support the uptake and sustained use of KOKU-Nut to empower and educate users to improve their diet. Older adults malnutrition digital health co-creation participatory design wellbeing Figures Figure 1 Background Lifespan is increasing and it is estimated that almost one fifth of the population in the United Kingdom (UK) are 65 years or older [ 1 ]. Nutrition is an important, modifiable and well-established risk factor for the development of disease that can mediate the ageing trajectory [ 2 – 4 ]. Furthermore, it is estimated that 1.3 million people in the UK over the age of 65 suffer from malnutrition and the majority (93%) are living in the community [ 5 ]. Malnutrition encompasses both over- and undernutrition and occurs from deficiencies, excesses or imbalances in energy and/ or nutrients [ 6 ]. The prevention of malnutrition is important given its prevalence and that it can further contribute to physical decline, frailty, musculoskeletal conditions and immune-senescence [ 7 , 8 ]. The James Lind Alliance (JLA) methodology brings together those with personal or professional experience to identify and prioritise unanswered questions and inform the research agenda [ 9 ]. A JLA Priority Setting Partnership (JLA-PSP) was conducted in 2020 on the topic of malnutrition and screening with 250 contributors. The report identified that early intervention in vulnerable groups to prevent malnutrition was the number one research priority [ 10 ]. Given that community-dwelling older adults are at a high risk of malnutrition, this highlights the rationale for developing an intervention to educate and nudge this population group to improve their dietary intake and prevent malnutrition. Furthermore, older adults in the community have more autonomy over their food choice compared to those in care homes or hospitals where meals are often provided. Digital technology is increasingly being encouraged to complement clinical approaches as it has the potential to make health systems more efficient and sustainable translating into greater outreach and savings [ 11 , 12 ]. Digital tools embedded with behaviour change theories can encourage the successful implementation and maintenance of positive lifestyle changes as they often consider social, emotional and cognitive factors [ 13 – 16 ]. Keep on Keep up (KOKU) is a digital tool offering strength and balance exercises based on the Otago exercise programme [ 17 ] and the EAST (easy, attractive, social, timely) framework to support behaviour change [ 18 ]. Trials in the UK and US have found that KOKU has high usability with improved balance, health status and confidence (relating to falling) after six weeks of independent use [ 19 – 21 ]. It is well established that diet, specifically protein intake can complement the effects of exercise in order to preserve and build muscle mass and strength [ 22 , 23 ]. However, a recent scoping review identified a lack of digital tools to support nutritional status in relation to fall prevention among older adults [ 24 ]. Given this, we aimed to develop a nutritional game to expand on KOKU’s health literacy game modules to improve the eating habits of community-dwelling older adults in line with UK dietary guidelines [ 25 ]. We used a person-centred approach such that end-users were involved in each step of the design process through focus groups and usability testing. Methods The Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines were followed when designing, conducting and writing up this study (Supplementary material) [ 26 ]. Study design The development process included three phases (1) Needs assessment (2) Application development and (3) Initial application testing. Phase 1: Needs assessment The first phase consisted of determining the product features and content required for the nutrition component of the digital intervention. A qualitative approach was undertaken such that older adults were invited to participate in a focus group. Data collection was loosely underpinned by principles of phenomenology as we are considering determinants of dietary intake by considering the experiences of the individuals [ 27 ]. To be included in a focus group, participants had to be at least 65 years old, be community dwelling and have the ability to give informed consent. Participants had to be able to communicate in English in order to understand the study information sheet, to provide informed consent and to participate in the discussion. Participants currently staying in a hospital or care home and those who have a known cognitive impairment were excluded. Participant recruitment We generated a sampling frame and participants were recruited through purposive sampling, focusing on identifying a mix of male and female participants, with a range of ages (≥ 65 years) from across different districts of Greater Manchester. Participants were recruited from assisted living facilities as these typically house residents aged ≥ 55 years and offer self-contained homes (private or rented) within a larger complex. Individuals at these facilities are responsible for their own meal preparation and cooking however, there is often a communal lounge where residents are invited to coffee mornings and regular activities. To maximise variation in sampling [ 28 ], we recruited participants from assisted living facilities of different sizes and geographical areas (inner city and suburban). Recruitment of participants continued until data saturation was achieved [ 29 ]. This was determined when discussions did not provide additional information or themes relating to the research question as data collection and analysis happened simultaneously. Data collection Focus groups were conducted between October and December 2022 in the communal area of assisted living facilities. Each group consisted of six to eight community dwelling older adults and lasted approximately 60 minutes in length. Focus groups were led by a female facilitator (CF) with a second researcher present (YT) to help moderate the discussion. The facilitator was a researcher with expertise in nutrition who had undertaken training in qualitative research and did not have a personal relationship with the participants. Before commencing the focus group, participants were reminded about the study’s aims and objectives, and the importance of confidentiality. Participants had the right to not participate in aspects of the discussion without providing an explanation and were reminded that they were welcome to take breaks as necessary. The discussion involved semi-structured questions and the facilitator was guided by the focus group topic guide (Supplementary material), as well as questions that sought to clarify and elaborate on emerging themes. A research journal was kept (by CF) to add context, document thoughts and experiences and to allow for reflection on the focus groups. Each discussion was audio recorded and transcribed verbatim by the research team (CF) removing all names and identifiable information prior to analysis. Audio recordings were destroyed after transcripts were verified. The transcript data was then uploaded and managed using NVivo Version 10 (QSR International Pty Ltd, Doncaster, VIC, Australia). Ethical considerations Ethical approval was obtained by The University of Manchester Research Ethics Committee on 22/07/22 (Ref: 2022-14724-24818) and complies with the Declaration of Helsinki. The study was conducted in accordance with the UK Policy Framework for Health and Social Care Research and other applicable guidance. All potential participants were provided with a detailed participant information sheet explaining the purpose of the study, their role as a participant, the potential risks and benefits of taking part and issues relating to confidentiality of data collection and reporting. Written informed consent was obtained from all participants prior to commencement in the research. Data analysis Transcript data was analysed thematically using an inductive approach [ 30 , 31 ]. Transcripts were read repeatedly to identify and code themes found in the text. One research (CF) coded the data and a second researcher (YT) independently reviewed 20% of the codes, any discrepancies were solved through discussion with other researchers (SB, ES). Similar codes were grouped together to form a hierarchy of themes and subthemes; subthemes were developed to allow specific segments of the text to be linked to specific circumstances described by respondents. Themes were generated iteratively alongside a thematic map by comparing the similarity within themes whilst ensuring that all themes reflect the research question and the overall dataset. Anonymised quotations provide examples of the data and highlight important points within each theme. Phase 2: Application development The second phase focused on the design and development of a nutrition game to nudge older adults to improve their nutritional intake in line with UK dietary guidelines [ 25 ]. Adherence to these guidelines remains low despite being associated with a range of health benefits including a reduced mortality risk [ 32 , 33 ]. An agile design sprint was utilised as this methodology encourages collaboration, adaptability and innovation in a timely manner [ 34 ]. Agile design sprints provide context to the problem; generate a variety of ideas and consider potential solutions for the users based on the resources and time available [ 35 ]. Furthermore, design sprints have the potential to be cost effective as they involve gaining feedback on early versions of mocked up prototypes before resources are used to create full versions [ 34 ]. A collaborative workshop was held with three researchers with expertise in digital interventions for older adults (ES) and nutrition (CF, SB). Their role was to reflect (prioritise and share) ideas from phase one alongside nutrition guidelines and behaviour change theories. The research team worked with designers who have extensive experience in producing tools created alongside people with lived experiences. Throughout the workshop, a primary emphasis was placed on generating ideas for mini games that were evidence-based (educational), innovative and engaging. Individuals at the workshop ideated and shared ideas for new mini games tailored to raise awareness of the best evidence and subsequently nudge users to improve their diet. To facilitate the visualisation and communication of ideas, potential solutions (without the limitation of time/ money/ resources) were considered and captured on post it notes. Presentations were followed by constructive discussions, enabling feedback and refinement of the ideas through collaborative input and suggestions. A “Crazy 8s” agile design sprint task was then led by the design team [ 36 ] such that everyone at the workshop sketched eight different game concepts in eight minutes before each sharing their ideas with the group. This process helped to quickly generate a large number of ideas before considering potential features that would complement and improve the user experience. After the initial ideation workshop, a separate session was conducted with the design team to refine the preliminary ideas into more solidified games and mechanics. Phase 3: Initial application testing In order to assess the practical capabilities, features, and user experience, participants who had taken part in phase one were invited to participate in the initial application testing. The demo was tested on Testflight for iPad [ 37 ] on potential end users with different health conditions and prior experience of using digital technology. Individuals were presented with information about the need for the intervention and the current design (app). Participants were involved in reviewing the current prototype and providing feedback both positive and negative on the game concept, ease of use and the educational content. Participants received an honorarium in the form of a book voucher (£20.00 GBP). Ease of using KOKU-Nut was also assessed using the 10-item system usability scale (SUS) [ 38 ]. Each question has a response based on a Likert scale ranging from strongly agree to strongly disagree and the responses provide a score as a measure of the overall usability of the system. A SUS greater than 68 is considered above average, a SUS between 71 and 84 is considered good and a score ≥ 85 is considered excellent [ 39 ]. Results Needs assessment results (Phase 1) Five focus groups each lasting approximately 60 minutes were conducted between October and December 2022. In total, 33 older adults (mean age 82.8 years, SD 