Back on the Road
Helping brain injury survivors return to driving
Project Overview
There are currently limited tools to support traumatic brain injury (TBI) survivors for a successful driving experience. “Back on the Road” is an app that assists TBI survivors as they return to driving and the therapists who are working on therapy plans with them. Its goals are to help drivers to be safe while driving and to help them regain their independence in their everyday life.
The app addresses cognitive deficits TBI survivors face on a daily basis such as attention, memory and visual-spatial abilities, and assists with these challenges as they may be encountered once back in a car. It offers tracking on progress they make over time and is customizable to each user’s preferences.
Our primary users were traumatic brain injury survivors who are returning to driving. They have a driver’s license or are in the process of obtaining a driver’s license. Secondary users were therapists, primarily occupational therapists and speech-language pathologists, who support patients recovering from TBIs. They develop individualized plans to help patients regain independence by assessing their current abilities and creating goals.
Research Overview
Our project was driven by the question: How can we support traumatic brain injury survivors by minimizing their cognitive load as they return to driving?
Survey
We created a 32-question survey for individuals with TBIs who had a drivers license or were in the process of obtaining one. Our survey included the participant’s demographics, medical history, challenges with driving, driving habits, and their suggestions of what could improve their driving experience. We also included a write-in section for information not covered in the survey and one to include contact details for follow-up. The survey was created through Google Forms and shared to a variety of places (e.g., TBI online groups, organizations, university departments). We received a total of 15 responses from 9 males and 6 females between the ages of 19 to 58. 13 participants were from the United States, 1 was from Canada, and 1 was from India. 8 people reported having a mild brain injury, 3 had a moderate one, 3 had a severe one, and 1 person was unsure.
Semi-Structured Interviews
Traumatic Brain Injury survivor who was injured as a teen and is now in his thirties
Occupational Therapist working at a CA hospital in a rehabilitation program who conducts driving evaluations with TBI survivors
Driver Rehabilitation Specialist who provides driving evaluations at a practice in Issaquah, WA
Driver Rehabilitation Specialists who provide driving evaluations at the University of Washington’s Driver Rehabilitation Program
Professor at the University of Washington’s Speech and Hearing Sciences Department who is a Certified Brain Injury Specialist
Competitive Product Analysis
We looked up existing tools and programs that addressed driving safety for individuals with cognitive impairments. We found few options, but these did not provide customization or integration with existing apps, nor have a therapy component.
Key Findings
Anxiety is a recurring issue with TBI survivors, however, they are not necessarily anxious about their skills as drivers. They are anxious about just being in a car. Some cannot articulate the source of their anxiety - being in a car is enough cause. Others feel anxiety from the complicated cognitive processes required to operate a car. Many cited memory and distractions as causes (more discussion below). And often, anxiety led to fatigue and/or frustration.
Distractibility is a major issue faced by most when returning to driving. We learned that anything can become a distraction, inside or outside of the car, moving or stationary. As each individual brain injury and its impact is unique to each person, one solution may not fit everyone’s needs. As we built and tested our prototypes, we learned just how customizable this tool needed to be. We also needed to be sure our solution did not become yet another source of distraction for the user.
TBI survivors value their independence. Overwhelmingly, when asked why driving was important, “independence” was repeatedly a top reason. This not only confirmed the second part of our rationale behind selecting our project, (“We hope to design a car interface that these individuals can feel comfortable using to maintain safety while driving and to regain their independence in their everyday life.”) it also helped us to understand the conflict TBI survivors are experiencing as they re-enter their lives.
TBI survivors have trouble with their memory. While their abilities to drive have not been impaired, they forget to complete tasks required to drive well. We received similar examples from both survey participants and from the interviews conducted. Some TBI survivors experience forgetfulness as related to driving specifically (e.g. forgetting to check their blind spot or for traffic before making a right turn at a stop light); others forget general tasks (e.g. an intended destination or once there, why they needed to be there at all). When asked what might be a helpful tool, both therapists and survivors responded “reminders”. In our interviews, we learned two interesting points that influenced the direction of our design requirements: 1) give patients clear cues in the beginning and then 2) help them cue themselves and continue to be self-aware.
