Archives of Design Research

The perceived stress scale (PSS) is one of the most widely used psychological tools for stress measurement. Cohen et al. originally developed PSS as a self-reported questionnaire to measure human stress when encountering stressful situations (Cohen et al., 1994). Its general questions, not focusing on specific experience, evaluate how much individuals perceive their life has been unpredictable, uncontrollable, and overloaded during the previous month. There are three versions: PSS-14 is the original version with 14 items, PSS-10 is a shortened version with ten items, and PSS-4 is for telephone interviews (Lee 2012). Although these methods are widely used, they have limitations in detecting stress levels at the right moment of stress arousal and alerting users to take prompt action.

On the other hand, we have smart devices on our wrists or in our hands almost all day, even while sleeping. Hence, they are advantageous to detect our daily data, including stress levels at the moment of stress arousal, and provide feedback to take necessary action for possibly relieving stress immediately (Hickey et al. 2021; Krishnamurthi et al. 2021). Recently released native health apps from Garmin, Apple, Fitbit, Samsung, and Google provide insight into stress through heartbeats per minute (BPM), heart rate variability (HRV), blood volume pulse (BVP), electrodermal activity (EDA), and skin temperature (ST) (Campos 2019; Sawh 2021). Technologies to detect and monitor stress with smart devices have been improving and play an essential role. There are studies regarding stress measuring and monitoring with smart devices (Smets et al. 2018; Ueafuea et al. 2020) and wearable devices for health behavior changes (Li et al. 2021; Patel et al. 2015; Christmann et al. 2017); there are also limited studies on stress-relieving methods using smart devices (Can et al. 2020; Larsen et al.; 2016).

Government organizations such as CDC and MHF suggested ways to cope with stress during COVID-19 as follows: reviewing your lifestyle (reorganizing and prioritizing, delegating to others, taking duties less seriously), caring body (deep breathing, meditating, healthy meals, regular exercise, restful sleep, awareness of drinking and smoking, vaccination when available), staying away from news and screens, making time for leisure, connecting with people you trust and your community, and lastly, seeking help if needed. Besides government organizations’ suggestions, the following techniques are widely practiced due to their proven effectiveness to cope with stress: progressive muscle relaxation (PMR), autogenic training (AT), guided imagery (GI), biofeedback-assisted relaxation (BFAR), diaphragmatic breathing (DB), meditation and mindfulness-based stress reduction (MBSR) to name a few (Table 1).

First, we developed a stress management flow based on Greenberg’s stress model (Figure 1). His stress model proceeds sequentially: 1) out-of-control situation happens, 2) cognitively perceive the situation as stressful, 3) emotionally react to the situation with fear, anxiety, frustration, overwhelmed, and more, 4) physiological arousal occurs with reactions in heart rate, muscle tension, blood pressure, skin temperature, immune system, and more, 5) consequence is stress (Greenberg, 2012).

Figure 1 Greenberg’s Stress Model (Greenberg 2012)

Based on Greenberg’s stress model above (Figure 1), we propose stress management flow with smart devices (Figure 2) as follows: 1) Life situations occur: there are many occasions causing stress in modern life, which is even more prevalent than before due to COVID-19. With the same stressors, people react differently due to their cognitive appraisal (Greenberg 2012, Lazarus and Folkman 1987). For instance, the life situation of losing a job could be perceived as a good opportunity by one person to take a rest and spend more time with family, however, it could be perceived as stressful to another person. 2) Perceived as stress: smart devices perceive the stress levels from sensors once out-of-control life situations occur, and then communicate with users overtly and covertly. Smart watches worn 24/7 detect physiological data through measuring heartbeats per minute (BPM), heart rate variability (HRV), blood volume pulse (BVP), electrodermal activity (EDA), and skin temperature (ST) (Sawh 2021; Smets et al. 2018). 3) Stress awareness: humans are aware of their stress overtly or covertly through smart devices depending on their stress levels. From this cognitively appraised human perception, emotional reactions such as fear, anger, frustration, or overwhelmed arose (Greenberg 2012, Lazarus and Folkman 1987). This emotional arousal brings physiological arousal such as increased heart rates, blood pressure, muscle tension or skin temperature. 4) Efforts to relieve stress: we suggest stress-relieving guidelines to help UX designers develop methods to overcome the COVID-19 related stress using smart devices. Step-by-step guidelines to follow from smart devices become interventions or roadblocks to prevent a stressor from resulting progressive negative consequences (Greenberg 2012). 5) Stress relieved: smart devices detect decreased stress level after users follow the guidelines. 6) Stress relieved: users recognize their stress is relieved through data from smart devices. Repeated experience reinforce users’ learning how to relieve stress. 7) Quality of life: finally, quality of life improves with stress relief as a consequence.