8.3) attended a focus group, most participants were female (78.8%) and of White British ethnicity (93.9%). Demographic characteristics of study participants are presented in Table 1 . Thematic analysis of the dataset resulted in four overarching core themes and a series of sub themes demonstrating the thoughts and opinions of the community-dwelling older adults (Table 2 ). Table 1 Demographic characteristics of study participants (community dwelling adults aged 65 years and older) Frequency (%) (N = 33) Mean (SD) Age 82.8 (8.3) Gender: Male Female 7 (21.2) 26 (78.8) Marital status: Single Separated/ divorced Married Widowed 5 (15.2) 6 (18.2) 3 (9.1) 19 (57.6) Ethnic origin: White British Black British 31 (93.9) 2 (6.1) Table 2 List of themes and subthemes identified Overarching theme Subthemes Change in diet due to age-related decline • Physiological factors • Social factors Perception of foods • Shop bought vs homemade • Health claims Food choice • Personal preferences • Cooking habits Perspectives towards digital tools to support nutritional intake • Attitude towards technology • Advance nutritional knowledge • Recipes • Increase motivation Theme 1: Change in diet due to age-related decline Many older adults noticed they had less of an appetite and this change in eating pattern was accompanied with an attitude of acceptance as an inevitable part of ageing. “I don’t know whether other people find this but I’ve found that as I’ve got older, I don’t get hungry” (P129, Female, aged 65–74) So your diet does change to a certain extent as you’re getting older and that happens (P134, Male, aged 85+) It is well established that dietary habits are developed over the lifetime and often revolve around social cues. Older adults can often lose these cues, which can then alter intake. As well as these psychosocial factors, poor dentition was also identified as a physiological barrier and factor influencing food intake: “Once you start cooking for one, it’s never the same” (P137, Female, aged 85+) “When you’re alone, you just don’t have the appetite” (P136, Female, aged 85+) “Another thing that’s affected me in terms of eating, is my teeth, you know, they are no good… and there’s lots of them missing now” (P115, Female, aged 75–84) Several participants were conscious of and sometimes restricted their fluid intake, especially in the evenings to prevent having to use the bathroom multiple times throughout the night. There was an awareness about the consequences of dehydration, but the decline and frustration associated with reduced bowel function was more of a concern and influencing factor when considering fluid intake amongst the sample. “I can’t drink after my evening meal… I’ve got a bladder problem, well a prostate problem actually which makes me want to go to the toilet every hour” (P134, Male, aged 85+) “It’s sort of a balancing act isn’t it, cause, you know, as you get older… you can be managing bladder problems” (P138, Male, aged 75–84) Health complications were both prevalent and a concern for many participants and influenced dietary intake. Participants were aware and consistently mentioned foods they should avoid, however never focused on foods they should be eating to maximise their health. “When I first became a diabetic I did find it a bit difficult because I used to love an ice cream cake… and I had to stop all that” (P141, Male, aged 75–84) “I have to watch my cholesterol… because I have high blood pressure” (P116, Female, aged 85+) Theme 2: Perception of foods In general, there was a negative attitude towards pre-packaged and processed foods with a focus on the importance of home cooking: “I try to cook by myself, because then I know what’s going in it” (P122, Female, aged 65–74) “When you do it yourself, course it takes a lot longer but I still prefer to do it that way” (P126, Female, aged 75–84) Participants also had perceptions relating to particular food groups such as dairy and salt and their impact on health. “I shouldn’t be having too much dairy but I’m afraid I do” (P111, Female, aged 75–84) “I’ve got to cut down on the salt” (P116, Female, aged 85+) Theme 3: Food choice: Personal preference and taste was also a key determinant of food intake. “It is a mix of what I like but also how easy it is” (P129, Female, aged 65–74) “A lot of your diet does go on taste” (P134, Male, aged 85+) This was also relevant for fluid consumption with many participants having strong preferences towards the temperature and flavour of their water. “I find water boring, so I add blackcurrant juice” (P113, Male, aged 75–84) “Well I usually drink water, but it’s got to be absolutely cold out the fridge” (P121, Female, aged 75–84) Cooking preference, ability and confidence was also something to consider as a factor that influences dietary intake. The following examples suggest that batch cooking was a popular technique used by this group. “Occasionally I’ll get a big pan of things and make a stew which will cover me for at least three days, maybe four if I stretch it out” (P138, Male, aged 75–84) “When I cook, I cook a certain amount and then freeze it so, then can take it out whenever I need to” (P116, Female, aged 85+) Theme 4: Perspectives towards digital tools to support dietary intake The final theme derived from the dataset focused on attitudes towards the digital intervention and possible features that could be incorporated into the nutritional component. Some people did not have access to iPads or smartphones and some people had access to but did not or could not use this technology. “I’ve got one that I need to use but I don’t know where to start with it” (P125, Female, aged 85+) “Though I must admit my patience with these things is getting worse and worse, what with all these bloody passwords and things” (P113, Male, aged 75–84) Despite the initial resistance towards digital technology, many people were interested in learning with the appropriate support and guidance. “Well I think I would like to learn because I’ve got to change my attitude to it and accept that it’s here to stay” (P138, Male, aged 75–84) “They’d have to be very patient and it would take a very long time, but yes I would like to learn” (P131, Female, aged 65–74) The majority of participants had a positive attitude towards the digital health intervention with many offering questions or suggestions around what they should be eating and what they would like to see in the nutritional component. Suggestions fell into three main categories: education, recipes and motivation. Education Many participants were engaged and interested in how they could improve their diet: “So where are you saying this proteins got to come from” (P138, Male, aged 75–84) “So what do I add to my porridge and toast?” (P134, Male, aged 85+) “I’m interested in why you should eat certain kinds of food… and what vitamins you need” (P129, Female, aged 65–74) Recipes Many participants also highlighted that recipes would be a useful addition to the digital tool with some participants interested in simple recipes that required minimal cooking equipment. “Recipes, information, reminders, …like what veg to put in it, what’s easier to use or different veg’s that you can make in the same type of dish” (P138, Male, aged 75–84) “I wouldn’t mind one or two vegetarian recipes” (P136, Female, aged 85+) “We need more simple meals” (P124, Male, aged 65–74) Motivation The dataset also highlighted the challenges around achieving behaviour change and identified that a motivational component within the digital tool would be beneficial to remind participants to stay on track. “It’s sticking to it; it’s the willpower that’s hard” (P127, Female, aged 85+) “It [notifications] would help me... just could say to you, have you drunk within the last whatever time or when was the last time you had a drink and then you can just say yay or nay... especially with your memory as you’re getting older” (P124, Male, aged 65–74) Result of application development (Phase 2) Four ideas were presented to the research team based on the ideation workshop. A matching pair’s card game concept was chosen as it was anticipated this would be the most engaging for users, easy to understand and allows an educational component to be easily incorporated into the game mechanics to provide nutritional information and nudge older adults to choose certain foods. The educational content was produced by the research team based on lay language description of best evidence information (the Eatwell guide) [ 25 ] and findings from phase 1. In particular, the app was designed to increase consumption of fruit and vegetables, lean protein and fibre whilst reducing intake of high fat and sugar foods. The game highlights the importance of including certain food groups in the diet and practical advice for how to make something like toast a more nutritious meal. The graphics were developed by the design team using Apple Xcode using the Swift development language for iPad [ 40 ], and Android Studio using the Java development language for Android [ 41 ]. The game involves the user choosing a pair of cards from a possible twelve that are faced downwards, with the aim of finding all matching items (Fig. 1). The twelve cards when turned over show six different images of food or nutritional related content (with each food item appearing on two cards). If a matching pair is found, a pop up will appear presenting a larger image of the matching food item along with information about the item (Fig. 1). If the cards are a mismatch, a message appears to say “not a match” and the cards will return to their original face down position. The game is complete once all pairs have been matched and the user is led to see important tips to improve diet and prevent malnutrition. For example, users are signposted who to speak to and offered simple tips if they were having difficulty chewing or a reduced appetite. Figure 1 Screenshot of matching pair’s game available on KOKU-Nut Result of initial application testing (Phase 3) A total of 10 end users tested the beta version of the app on an iPad provided by the research team. Testing took place face-to-face in January 2024 and involvement typically lasted 45 minutes. A think-aloud approach was utilised such that the researcher (CF) observed participants using the intervention who were encouraged to say their thoughts out loud in order to provide detailed insight into their interpretation, experiences and barriers of using the intervention. At the end of the testing period, users also completed the SUS to quantitatively evaluate the usability of the app (KOKU-Nut) [ 38 , 39 ]. The median score was 87.5 (IQR: 65, 95) out of 100 indicating the intervention had excellent usability [ 39 ]. Feedback from end users was noted by the researcher (CF) and then discussed with the wider research team (ES, SB). Criteria for making modifications was based on if the feedback aligned with the evidence base, if the same issue was reported by multiple users or would be appropriate to a wider audience and if the changes could be easily incorporated into the game [ 42 , 43 ]. Individuals generally had positive feedback, found the game enjoyable and the content clear, informative and interesting. Table 3 highlights the feedback and amendments made to improve the clarity of the educational content and so that the instructions page was more intuitive for the user. This testing process allowed older adults to be active co-creators in the development of KOKU-Nut, highlighted issues that were not initially obvious to the research team and helped to ensure the final app was user friendly. Amendments confirmed by the research team were then incorporated by the design team and the game was developed for both Android and iOS to increase accessibility across a range of devices (iPads and tablets). Table 3 Changes made to KOKU-Nut based on user feedback Feedback from user Action taken One participant found the game too challenging and thought there were too many cards on the screen Despite this comment other users thought the difficulty level was appropriate and were able to complete the game so the number of cards have not been changed The word phytochemical is too technical Phytochemicals has been replaced with vitamins Not clear what 14 units of alcohol translates to This has been removed One participant suggested that a quiz at the end of the game would be helpful to test knowledge This has been noted as a suggestion for a possible future iteration A few participants missed the ‘next’ button on the instructions page and tried to play on this screen Additional