Scope
The intended audience for this design specification is the development team in charge of implementing the Back on the Road application. Our scope included:
Implementation on iOS platform
Onboarding Process
Personalization of settings for the app
Integration of third party to do list apps
Past progress statistical visualization
Pre-driving checklist
Functionality for adding personal/therapy related goals
Visual cues integration with Google Maps
Design Requirements
Focus on addressing executive functions: These are the functions that deal with managing oneself and one’s resources to achieve a goal. Executive functions encompass various cognitive processes such as attention, planning, organization & prioritization, staying focused, understanding different points of view, regulating emotions, and self-monitoring which makes their role critical in novel or demanding driving situations. Based on the survey results, we found out a majority of people had a hard time maintaining focus on the task in hand such as keeping in lanes, getting distracted by something inside/outside the vehicle, keeping a safe distance from a nearby vehicle, and reacting quickly to unexpected driving situations.
Reminders: Many survey participants as well as therapists suggested an in-vehicle reminder system. However, since each individual’s injury is different, what might be helpful to one may be a distraction for the other. Therefore, we are looking to provide customization in the method by which the reminders are notified. Possible methods include audio cues, visual cues and sensory cues (such as vibrations from a wearable device). Based on the comfort of the user, the system can be customized to a specific user’s preferences.
Inform user about the destination, how far they are from there home, when will they arrive on their destination etc.
Make better turns/lane switches by incorporating cues in GPS that remind the user about the turn beforehand rather than alerting abruptly.
By prompting the user to relax and take breaks between long driving sessions.
Spatial and visual (turning, switching lanes, traffic)
Reduce cognitive load of the user by allowing them to create a to-do list before commencing with driving and reminding them upon reaching the destination. Also allow sync facility with the popular organizational applications such as Google Keep, ToDoIST
Alert user when leaving a familiar perimeter (e.g. home)
Wearable device (bracelet) + ApplicatIon (smartphone, smartwatch): Pairing a wearable device with the in-car infotainment system can help detect spikes in the pulse rate of user, which could in turn set off audio cues that instruct the user about taking the next steps. For instance, in case when a user forgets the directions and begins to panic, the wearable device would be able to detect the increase in pulse rate. The infotainment system with the help of audio cues navigates the user back to a familiar location.
Extension of a therapy plan: In addition to serving the primary stakeholders, we thought of an extension of the current design idea that also helps the therapists by accessing a log of user (much like a driving “Black Box”) driving habits and assess them in order to comprehend what challenges does the user faces as what they say might be very contrasting from what they actually do.
Therapist and patient develop plan together, setting parameters and timelines.
Application tracks driving activity in a log.
Therapist has access to viewing activity.
Include positive reinforcement audio message.
Therapist fades cues (e.g., first provides direct cues on attending to any issues then move towards patient self-cueing).
Prototypes & Usability Testing
We had 3 participants which included one driver who is Speech-Language Pathologist/Brain Injury Specialist, one driver who had a Traumatic Brain Injury (TBI), and one driver without a TBI. Our main goal of mid-fidelity prototype testing was to allow the participants to interact more with the phone application during the set-up phase and experience examples of reminders that would be presented on the car dashboard while they were driving so that we could assess their experience in more depth. We also wanted to address the issues from initial testing with our paper prototype and identify possible issues in our current prototype. We used Sketch to create our mockups first and then we used InVision to add interaction between views. We used a revised scenario and task list from our paper prototype during our high-fidelity prototype testing.
KEY FINDINGS
Severity 1:
Two out of the three participants found the visual cues in the midst of driving to be ‘verbose’ and an actual distraction to go about reading them while driving
Two participants found ‘Positive reinforcements’ in the middle of a driving session to be distracting and suggested they appear post completion of the session along with more stress on safety and navigation.
Severity 2:
All participants appreciated the ability to customize every setting in the setup screens but they also found the font on the setup screens to be small for proper readability.
Severity 3:
Two of the participants tried to click on the checkboxes next to individual list items rather than the entire list during the to-do list setup screen so there was a delay in that task.
One of the participants was confused whether to wait for the in-driving visual cue to disappear or to close it manually.
Design Rationale
Designing for Mobile Phone Application and Car Dashboard
From user research, we learned that the ability to customize settings beforehand is crucial for our population. Since their brain injuries vary widely, this results in different needs for each individual. Thus, we designed our system on a mobile phone application so that it could be set up by the driver at their own convenience. Since there are options to set your preferences before driving and view your driving progress data, we wanted to give users the opportunity to do it anywhere and not necessarily when they are in the car. In addition, we designed example reminders that would appear on the car dashboard (synced with the application) because we did not want the driver to be required to look at their phone screen while driving. Our user research with Driver Rehabilitation and Brain Injury Specialists indicated that looking at phones during driving was too distracting and was a clear safety risk so we kept visual cues on the dashboard to minimize that issue.