Figure 2 Stress Management Flow with Smart Devices

Along with this proposed stress management flow with smart devices, we developed the guidelines on how to relieve stress with the literature review in the following section.

We use our stress management flow (Figure 2) as the basis for the step-by-step stress managing sequence with smart devices.

• Step 1: Life Situation Occurs (Human)

There are many occasions causing stress in modern life, which is even more prevalent than before due to COVID-19. For example, 78% of adults in America say the coronavirus pandemic is a significant source of stress in their lives (American Psychological Association 2020).

• Step 2: Perceived as Stress (Device)

Once stressful situations occur, smart devices perceive the stress levels from sensors and communicate with users overtly and covertly. Among various smart devices from Samsung, Apple, Garmin, and Fitbit (Samsung 2021; Apple 2021; Garmin 2021; Fitbit 2021), we followed Garmin’s stress level system for guideline. It provides a stress scale of 0–25 as resting state, 26–50 as low stress, 51–75 as medium stress, and 76–100 as high stress (Garmin 2021). Smart devices communicate with users directly and instantly as overt communication when they detect a high-stress level between 76 and 100. Overt communication is an apparent and implicit method of communication for users to be informed without explication (Park et al. 2020). On the contrary, smart devices communicate with users indirectly and subtly as covert communication when they detect medium stress between 51 and 75. Covert communication is “subtle, largely nonverbal, and ordinarily unintended” (Rosenthal 2003). Due to possible adverse effects for users to get stressed from information overload, these notifications should be collected on the application’s backend and presented once a day or only when requested.

• Step 3: Stress Awareness (Human)

Depending on their stress levels, people get informed about their stress status overtly or covertly through smart devices. Stress awareness via working memory is encoded to the long-term memory and retrieved when similar stress occurs. Thus, users can learn when they get stressed and eventually prevent those situations in the future (Baddeley 1983). Then, the user tries to understand the method to escape the stressful situation by executing some preferred actions (Lewis 2004).

• Step 4: Efforts to Relieve Stress (Device)

There are four types of stressors: physical stress, psychological stress, psychosocial stress, and psycho-spiritual stress, according to Vasantha (Vasantha 2017). Under each category, we defined COVID-19-specific stressors and methods to relieve stress.

a. Physical Stress: One of the stressors during COVID-19 is lack of movement. Restricted physical activity increases the risk to the immune system, causes weight gain from reduced energy consumption, and affects mental health through anxiety, frustration, and depression (Fallon 2020; Lippi et al. 2020). Health experts recommend home-based exercise with simple household items (Fallon 2020), and government organizations urge us to take care of our body and get moving to lessen fatigue, anxiety, or sadness (CDC 2021; Mental Health Foundation 2017). Our suggested guideline to prevent lack of movement is that once the smart device senses less movement, it notifies the user to recognize their activity and suggests several options for home-based exercise alone or remotely together.