sentence has been added into instructions page to clearly direct users to start the game One participant thought the game was very text heavy Despite this comment, other users found the content informative and the right level so no changes were made Found the game difficult at first but then really enjoyed it “would rather do this than watch the soaps” - Thought the cards disappeared/ faced down too quickly so it was difficult to see where cards went If a matching pair is not found, cards now return to face down position one by one rather than at the same time Liked information about canned/ frozen fruit and vegetables - Thought it was very informative, entertaining and not patronising - “I love it and would recommend it to my friends” - “The advice contained in KOKU would be highly beneficial to the user... I am convinced it would enhance the lives of many people” - “KOKU is both stimulating and enjoyable. It brings great satisfaction and most importantly promotes good health” - A few participants found the term sarcopenia too technical The term sarcopenia has been removed so now just says “to help maintain muscle mass and strength” One participant thought that meat should also be included as an example of processed food. This has been updated to include bacon as an example of an ultra-processed food Table 3 Discussion This study has demonstrated the process of using a person centred approach to create a digital nutrition game with and for community-dwelling older adults with input from a multi-disciplinary team of experts. A person-centred approach draws on users’ views and experiences to inform the design and planning of an intervention, to ensure that it is engaging and persuasive [ 44 , 45 ]. A qualitative approach was utilised in phase one as recommended by the literature [ 46 , 47 ] to explore the current attitudes and determinants of dietary habits in older adults, to provide context to the intervention and to identify how to manipulate future food choices to improve intake. These findings were then used to inform phase two (the development of KOKU-Nut) by prioritising and incorporating user perspectives wherever possible alongside best evidence to support behaviour change [ 16 , 48 ] to align with nutritional guidelines [ 25 ]. Application testing in phase three allowed feedback early on in the design process so that changes could be incorporated into the digital tool to support the preferences of end users. This person-centred approach has been shown to improve the relevance and overall quality of the research to ensure that it prioritises and considers aspects that are important to the people the research is aimed at [ 49 , 50 ]. We anticipate this consideration at all stages of the design process has contributed to the high usability score and will lead to sustained use of the intervention. Phase one identified that the main determinants of intake were change in diet due to age-related decline (psychosocial and physiological factors such as change to living situation and poor oral health), their perception of foods (food quality, health benefits of foods) and food choice (taste, cooking habits). These findings are consistent with the wider literature and reflect the complexity of food intake demonstrating the influence from physical, psychological and social change that occurs in old age [ 51 , 52 ]. Participants in phase one were aware of the importance of food on health status, but not how intake should change with age. It became apparent that dietary advice received by this population throughout their adult life was still a concern. This highlights the rationale for developing a specialist and evidence-based tool targeted for older adults given the additional nutritional challenges within this population [ 53 ]. Participants also spoke about having a reduced appetite, often termed anorexia of ageing and this is likely to contribute to the risk of malnutrition [ 54 ]. Malnutrition is a challenging health concern that commonly occurs in older adults [ 5 , 55 , 56 ] but awareness among this population group remains low [ 57 ]. Findings from phase one informed the educational component within KOKU-Nut to provide messaging around areas such as unplanned weight loss and guidelines for dairy consumption. In phase one, participants’ also highlighted barriers to using technology including a lack of knowledge around these devices, low confidence and the excessive use of passwords. Despite some concerns around the use of digital technology, recent evidence has shown that age does not appear to be a barrier for use [ 58 ]. A review by the Organization for the Review of Care and Health Apps (ORCHA), a digital health evaluation and distribution organization found that more than half (52%) of people surveyed who were aged 65 years and older support the move to digital health [ 59 ]. Digital health tools can help make health systems more efficient and sustainable; allow aspects of care to be conducted from the patient’s home; and supports patients being actively involved in their care [ 60 , 61 ]. Digital tools are likely to help engage hard to reach and vulnerable groups who may struggle or feel excluded from traditional face-to-face approaches [ 59 ]. Moreover, the development of the nutrition game was guided by the thoughts, needs and ideals of potential end users. This form of participatory design [ 62 ] helps to maximise the acceptability, usability and effectiveness of an intervention amongst users [ 16 , 63 ]. A review of studies including older people in the design process of technology innovations showed that user involvement can prevent ageism, create a positive sense of ownership and improve the quality of the intervention [ 64 ]. Findings from phase three of the current study demonstrated that potential end users liked the concept, information and graphics and reported the nutrition game to have high usability. A systematic review including 46 studies reported that gamification makes a typically boring activity more enjoyable, competitive and engaging [ 65 ]. Gamification can be defined as entertaining the user as they learn or change behaviour [ 66 ]. This is likely to contribute to the use of gamification to successfully promote and sustain healthy behaviours by incorporating strategies such as goal setting, feedback on performance, progress tracking and social connectivity, which share key elements with established behaviour change techniques [ 16 , 67 ]. We anticipate the gamification within KOKU-Nut will increase engagement levels and the enjoyment provided to users will support regular use of the app. Strengths and limitations There were several limitations to this study including that it was a relatively homogeneous sample, the majority of which were white British females. This ethnic profile reflects the population of older adults living in England and Wales in 2021 [ 68 ] however the socio-cultural influences on eating behaviour would be better assessed by recruiting a culturally diverse group from different socio-economic backgrounds. In addition, important characteristics of participants were not collected including educational level and digital literacy. Furthermore, it is likely that findings were influenced by social desirability bias, given that nutritional information is often misreported [ 69 ] and participants in the current study were aware that they were speaking to a nutritionist. Objective measures such as dietary surveillance can improve the precision of data and provide a more accurate measure of intake however; this involves large administrative costs, participant burden and intrusion. It would have been beneficial to consider and explore other stakeholders perspectives (such as dietitians, geriatric consultants and community outreach teams) as part of the design process however this was not possible due to time and financial limitations. The main strength of this study was the engagement of participants at both the needs assessment and initial application testing phase. This interaction and feedback allowed the user’s needs, desires and abilities to be considered and incorporated into the design process. Conclusion We anticipate this person-centred design approach will support the uptake and sustained use of KOKU-Nut to empower and educate users to improve their diet and take control of their health. We plan to continue to develop and iteratively revise the app to maximise its potential and usefulness. Future research should seek to study more ethnically diverse perspectives given the influence of culture and upbringing on dietary habits and the heterogeneity of the sample in the current study. Abbreviations UK- United Kingdom JLA-PSP- James Lind Alliance Priority Setting Partnership KOKU- Keep on Keep up COREQ- Consolidated Criteria for Reporting Qualitative Research KOKU-Nut- Keep on Keep up Nutrition SUS- System usability scale ORCHA- Organization for the Review of Care and Health Apps Declarations Ethics approval and consent to participate: Ethical approval was obtained by The University of Manchester Research Ethics Committee on 22/07/22 (Ref: 2022-14724-24818) and complies with the Declaration of Helsinki. Written informed consent was obtained from all participants prior to commencement in the research. Consent for publication: Not applicable Availability of data and materials: The data presented in this study are available on request from the corresponding author. Competing interests: ES is the director of KOKU health which is a non-for-profit company. CF and SB have no competing interests Funding: CF receives financial support from the Medical Research Council (CASE Entry- MR/R015767/1). Authors’ contributions: CF, ES and SB designed the study. CF was involved with data collection and analysis which was overseen by ES and SB. CF primarily wrote the paper which was refined from comments by ES and SB. All authors reviewed the final manuscript. Acknowledgement: The authors would like to thank Yimin Tang (YT) for her help with this study, participants for their contribution, and staff at the assisted living facilities for their support with recruitment. The authors would also like to thank Christian Shannon, David Seward and the team at Reason Digital for their help with the development of the intervention. References Office for National Statistics, Population estimates for the UK, England and Wales, Scotland and Northern IReland . 2021. Hlaing-Hlaing, H., et al., Diet Quality and Incident Non-Communicable Disease in the 1946-1951 Cohort of the Australian Longitudinal Study on Women's Health. Int J Environ Res Public Health, 2021. 18 (21). Noce, A., A. Romani, and R. Bernini, Dietary Intake and Chronic Disease Prevention. Nutrients, 2021. 13 (4). Kiefte-de Jong, J.C., J.C. Mathers, and O.H. Franco, Nutrition and healthy ageing: the key ingredients. Proc Nutr Soc, 2014. 73 (2): p. 249-59. Public Health England, Impact assessment. Helping older people maintain a healthy diet: A review of what works . 2017. World Health Organization, Malnutrition . 2020. Lengele, L., et al., Impact of Malnutrition Status on Muscle Parameter Changes over a 5-Year Follow-Up of Community-Dwelling Older Adults from the SarcoPhAge Cohort. Nutrients, 2021. 13 (2). Jeejeebhoy, K.N., Malnutrition, fatigue, frailty, vulnerability, sarcopenia and cachexia: overlap of clinical features. Curr Opin Clin Nutr Metab Care, 2012. 15 (3): p. 213-9. James Lind Alliance. The James Lind Alliance Guidebook version 10 . 2021; Available from: https://www.jla.nihr.ac.uk/jla-guidebook/. Jones, D.J., et al., Priority setting for adult malnutrition and nutritional screening in healthcare: a James Lind Alliance. J Hum Nutr Diet, 2020. 33 (2): p. 274-283. Gentili, A., et al., The cost-effectiveness of digital health interventions: A systematic review of the literature. Front Public Health, 2022. 10 : p. 787135. World Health Organization, Global strategy on digital health 2020-2025 . 2021, Licence: CC BY-NC-SA 3.0 IGO: Geneva: World Health Organization. Samdal, G.B., et al., Effective behaviour change techniques for physical activity and healthy eating in overweight and obese adults; systematic review and meta-regression analyses. International Journal of Behavioral Nutrition and Physical Activity, 2017. 14 (1): p. 1-14. Boulton, E., et al., Implementing behaviour change theory and techniques to increase physical activity and prevent functional decline among adults aged 61-70: The PreventIT project. Progress in Cardiovascular Diseases, 2019. 62 (2): p. 147-156. National Institute for Health and Care Excellence, Behaviour change: digitial and mobile health interventions . 