Tone and Voice
Through our user research and testing, we discovered the importance of using positive and conversational language. The majority of TBI survivors who responded to our survey also reported that they felt anxiety during driving so we wanted to provide supportive comments to make them feel more comfortable. In addition, based on feedback from another team, we wanted to make sure to word the name of our app in way that was not pointing out their injury and instead motivating them to use our product. Then after user testing, we decided on a neutral app name “Back on the Road” to reduce any privacy concerns. This did not signify that the app was designed for individuals with brain injuries to minimize any risks of making them feel self-conscious when using the application.
Driving Reminders
We provided reminders in areas related to: safety, navigation, health & wellness, motivational comments, taking breaks, pre-driving car checks, and items to bring during driving. From user research and testing, we found these to be important areas for drivers to be aware of for their driving trip. We included reminders in the first place because research clearly shows that TBI survivors have more difficulty with cognitive skills after their injury (e.g., memory, attention, planning, self-monitoring). It is not necessarily that they do not remember how to drive but that they may struggle with focusing on what is important to be aware of before/during driving (e.g., remembering to bring their driver’s license, maintaining safe distance between another car) and how to react appropriately to unexpected situations (e.g., made a wrong turn). They may get more easily frustrated so that is why we wanted to provide some positive feedback after their accomplishments. Since each person’s needs will also vary depending on their brain injury and driving purpose, we gave them the opportunity to customize what type of driving reminders were included.
Driving Goals and Progress Tracking
After talking to Driver Rehabilitation Specialists, we decided to include driving goals and progress tracking in our product because we wanted to provide an extension of their driving plan. Based on their feedback, it was important for both the instructors and drivers to have a clear way of seeing what areas they were trying to improve and how they have been performing over a certain period of time. Strengthening the connection between the two sides through this technology can be helpful for the driver’s long-term success. This function can also encourage the driver to be more accountable for their goals.
To-Do List App Integration
From research and testing, we found that most users already used some type of list app (e.g., Evernote, Google Keep) so we did not think it made sense to create a separate to-do list function for our app. Instead we added a function to allow them to select their preferred list app and sync the data from there to our app. We wanted to integrate their to-do lists in the first place because our research showed that individuals with a TBI often have difficulties with organization, memory, and planning. Thus, we wanted to address those challenges by incorporating any to-do lists that they would need during their driving trips.
Future Design
Expand on onboarding for the application
After conducting usability testing, we wanted to add a more detailed introduction guide to using the application. Since there are many functions and screens, a general overview to orient the users first could be minimize any confusion later.
Collaborate more with Driver Rehabilitation Specialists
We want to obtain more information with Driver Rehab Specialists so that we can make sure we are tracking goals in a way that is consistent with their method. For example, we may want to explore if there is a way to efficiently sync the information in their system with our application and creating a login screen for them that is separate from the patients.
Getting more user health data
Based on user testing, we discovered that it would also be important to obtain data about other health conditions that they may have which can also affect their driving experience. We want to investigate how to do this while also respecting the privacy of the user by examining other products that have this function.
Emergency scenario screen and emergency button
After usability testing, we determined that another helpful function to add would be support for emergency driving situations. For example, including a car accident checklist with important tasks to do during that situation. Since research indicates that TBI survivors have difficulty with memory and planning, this would remind them of what they need to do.
Modifying Type of Reminders
Based on usability testing, we want to remove “Health and Wellness” category and separate “Safety and Navigation” into two different categories in the Settings screen. The TBI survivor participated reported that an issue related to health and wellness is more of a safety issue to them.
Different symbols for different type of reminders
During testing of our prototype, we found that the text of the reminders on the dashboard might require a lot of processing from the TBI survivors. To minimize that cognitive load, we want to explore a symbol system where different symbols can represent different types of reminders (e.g., stop sign to remind someone to take a break)
Audio cues
Due to time constraints, we only had time to explore the visual cues for our prototype but we want to look into our audio cues option for our prototype. From our user research and testing, we learned about incorporating different cues depending on each person’s needs so this would be an important feature to do more work on.
Vibration cues
Since we were on a deadline, we did not have the opportunity to design for the vibration cues on a wearable device, but this could be a helpful option to include. This can be one way to minimize distraction of having to look at the dashboard screen or reduce auditory processing that is needed for audio cues, depending on the individual’s preferences.