2020. Edwards, E.A., et al., Gamification for health promotion: systematic review of behaviour change techniques in smartphone apps. BMJ Open, 2016. 6 (10): p. e012447. Yi, M., et al., The effectiveness of Otago exercise program in older adults with frailty or pre-frailty: A systematic review and meta-analysis. Arch Gerontol Geriatr, 2023. 114 : p. 105083. 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Moran, D., What is the phenomenological approach? Revisiting intentional explication. Phenomenol. Mind, 2018: p. 72-90. Palinkas, L.A., et al., Purposeful Sampling for Qualitative Data Collection and Analysis in Mixed Method Implementation Research. Adm Policy Ment Health, 2015. 42 (5): p. 533-44. Guest, G., Bunce, A., Johnson, L., How Many Interviews Are Enough? An Experiment with Data Saturation and Variability. Field Methods, 2006. 18 (1): p. 59-82. Braun, V., Clarke, V., Using thematic analysis in psychology. Qualitative Research in Psychology, 2006. 3 (2): p. 77-101. Braun, V., Clarke, V., Hayfield, N., Terry, G., Thematic analysis . Handbook of research methods in health social sciences, ed. P. Liamputtong. 2019, Singapore: Spinger Singapore. Scheelbeek, P., et al., Health impacts and environmental footprints of diets that meet the Eatwell Guide recommendations: analyses of multiple UK studies. BMJ Open, 2020. 10 (8): p. e037554. Shannon, O.M., et al., Adherence to the Eatwell Guide and population and planetary health: A Rank Prize Forum report. Nutr Bull, 2024. 49 (1): p. 108-119. Jake-Schoffman, D.E., McVay, M.A., Using the Design Sprint process to enhance and accelerate behavioral medicine progress: a case study and guidance. Transl Behav Med, 2021. 11 (5). Hekler, E.B., et al., Agile science: creating useful products for behavior change in the real world. Transl Behav Med, 2016. 6 (2): p. 317-28. Google. Design Sprint Methodology . Available from: https://designsprintkit.withgoogle.com/methodology/overview. Apple Inc. Beta Testing made simple with TestFlight . 2024; Available from: https://developer.apple.com/testflight/. Brooke, J., SUS: A quick and dirty usability scale. 1996. Sauro J, L.J., Quantifying the User Experience: Practical Statistics for User Research . Vol. 2nd ed. 2016, Burlington, MA: Elsevier/ Morgan Kaufmann. Apple Inc. and Swift project authors, The Swift Programming Language (5.10) . Available from: https://docs.swift.org/swift-book/documentation/the-swift-programming-language/. Oracle, Java . Bradbury, K., et al., Using the Person-Based Approach to optimise a digital intervention for the management of hypertension. PLoS One, 2018. 13 (5): p. e0196868. Bradbury, K., et al., Developing digital interventions: a methodological guide. Evid Based Complement Alternat Med, 2014. 2014 : p. 561320. Yardley, L., et al., The person-based approach to intervention development: application to digital health-related behavior change interventions. J Med Internet Res, 2015. 17 (1): p. e30. Abras, C.M.-K., D., Preece, J., User-centered design , in Encyclopedia of Human-Computer Interaction . 2004, Sage Publications: Thousand Oaks, CA. p. 445-456. Corbett, T., et al., Understanding acceptability of and engagement with Web-based interventions aiming to improve quality of life in cancer survivors: A synthesis of current research. Psychooncology, 2018. 27 (1): p. 22-33. Morrison, L., Muller I., Yardley, L., Bradbury, K., The person-based approach to planning, optimising, evaluating and implementing behavioural health interventions. The European Health Psychologist, 2018. 20 : p. 464-9. Public Health England, Achieving behaviour change: A guide for national government , C.f.b. change, Editor. 2020. Staniszewska, S., et al., The GRIPP checklist: strengthening the quality of patient and public involvement reporting in research. Int J Technol Assess Health Care, 2011. 27 (4): p. 391-9. Chen, K. and A.H. Chan, Use or non-use of gerontechnology--a qualitative study. Int J Environ Res Public Health, 2013. 10 (10): p. 4645-66. Payne, L., et al., Beliefs about inevitable decline among home-living older adults at risk of malnutrition: a qualitative study. J Hum Nutr Diet, 2020. 33 (6): p. 841-851. Whitelock, E. and H. Ensaff, On Your Own: Older Adults' Food Choice and Dietary Habits. Nutrients, 2018. 10 (4). Volkert, D., et al., ESPEN practical guideline: Clinical nutrition and hydration in geriatrics. Clin Nutr, 2022. 41 (4): p. 958-989. Cox, N.J., et al., New horizons in appetite and the anorexia of ageing. Age Ageing, 2020. 49 (4): p. 526-534. Kaiser, M.J., et al., Frequency of malnutrition in older adults: a multinational perspective using the mini nutritional assessment. J Am Geriatr Soc, 2010. 58 (9): p. 1734-8. Crichton, M., et al., A systematic review, meta-analysis and meta-regression of the prevalence of protein-energy malnutrition: associations with geographical region and sex. Age Ageing, 2019. 48 (1): p. 38-48. Malnutrition Task Force, State of the Nation 2021 . 2021. Secretariat., O., Organisation for Exonomic Cooperation and Development (OECD). OECD Digital Economy Outlook 2017, 2017. Orcha Health, Digital health in the UK: National attitudes and behaviour research . 2021; Available from: https://orchahealth.com/wp-content/uploads/2021/07/2107_ICS_Research_Report_2021_National_v2.pdf. Murray, E., et al., Evaluating Digital Health Interventions: Key Questions and Approaches. Am J Prev Med, 2016. 51 (5): p. 843-851. Topol, E., The Topol Review: Preparing the healthcare workforce to deliver the digital future . 2019: London. Schuler, D., & Namioka, A., Participatory Design: Principles and Practices . 1993: Hillsdale, NJ: Lawrence Erlbaum Associates. Tritter, J.Q. and A. McCallum, The snakes and ladders of user involvement: Moving beyond Arnstein. Health Policy, 2006. 76 (2): p. 156-68. Fischer, B., A. Peine, and B. Ostlund, The Importance of User Involvement: A Systematic Review of Involving Older Users in Technology Design. Gerontologist, 2020. 60 (7): p. e513-e523. Sardi, L., A. Idri, and J.L. Fernandez-Aleman, A systematic review of gamification in e-Health. J Biomed Inform, 2017. 71 : p. 31-48. Stokes, B.G., Videogames have changed: time to consider Serious Games? Development Education Journal, 2005. 11 (3): p. 12. Cugelman, B., Gamification: what it is and why it matters to digital health behavior change developers. JMIR Serious Games, 2013. 1 (1): p. e3. Census, Profile of the older population living in England and Wales in 2021 and changes since 2011 . 2021. Hebert, J.R., et al., Social desirability bias in dietary self-report may compromise the validity of dietary intake measures. Int J Epidemiol, 1995. 24 (2): p. 389-98. Additional Declarations Competing interest reported. ES is the Director of KOKU Health which is a non-profit company. Supplementary Files Supplementaryinformation.docx Cite Share Download PDF Status: Published Journal Publication published 18 Nov, 2025 Read the published version in BMC Geriatrics → Version 1 posted Editorial decision: Revision requested 27 Dec, 2024 Reviews received at journal 18 Dec, 2024 Reviewers agreed at journal 18 Dec, 2024 Reviewers agreed at journal 28 May, 2024 Reviews received at journal 18 May, 2024 Reviewers agreed at journal 28 Apr, 2024 Reviewers invited by journal 26 Apr, 2024 Editor assigned by journal 26 Apr, 2024 Editor invited by journal 11 Apr, 2024 Submission checks completed at journal 11 Apr, 2024 First submitted to journal 03 Apr, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4212596","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":290947325,"identity":"d471015e-37a5-4ce3-b8dd-ebeef61f3430","order_by":0,"name":"Chloe French","email":"data:image/png;base64,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","orcid":"","institution":"University of Manchester","correspondingAuthor":true,"prefix":"","firstName":"Chloe","middleName":"","lastName":"French","suffix":""},{"id":290947326,"identity":"34c76582-e845-4040-bfe8-3b9b1e9704ea","order_by":1,"name":"Sorrel Burden","email":"","orcid":"","institution":"University of Manchester","correspondingAuthor":false,"prefix":"","firstName":"Sorrel","middleName":"","lastName":"Burden","suffix":""},{"id":290947327,"identity":"c75c74d1-4fb5-42fb-9061-2e9581546366","order_by":2,"name":"Emma Stanmore","email":"","orcid":"","institution":"University of Manchester","correspondingAuthor":false,"prefix":"","firstName":"Emma","middleName":"","lastName":"Stanmore","suffix":""}],"badges":[],"createdAt":"2024-04-03 12:06:31","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4212596/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4212596/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12877-025-06434-2","type":"published","date":"2025-11-18T15:58:52+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":54995497,"identity":"c536c804-46dc-4c30-aa46-11acdd9237d5","added_by":"auto","created_at":"2024-04-19 17:54:52","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":356294,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eScreenshot of matching pair’s game available on KOKU-Nut\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4212596/v1/2bc089ac970b0c7ae0cb0218.png"},{"id":96650409,"identity":"027af128-c4ea-4596-baf6-276d5c96032f","added_by":"auto","created_at":"2025-11-24 16:12:01","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1344211,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4212596/v1/ef30af19-678b-46ff-81e5-8683ebdfdb52.pdf"},{"id":54995496,"identity":"02029ed5-705e-4cdd-9352-f974e06dc120","added_by":"auto","created_at":"2024-04-19 17:54:52","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":34120,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryinformation.docx","url":"https://assets-eu.researchsquare.com/files/rs-4212596/v1/d037f6abbe638f4f444ca3af.docx"}],"financialInterests":"Competing interest reported. ES is the Director of KOKU Health which is a non-profit company.","formattedTitle":"A Person Centred Approach to Developing a Digital Tool (KOKU-Nut) to Improve Dietary Intake in Community-Dwelling Older Adults","fulltext":[{"header":"Background","content":"\u003cp\u003eLifespan is increasing and it is estimated that almost one fifth of the population in the United Kingdom (UK) are 65 years or older [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Nutrition is an important, modifiable and well-established risk factor for the development of disease that can mediate the ageing trajectory [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Furthermore, it is estimated that 1.3\u0026nbsp;million people in the UK over the age of 65 suffer from malnutrition and the majority (93%) are living in the community [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Malnutrition encompasses both over- and undernutrition and occurs from deficiencies, excesses or imbalances in energy and/ or nutrients [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe prevention of malnutrition is important given its prevalence and that it can further contribute to physical decline, frailty, musculoskeletal conditions and immune-senescence [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The James Lind Alliance (JLA) methodology brings together those with personal or professional experience to identify and prioritise unanswered questions and inform the research agenda [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. A JLA Priority Setting Partnership (JLA-PSP) was conducted in 2020 on the topic of malnutrition and screening with 250 contributors. The report identified that early intervention in vulnerable groups to prevent malnutrition was the number one research priority [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Given that community-dwelling older adults are at a high risk of malnutrition, this highlights the rationale for developing an intervention to educate and nudge this population group to improve their dietary intake and prevent malnutrition. Furthermore, older adults in the community have more autonomy over their food choice compared to those in care homes or hospitals where meals are often provided.\u003c/p\u003e \u003cp\u003eDigital technology is increasingly being encouraged to complement clinical approaches as it has the potential to make health systems more efficient and sustainable translating into greater outreach and savings [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Digital tools embedded with behaviour change theories can encourage the successful implementation and maintenance of positive lifestyle changes as they often consider social, emotional and cognitive factors [\u003cspan additionalcitationids=\"CR14 CR15\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Keep on Keep up (KOKU) is a digital tool offering strength and balance exercises based on the Otago exercise programme [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] and the EAST (easy, attractive, social, timely) framework to support behaviour change [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Trials in the UK and US have found that KOKU has high usability with improved balance, health status and confidence (relating to falling) after six weeks of independent use [\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIt is well established that diet, specifically protein intake can complement the effects of exercise in order to preserve and build muscle mass and strength [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. However, a recent scoping review identified a lack of digital tools to support nutritional status in relation to fall prevention among older adults [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Given this, we aimed to develop a nutritional game to expand on KOKU\u0026rsquo;s health literacy game modules to improve the eating habits of community-dwelling older adults in line with UK dietary guidelines [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. We used a person-centred approach such that end-users were involved in each step of the design process through focus groups and usability testing.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines were followed when designing, conducting and writing up this study (Supplementary material) [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eThe development process included three phases (1) Needs assessment (2) Application development and (3) Initial application testing.\u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003ch2\u003ePhase 1: Needs assessment\u003c/h2\u003e \u003cp\u003eThe first phase consisted of determining the product features and content required for the nutrition component of the digital intervention. A qualitative approach was undertaken such that older adults were invited to participate in a focus group. Data collection was loosely underpinned by principles of phenomenology as we are considering determinants of dietary intake by considering the experiences of the individuals [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. To be included in a focus group, participants had to be at least 65 years old, be community dwelling and have the ability to give informed consent. Participants had to be able to communicate in English in order to understand the study information sheet, to provide informed consent and to participate in the discussion. Participants currently staying in a hospital or care home and those who have a known cognitive impairment were excluded.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003eParticipant recruitment\u003c/h2\u003e \u003cp\u003e We generated a sampling frame and participants were recruited through purposive sampling, focusing on identifying a mix of male and female participants, with a range of ages (\u0026ge;\u0026thinsp;65 years) from across different districts of Greater Manchester. Participants were recruited from assisted living facilities as these typically house residents aged\u0026thinsp;\u0026ge;\u0026thinsp;55 years and offer self-contained homes (private or rented) within a larger complex. Individuals at these facilities are responsible for their own meal preparation and cooking however, there is often a communal lounge where residents are invited to coffee mornings and regular activities. To maximise variation in sampling [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], we recruited participants from assisted living facilities of different sizes and geographical areas (inner city and suburban). Recruitment of participants continued until data saturation was achieved [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. This was determined when discussions did not provide additional information or themes relating to the research question as data collection and analysis happened simultaneously.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eFocus groups were conducted between October and December 2022 in the communal area of assisted living facilities. Each group consisted of six to eight community dwelling older adults and lasted approximately 60 minutes in length. Focus groups were led by a female facilitator (CF) with a second researcher present (YT) to help moderate the discussion. The facilitator was a researcher with expertise in nutrition who had undertaken training in qualitative research and did not have a personal relationship with the participants. Before commencing the focus group, participants were reminded about the study\u0026rsquo;s aims and objectives, and the importance of confidentiality. Participants had the right to not participate in aspects of the discussion without providing an explanation and were reminded that they were welcome to take breaks as necessary. The discussion involved semi-structured questions and the facilitator was guided by the focus group topic guide (Supplementary material), as well as questions that sought to clarify and elaborate on emerging themes. A research journal was kept (by CF) to add context, document thoughts and experiences and to allow for reflection on the focus groups. Each discussion was audio recorded and transcribed verbatim by the research team (CF) removing all names and identifiable information prior to analysis. Audio recordings were destroyed after transcripts were verified. The transcript data was then uploaded and managed using NVivo Version 10 (QSR International Pty Ltd, Doncaster, VIC, Australia).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eEthical considerations\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eEthical approval\u003c/strong\u003e \u003cp\u003e was obtained by The University of Manchester Research Ethics Committee on 22/07/22 (Ref: 2022-14724-24818) and complies with the Declaration of Helsinki. The study was conducted in accordance with the UK Policy Framework for Health and Social Care Research and other applicable guidance. All potential participants were provided with a detailed participant information sheet explaining the purpose of the study, their role as a participant, the potential risks and benefits of taking part and issues relating to confidentiality of data collection and reporting. Written informed consent was obtained from all participants prior to commencement in the research.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eTranscript data was analysed thematically using an inductive approach [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Transcripts were read repeatedly to identify and code themes found in the text. One research (CF) coded the data and a second researcher (YT) independently reviewed 20% of the codes, any discrepancies were solved through discussion with other researchers (SB, ES). Similar codes were grouped together to form a hierarchy of themes and subthemes; subthemes were developed to allow specific segments of the text to be linked to specific circumstances described by respondents. Themes were generated iteratively alongside a thematic map by comparing the similarity within themes whilst ensuring that all themes reflect the research question and the overall dataset. Anonymised quotations provide examples of the data and highlight important points within each theme.\u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003ePhase 2: Application development\u003c/h2\u003e \u003cp\u003eThe second phase focused on the design and development of a nutrition game to nudge older adults to improve their nutritional intake in line with UK dietary guidelines [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Adherence to these guidelines remains low despite being associated with a range of health benefits including a reduced mortality risk [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAn agile design sprint was utilised as this methodology encourages collaboration, adaptability and innovation in a timely manner [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Agile design sprints provide context to the problem; generate a variety of ideas and consider potential solutions for the users based on the resources and time available [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Furthermore, design sprints have the potential to be cost effective as they involve gaining feedback on early versions of mocked up prototypes before resources are used to create full versions [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. A collaborative workshop was held with three researchers with expertise in digital interventions for older adults (ES) and nutrition (CF, SB). Their role was to reflect (prioritise and share) ideas from phase one alongside nutrition guidelines and behaviour change theories. The research team worked with designers who have extensive experience in producing tools created alongside people with lived experiences. Throughout the workshop, a primary emphasis was placed on generating ideas for mini games that were evidence-based (educational), innovative and engaging. Individuals at the workshop ideated and shared ideas for new mini games tailored to raise awareness of the best evidence and subsequently nudge users to improve their diet. To facilitate the visualisation and communication of ideas, potential solutions (without the limitation of time/ money/ resources) were considered and captured on post it notes. Presentations were followed by constructive discussions, enabling feedback and refinement of the ideas through collaborative input and suggestions. A \u0026ldquo;Crazy 8s\u0026rdquo; agile design sprint task was then led by the design team [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e] such that everyone at the workshop sketched eight different game concepts in eight minutes before each sharing their ideas with the group. This process helped to quickly generate a large number of ideas before considering potential features that would complement and improve the user experience. After the initial ideation workshop, a separate session was conducted with the design team to refine the preliminary ideas into more solidified games and mechanics.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003ePhase 3: Initial application testing\u003c/h2\u003e \u003cp\u003eIn order to assess the practical capabilities, features, and user experience, participants who had taken part in phase one were invited to participate in the initial application testing. The demo was tested on Testflight for iPad [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e] on potential end users with different health conditions and prior experience of using digital technology. Individuals were presented with information about the need for the intervention and the current design (app). Participants were involved in reviewing the current prototype and providing feedback both positive and negative on the game concept, ease of use and the educational content. Participants received an honorarium in the form of a book voucher (\u0026pound;20.00 GBP). Ease of using KOKU-Nut was also assessed using the 10-item system usability scale (SUS) [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Each question has a response based on a Likert scale ranging from strongly agree to strongly disagree and the responses provide a score as a measure of the overall usability of the system. A SUS greater than 68 is considered above average, a SUS between 71 and 84 is considered good and a score\u0026thinsp;\u0026ge;\u0026thinsp;85 is considered excellent [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eNeeds assessment results (Phase 1)\u003c/h2\u003e \u003cp\u003eFive focus groups each lasting approximately 60 minutes were conducted between October and December 2022. In total, 33 older adults (mean age 82.8 years, SD 8.3) attended a focus group, most participants were female (78.8%) and of White British ethnicity (93.9%). Demographic characteristics of study participants are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Thematic analysis of the dataset resulted in four overarching core themes and a series of sub themes demonstrating the thoughts and opinions of the community-dwelling older adults (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eDemographic characteristics of study participants (community dwelling adults aged 65 years and older)\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency (%)\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;33)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean (SD) Age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e82.8 (8.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender:\u003c/p\u003e \u003cp\u003eMale\u003c/p\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (21.2)\u003c/p\u003e \u003cp\u003e26 (78.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarital status:\u003c/p\u003e \u003cp\u003eSingle\u003c/p\u003e \u003cp\u003eSeparated/ divorced\u003c/p\u003e \u003cp\u003eMarried\u003c/p\u003e \u003cp\u003eWidowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (15.2)\u003c/p\u003e \u003cp\u003e6 (18.2)\u003c/p\u003e \u003cp\u003e3 (9.1)\u003c/p\u003e \u003cp\u003e19 (57.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEthnic origin:\u003c/p\u003e \u003cp\u003eWhite British\u003c/p\u003e \u003cp\u003eBlack British\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31 (93.9)\u003c/p\u003e \u003cp\u003e2 (6.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eList of themes and subthemes identified\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverarching theme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSubthemes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChange in diet due to age-related decline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Physiological factors\u003c/p\u003e \u003cp\u003e\u0026bull; Social factors\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerception of foods\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Shop bought vs homemade\u003c/p\u003e \u003cp\u003e\u0026bull; Health claims\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFood choice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Personal preferences\u003c/p\u003e \u003cp\u003e\u0026bull; Cooking habits\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerspectives towards digital tools to support nutritional intake\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Attitude towards technology\u003c/p\u003e \u003cp\u003e\u0026bull; Advance nutritional knowledge\u003c/p\u003e \u003cp\u003e\u0026bull; Recipes\u003c/p\u003e \u003cp\u003e\u0026bull; Increase motivation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eTheme 1: Change in diet due to age-related decline\u003c/h2\u003e \u003cp\u003eMany older adults noticed they had less of an appetite and this change in eating pattern was accompanied with an attitude of acceptance as an inevitable part of ageing.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I don\u0026rsquo;t know whether other people find this but I\u0026rsquo;ve found that as I\u0026rsquo;ve got older, I don\u0026rsquo;t get hungry\u0026rdquo; (P129, Female, aged 65\u0026ndash;74)\u003c/em\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eSo your diet does change to a certain extent as you\u0026rsquo;re getting older and that happens\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e(P134, Male, aged 85+)\u003c/h2\u003e \u003cp\u003eIt is well established that dietary habits are developed over the lifetime and often revolve around social cues. Older adults can often lose these cues, which can then alter intake. As well as these psychosocial factors, poor dentition was also identified as a physiological barrier and factor influencing food intake:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Once you start cooking for one, it\u0026rsquo;s never the same\u0026rdquo; (P137, Female, aged 85+)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;When you\u0026rsquo;re alone, you just don\u0026rsquo;t have the appetite\u0026rdquo; (P136, Female, aged 85+)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Another thing that\u0026rsquo;s affected me in terms of eating, is my teeth, you know, they are no good\u0026hellip; and there\u0026rsquo;s lots of them missing now\u0026rdquo; (P115, Female, aged 75\u0026ndash;84)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e Several participants were conscious of and sometimes restricted their fluid intake, especially in the evenings to prevent having to use the bathroom multiple times throughout the night. There was an awareness about the consequences of dehydration, but the decline and frustration associated with reduced bowel function was more of a concern and influencing factor when considering fluid intake amongst the sample.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I can\u0026rsquo;t drink after my evening meal\u0026hellip; I\u0026rsquo;ve got a bladder problem, well a prostate problem actually which makes me want to go to the toilet every hour\u0026rdquo; (P134, Male, aged 85+)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;It\u0026rsquo;s sort of a balancing act isn\u0026rsquo;t it, cause, you know, as you get older\u0026hellip; you can be managing bladder problems\u0026rdquo; (P138, Male, aged 75\u0026ndash;84)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eHealth complications were both prevalent and a concern for many participants and influenced dietary intake. Participants were aware and consistently mentioned foods they should avoid, however never focused on foods they should be eating to maximise their health.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;When I first became a diabetic I did find it a bit difficult because I used to love an ice cream cake\u0026hellip; and I had to stop all that\u0026rdquo; (P141, Male, aged 75\u0026ndash;84)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I have to watch my cholesterol\u0026hellip; because I have high blood pressure\u0026rdquo; (P116, Female, aged 85+)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eTheme 2: Perception of foods\u003c/h2\u003e \u003cp\u003eIn general, there was a negative attitude towards pre-packaged and processed foods with a focus on the importance of home cooking:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I try to cook by myself, because then I know what\u0026rsquo;s going in it\u0026rdquo; (P122, Female, aged 65\u0026ndash;74)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;When you do it yourself, course it takes a lot longer but I still prefer to do it that way\u0026rdquo; (P126, Female, aged 75\u0026ndash;84)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e Participants also had perceptions relating to particular food groups such as dairy and salt and their impact on health.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I shouldn\u0026rsquo;t be having too much dairy but I\u0026rsquo;m afraid I do\u0026rdquo; (P111, Female, aged 75\u0026ndash;84)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I\u0026rsquo;ve got to cut down on the salt\u0026rdquo; (P116, Female, aged 85+)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eTheme 3: Food choice:\u003c/h2\u003e \u003cp\u003ePersonal preference and taste was also a key determinant of food intake.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;It is a mix of what I like but also how easy it is\u0026rdquo; (P129, Female, aged 65\u0026ndash;74)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;A lot of your diet does go on taste\u0026rdquo; (P134, Male, aged 85+)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e This was also relevant for fluid consumption with many participants having strong preferences towards the temperature and flavour of their water.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I find water boring, so I add blackcurrant juice\u0026rdquo; (P113, Male, aged 75\u0026ndash;84)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Well I usually drink water, but it\u0026rsquo;s got to be absolutely cold out the fridge\u0026rdquo; (P121, Female, aged 75\u0026ndash;84)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eCooking preference, ability and confidence was also something to consider as a factor that influences dietary intake. The following examples suggest that batch cooking was a popular technique used by this group.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Occasionally I\u0026rsquo;ll get a big pan of things and make a stew which will cover me for at least three days, maybe four if I stretch it out\u0026rdquo; (P138, Male, aged 75\u0026ndash;84)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;When I cook, I cook a certain amount and then freeze it so, then can take it out whenever I need to\u0026rdquo; (P116, Female, aged 85+)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eTheme 4: Perspectives towards digital tools to support dietary intake\u003c/h2\u003e \u003cp\u003eThe final theme derived from the dataset focused on attitudes towards the digital intervention and possible features that could be incorporated into the nutritional component. Some people did not have access to iPads or smartphones and some people had access to but did not or could not use this technology.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I\u0026rsquo;ve got one that I need to use but I don\u0026rsquo;t know where to start with it\u0026rdquo; (P125, Female, aged 85+)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Though I must admit my patience with these things is getting worse and worse, what with all these bloody passwords and things\u0026rdquo; (P113, Male, aged 75\u0026ndash;84)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eDespite the initial resistance towards digital technology, many people were interested in learning with the appropriate support and guidance.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Well I think I would like to learn because I\u0026rsquo;ve got to change my attitude to it and accept that it\u0026rsquo;s here to stay\u0026rdquo; (P138, Male, aged 75\u0026ndash;84)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;They\u0026rsquo;d have to be very patient and it would take a very long time, but yes I would like to learn\u0026rdquo; (P131, Female, aged 65\u0026ndash;74)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe majority of participants had a positive attitude towards the digital health intervention with many offering questions or suggestions around what they should be eating and what they would like to see in the nutritional component. Suggestions fell into three main categories: education, recipes and motivation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eEducation\u003c/h2\u003e \u003cp\u003eMany participants were engaged and interested in how they could improve their diet:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;So where are you saying this proteins got to come from\u0026rdquo; (P138, Male, aged 75\u0026ndash;84)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;So what do I add to my porridge and toast?\u0026rdquo; (P134, Male, aged 85+)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I\u0026rsquo;m interested in why you should eat certain kinds of food\u0026hellip; and what vitamins you need\u0026rdquo; (P129, Female, aged 65\u0026ndash;74)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eRecipes\u003c/h2\u003e \u003cp\u003e Many participants also highlighted that recipes would be a useful addition to the digital tool with some participants interested in simple recipes that required minimal cooking equipment.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Recipes, information, reminders, \u0026hellip;like what veg to put in it, what\u0026rsquo;s easier to use or different veg\u0026rsquo;s that you can make in the same type of dish\u0026rdquo; (P138, Male, aged 75\u0026ndash;84)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I wouldn\u0026rsquo;t mind one or two vegetarian recipes\u0026rdquo; (P136, Female, aged 85+)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We need more simple meals\u0026rdquo; (P124, Male, aged 65\u0026ndash;74)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eMotivation\u003c/h2\u003e \u003cp\u003eThe dataset also highlighted the challenges around achieving behaviour change and identified that a motivational component within the digital tool would be beneficial to remind participants to stay on track.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;It\u0026rsquo;s sticking to it; it\u0026rsquo;s the willpower that\u0026rsquo;s hard\u0026rdquo; (P127, Female, aged 85+)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;It [notifications] would help me... just could say to you, have you drunk within the last whatever time or when was the last time you had a drink and then you can just say yay or nay... especially with your memory as you\u0026rsquo;re getting older\u0026rdquo; (P124, Male, aged 65\u0026ndash;74)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eResult of application development (Phase 2)\u003c/h2\u003e \u003cp\u003eFour ideas were presented to the research team based on the ideation workshop. A matching pair\u0026rsquo;s card game concept was chosen as it was anticipated this would be the most engaging for users, easy to understand and allows an educational component to be easily incorporated into the game mechanics to provide nutritional information and nudge older adults to choose certain foods. The educational content was produced by the research team based on lay language description of best evidence information (the Eatwell guide) [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] and findings from phase 1. In particular, the app was designed to increase consumption of fruit and vegetables, lean protein and fibre whilst reducing intake of high fat and sugar foods. The game highlights the importance of including certain food groups in the diet and practical advice for how to make something like toast a more nutritious meal.\u003c/p\u003e \u003cp\u003eThe graphics were developed by the design team using Apple Xcode using the Swift development language for iPad [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e], and Android Studio using the Java development language for Android [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. The game involves the user choosing a pair of cards from a possible twelve that are faced downwards, with the aim of finding all matching items (Fig.\u0026nbsp;1). The twelve cards when turned over show six different images of food or nutritional related content (with each food item appearing on two cards). If a matching pair is found, a pop up will appear presenting a larger image of the matching food item along with information about the item (Fig.\u0026nbsp;1). If the cards are a mismatch, a message appears to say \u0026ldquo;not a match\u0026rdquo; and the cards will return to their original face down position. The game is complete once all pairs have been matched and the user is led to see important tips to improve diet and prevent malnutrition. For example, users are signposted who to speak to and offered simple tips if they were having difficulty chewing or a reduced appetite.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eFigure 1\u003c/strong\u003e \u003cp\u003e \u003cem\u003eScreenshot of matching pair\u0026rsquo;s game available on KOKU-Nut\u003c/em\u003e \u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eResult of initial application testing (Phase 3)\u003c/h2\u003e \u003cp\u003eA total of 10 end users tested the beta version of the app on an iPad provided by the research team. Testing took place face-to-face in January 2024 and involvement typically lasted 45 minutes. A think-aloud approach was utilised such that the researcher (CF) observed participants using the intervention who were encouraged to say their thoughts out loud in order to provide detailed insight into their interpretation, experiences and barriers of using the intervention. At the end of the testing period, users also completed the SUS to quantitatively evaluate the usability of the app (KOKU-Nut) [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. The median score was 87.5 (IQR: 65, 95) out of 100 indicating the intervention had excellent usability [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFeedback from end users was noted by the researcher (CF) and then discussed with the wider research team (ES, SB). Criteria for making modifications was based on if the feedback aligned with the evidence base, if the same issue was reported by multiple users or would be appropriate to a wider audience and if the changes could be easily incorporated into the game [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Individuals generally had positive feedback, found the game enjoyable and the content clear, informative and interesting. Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e highlights the feedback and amendments made to improve the clarity of the educational content and so that the instructions page was more intuitive for the user. This testing process allowed older adults to be active co-creators in the development of KOKU-Nut, highlighted issues that were not initially obvious to the research team and helped to ensure the final app was user friendly. Amendments confirmed by the research team were then incorporated by the design team and the game was developed for both Android and iOS to increase accessibility across a range of devices (iPads and tablets).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eChanges made to KOKU-Nut based on user feedback\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFeedback from user\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAction taken\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOne participant found the game too challenging and thought there were too many cards on the screen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDespite this comment other users thought the difficulty level was appropriate and were able to complete the game so the number of cards have not been changed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe word phytochemical is too technical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhytochemicals has been replaced with vitamins\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot clear what 14 units of alcohol translates to\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThis has been removed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOne participant suggested that a quiz at the end of the game would be helpful to test knowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThis has been noted as a suggestion for a possible future iteration\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA few participants missed the \u0026lsquo;next\u0026rsquo; button on the instructions page and tried to play on this screen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdditional sentence has been added into instructions page to clearly direct users to start the game\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOne participant thought the game was very text heavy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDespite this comment, other users found the content informative and the right level so no changes were made\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFound the game difficult at first but then really enjoyed it \u0026ldquo;would rather do this than watch the soaps\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThought the cards disappeared/ faced down too quickly so it was difficult to see where cards went\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIf a matching pair is not found, cards now return to face down position one by one rather than at the same time\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiked information about canned/ frozen fruit and vegetables\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThought it was very informative, entertaining and not patronising\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ldquo;I love it and would recommend it to my friends\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ldquo;The advice contained in KOKU would be highly beneficial to the user... I am convinced it would enhance the lives of many people\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ldquo;KOKU is both stimulating and enjoyable. It brings great satisfaction and most importantly promotes good health\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA few participants found the term sarcopenia too technical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe term sarcopenia has been removed so now just says \u0026ldquo;to help maintain muscle mass and strength\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOne participant thought that meat should also be included as an example of processed food.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThis has been updated to include bacon as an example of an ultra-processed food\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study has demonstrated the process of using a person centred approach to create a digital nutrition game with and for community-dwelling older adults with input from a multi-disciplinary team of experts. A person-centred approach draws on users\u0026rsquo; views and experiences to inform the design and planning of an intervention, to ensure that it is engaging and persuasive [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. A qualitative approach was utilised in phase one as recommended by the literature [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e] to explore the current attitudes and determinants of dietary habits in older adults, to provide context to the intervention and to identify how to manipulate future food choices to improve intake. These findings were then used to inform phase two (the development of KOKU-Nut) by prioritising and incorporating user perspectives wherever possible alongside best evidence to support behaviour change [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e] to align with nutritional guidelines [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Application testing in phase three allowed feedback early on in the design process so that changes could be incorporated into the digital tool to support the preferences of end users. This person-centred approach has been shown to improve the relevance and overall quality of the research to ensure that it prioritises and considers aspects that are important to the people the research is aimed at [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. We anticipate this consideration at all stages of the design process has contributed to the high usability score and will lead to sustained use of the intervention.\u003c/p\u003e \u003cp\u003ePhase one identified that the main determinants of intake were change in diet due to age-related decline (psychosocial and physiological factors such as change to living situation and poor oral health), their perception of foods (food quality, health benefits of foods) and food choice (taste, cooking habits). These findings are consistent with the wider literature and reflect the complexity of food intake demonstrating the influence from physical, psychological and social change that occurs in old age [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. Participants in phase one were aware of the importance of food on health status, but not how intake should change with age. It became apparent that dietary advice received by this population throughout their adult life was still a concern. This highlights the rationale for developing a specialist and evidence-based tool targeted for older adults given the additional nutritional challenges within this population [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. Participants also spoke about having a reduced appetite, often termed anorexia of ageing and this is likely to contribute to the risk of malnutrition [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. Malnutrition is a challenging health concern that commonly occurs in older adults [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e] but awareness among this population group remains low [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. Findings from phase one informed the educational component within KOKU-Nut to provide messaging around areas such as unplanned weight loss and guidelines for dairy consumption.\u003c/p\u003e \u003cp\u003eIn phase one, participants\u0026rsquo; also highlighted barriers to using technology including a lack of knowledge around these devices, low confidence and the excessive use of passwords. Despite some concerns around the use of digital technology, recent evidence has shown that age does not appear to be a barrier for use [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. A review by the Organization for the Review of Care and Health Apps (ORCHA), a digital health evaluation and distribution organization found that more than half (52%) of people surveyed who were aged 65 years and older support the move to digital health [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. Digital health tools can help make health systems more efficient and sustainable; allow aspects of care to be conducted from the patient\u0026rsquo;s home; and supports patients being actively involved in their care [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e]. Digital tools are likely to help engage hard to reach and vulnerable groups who may struggle or feel excluded from traditional face-to-face approaches [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. Moreover, the development of the nutrition game was guided by the thoughts, needs and ideals of potential end users. This form of participatory design [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e] helps to maximise the acceptability, usability and effectiveness of an intervention amongst users [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e]. A review of studies including older people in the design process of technology innovations showed that user involvement can prevent ageism, create a positive sense of ownership and improve the quality of the intervention [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFindings from phase three of the current study demonstrated that potential end users liked the concept, information and graphics and reported the nutrition game to have high usability. A systematic review including 46 studies reported that gamification makes a typically boring activity more enjoyable, competitive and engaging [\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e]. Gamification can be defined as entertaining the user as they learn or change behaviour [\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e]. This is likely to contribute to the use of gamification to successfully promote and sustain healthy behaviours by incorporating strategies such as goal setting, feedback on performance, progress tracking and social connectivity, which share key elements with established behaviour change techniques [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e]. We anticipate the gamification within KOKU-Nut will increase engagement levels and the enjoyment provided to users will support regular use of the app.\u003c/p\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eThere were several limitations to this study including that it was a relatively homogeneous sample, the majority of which were white British females. This ethnic profile reflects the population of older adults living in England and Wales in 2021 [\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e] however the socio-cultural influences on eating behaviour would be better assessed by recruiting a culturally diverse group from different socio-economic backgrounds. In addition, important characteristics of participants were not collected including educational level and digital literacy. Furthermore, it is likely that findings were influenced by social desirability bias, given that nutritional information is often misreported [\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e] and participants in the current study were aware that they were speaking to a nutritionist. Objective measures such as dietary surveillance can improve the precision of data and provide a more accurate measure of intake however; this involves large administrative costs, participant burden and intrusion. It would have been beneficial to consider and explore other stakeholders perspectives (such as dietitians, geriatric consultants and community outreach teams) as part of the design process however this was not possible due to time and financial limitations.\u003c/p\u003e \u003cp\u003eThe main strength of this study was the engagement of participants at both the needs assessment and initial application testing phase. This interaction and feedback allowed the user\u0026rsquo;s needs, desires and abilities to be considered and incorporated into the design process.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWe anticipate this person-centred design approach will support the uptake and sustained use of KOKU-Nut to empower and educate users to improve their diet and take control of their health. We plan to continue to develop and iteratively revise the app to maximise its potential and usefulness. Future research should seek to study more ethnically diverse perspectives given the influence of culture and upbringing on dietary habits and the heterogeneity of the sample in the current study.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eUK- United Kingdom\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eJLA-PSP- James Lind Alliance Priority Setting Partnership\u003c/p\u003e\n\u003cp\u003eKOKU- Keep on Keep up\u003c/p\u003e\n\u003cp\u003eCOREQ- Consolidated Criteria for Reporting Qualitative Research\u003c/p\u003e\n\u003cp\u003eKOKU-Nut- Keep on Keep up Nutrition\u003c/p\u003e\n\u003cp\u003eSUS- System usability scale\u003c/p\u003e\n\u003cp\u003eORCHA- Organization for the Review of Care and Health Apps\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eEthical approval was obtained by The University of Manchester Research Ethics Committee on 22/07/22 (Ref: 2022-14724-24818) and complies with the Declaration of Helsinki. Written informed consent was obtained from all participants prior to commencement in the research.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eThe data presented in this study are available on request from the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eES is the director of KOKU health which is a non-for-profit company. CF and SB have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eCF receives financial support from the Medical Research Council (CASE Entry- MR/R015767/1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions:\u0026nbsp;\u003c/strong\u003eCF, ES and SB designed the study. CF was involved with data collection and analysis which was overseen by ES and SB. CF primarily wrote the paper which was refined from comments by ES and SB. All authors reviewed the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement:\u0026nbsp;\u003c/strong\u003eThe authors would like to thank Yimin Tang (YT) for her help with this study, participants for their contribution, and staff at the assisted living facilities for their support with recruitment. The authors would also like to thank Christian Shannon, David Seward and the team at Reason Digital for their help with the development of the intervention.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eOffice for National Statistics, \u003cem\u003ePopulation estimates for the UK, England and Wales, Scotland and Northern IReland\u003c/em\u003e. 2021.\u003c/li\u003e\n\u003cli\u003eHlaing-Hlaing, H., et al., \u003cem\u003eDiet Quality and Incident Non-Communicable Disease in the 1946-1951 Cohort of the Australian Longitudinal Study on Women\u0026apos;s Health.\u003c/em\u003e Int J Environ Res Public Health, 2021. \u003cstrong\u003e18\u003c/strong\u003e(21).\u003c/li\u003e\n\u003cli\u003eNoce, A., A. Romani, and R. Bernini, \u003cem\u003eDietary Intake and Chronic Disease Prevention.\u003c/em\u003e Nutrients, 2021. \u003cstrong\u003e13\u003c/strong\u003e(4).\u003c/li\u003e\n\u003cli\u003eKiefte-de Jong, J.C., J.C. 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Fernandez-Aleman, \u003cem\u003eA systematic review of gamification in e-Health.\u003c/em\u003e J Biomed Inform, 2017. \u003cstrong\u003e71\u003c/strong\u003e: p. 31-48.\u003c/li\u003e\n\u003cli\u003eStokes, B.G., \u003cem\u003eVideogames have changed: time to consider Serious Games?\u003c/em\u003e Development Education Journal, 2005. \u003cstrong\u003e11\u003c/strong\u003e(3): p. 12.\u003c/li\u003e\n\u003cli\u003eCugelman, B., \u003cem\u003eGamification: what it is and why it matters to digital health behavior change developers.\u003c/em\u003e JMIR Serious Games, 2013. \u003cstrong\u003e1\u003c/strong\u003e(1): p. e3.\u003c/li\u003e\n\u003cli\u003eCensus, \u003cem\u003eProfile of the older population living in England and Wales in 2021 and changes since 2011\u003c/em\u003e. 2021.\u003c/li\u003e\n\u003cli\u003eHebert, J.R., et al., \u003cem\u003eSocial desirability bias in dietary self-report may compromise the validity of dietary intake measures.\u003c/em\u003e Int J Epidemiol, 1995. \u003cstrong\u003e24\u003c/strong\u003e(2): p. 389-98.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Older adults, malnutrition, digital health, co-creation, participatory design, wellbeing","lastPublishedDoi":"10.21203/rs.3.rs-4212596/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4212596/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eDigital tools embedded with behaviour change theories can encourage the successful implementation and maintenance of positive lifestyle changes. Keep on Keep up (KOKU) is a wellbeing app offering strength and balance exercises and educational games to raise awareness of fall prevention. We aimed to further develop KOKU using a person-centred approach to support nutritional intake and align with the service users\u0026rsquo; needs and priorities to maximise engagement and usability.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eInitially, adults aged 65 and over were recruited from assisted living facilities across Greater Manchester. Five focus groups involving 33 older adults (aged 69\u0026ndash;96 years) were conducted between October and December 2022. A topic guide was used flexibly to understand factors that influence the groups eating habits and explore their thoughts around a digital tool to support nutritional intake. Conversations were audio-recorded, transcribed verbatim and analysed using an inductive thematic approach. Researchers then collaborated with designers to develop a nutrition game based on UK dietary guidelines and findings from the focus groups. The nutrition game was tested with end users in January 2024 before making any necessary changes. Users provided feedback and completed the system usability scale (SUS).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFour themes emerged from the dataset. The main determinants of food intake were personal preference, perceptions of foods and changes as a result of age-related decline. The ability, engagement and willingness to use digital technology varied among participants but the majority had a positive attitude towards the digital service. A matching pair\u0026rsquo;s card game was chosen and the educational content was produced by the research team. A prototype of the nutrition game (KOKU-Nut) was tested with 10 end users on an iPad provided by the research team. Feedback was generally positive and the median SUS was 87.5 (IQR: 65, 95) out of 100 indicating the nutrition game had excellent usability.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eWe anticipate this person-centred approach will support the uptake and sustained use of KOKU-Nut to empower and educate users to improve their diet.\u003c/p\u003e","manuscriptTitle":"A Person Centred Approach to Developing a Digital Tool (KOKU-Nut) to Improve Dietary Intake in Community-Dwelling Older Adults","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-19 17:54:47","doi":"10.21203/rs.3.rs-4212596/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-12-27T09:54:41+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-12-18T17:00:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"140174166502318063718408498734511932905","date":"2024-12-18T16:27:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"108771437971050931405139012004566323216","date":"2024-05-28T14:56:57+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-05-18T17:50:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"44c6548a-a4ac-40bf-91dc-058d75523e05","date":"2024-04-28T12:20:05+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-04-26T08:28:43+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-04-26T08:24:41+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-04-11T07:36:45+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-04-11T07:31:05+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Geriatrics","date":"2024-04-03T12:05:14+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3aa614d2-0501-4877-97fc-e8e00b6a436d","owner":[],"postedDate":"April 19th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-11-24T16:07:44+00:00","versionOfRecord":{"articleIdentity":"rs-4212596","link":"https://doi.org/10.1186/s12877-025-06434-2","journal":{"identity":"bmc-geriatrics","isVorOnly":false,"title":"BMC Geriatrics"},"publishedOn":"2025-11-18 15:58:52","publishedOnDateReadable":"November 18th, 2025"},"versionCreatedAt":"2024-04-19 17:54:47","video":"","vorDoi":"10.1186/s12877-025-06434-2","vorDoiUrl":"https://doi.org/10.1186/s12877-025-06434-2","workflowStages":[]},"version":"v1","identity":"rs-4212596","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4212596","identity":"rs-4212596","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}