b. Psychological Stress: Not only physical stressors but psychological stressors are also significant during the pandemic. Feelings of fear, anxiety, frustration, overwhelm, worry, and stress from uncertainty are prevalent. Therefore, MHF recommends reflecting and practicing mindfulness regularly, which can be done anytime, anywhere (Mental Health Foundation 2017). Also, widely-practiced techniques such as diaphragmatic breathing (DB), progressive muscle relaxation (PMR), mindfulness-based stress reduction (MBSR), or meditation are beneficial for general psychological health, enhancing positive emotions and quality of life (Grossman et al. 2004). Our suggested mindfulness guideline includes wearable devices that detect heartbeats per minute, heart rate variability, electrodermal activity, skin temperature, and more. We then suggest several well-known stress-relieving methods such as DB, PMR, MBSR, and/or meditation to suit.

c. Psychosocial Stress: Mandatory quarantine and voluntary social distancing to limit COVID-19 infection spread place psychosocial stress and mental health at risk (Hwang et al. 2020) Loneliness and social isolation are intimately associated with stress (Campagne 2019). Government organizations urge us to connect safely with family and friends, get support, and share feelings (CDC 2021; Mental Health Foundation 2017), and others also recommend maintaining social connections with technology (Hwang et al. 2020). Our guideline to prevent loneliness and social isolation is that once devices detect less social activities, the device suggests regular video chats and calls with family and friends. Bringing back memories from previous travel or anniversary photos in their photo gallery is another way.

d. Psycho-spiritual Stress: Limitation for faith community routine due to social distancing from COVID-19 is psycho-spiritual stress. Individuals with a positive spiritual identity cope with stress more efficiently and have strong immunity to stressful situations with spiritual beliefs, which are a source of support, hope, meaning, and purpose of life (Graham et al. 2001; Koenig 2010). The WHO recommends remote faith activities because communities can still connect remotely and virtually through low and high technologies (World Health Organization 2020). Our guideline to prevent psycho-spiritual stress is that once devices detect users are apart from faith community routine, the device suggests daily religious phrases, quiet praying time, and virtual community activities.

• Step 5: Stress Relieved (Device)

If users follow the guidelines above, then smart devices detect decreased stress levels. Based on our literature review, individuals can effectively ease their stress following wearable devices’ breathing-regulating app and vibration transmitted to their wrist (Yamane 2021). Also, a stress checklist indicating “not-relieved stress” as red and “relieved stress” as green (Park et al. 2018) helps users track their stress status.

• Step 6: Stress Relieved (Human)

People recognize through smart device data that their stress is relieved. Stress-relieving experiences reinforce human learning on how to relieve stress more rapidly and effectively. People eventually get out of their stressed state faster through this process by using their working and long-term memory (Baddeley 1983).

• Step 7: Quality of Life (Human)

Finally, people experience improved quality of life through stress relief. Accumulating stress overwhelms one’s life. Therefore, early stress awareness and attention can enhance the quality of life and eventually impact a person’s lifespan (Cushway 1996).

With stress management flow correlating human cognitive processes and smart devices’ interventions, we suggested COVID-19 related the new stress management guidelines under four stress categories. The guidelines aim to help UX designers create methods for overcoming COVID-19-related stress using smart devices. In the following section, we present a case study.

We recruited participants using an online survey gauging their recent physical, psychological, psychosocial, and psycho-spiritual stress from COVID-19 on a scale from “0” (not at all) to “4” (very often). From the survey participants, we chose 24 participants and assigned six participants to each stress category based on those who responded as stressed “often” (scale 3) or “very often” (scale 4) in specific stress categories. Prototype testing was done in person for an hour per each person. Each participant was asked to answer perceived stress scale (PSS) with 14 questions before the testing. Participants who had high physical stress in the recruiting survey were asked to use a mobile prototype designed to relieve physical stress. Then we measured PSS-14 after the testing. The other stress responders were subjected to related stress prototype testing.

Apple MacBook, iPad, iPhone, and Apple Watch were used for case study testing. We prepared three static prototypes for Apple Watch indicating a) stress-detection status, b) mobile-pairing notification to relieve stress, and c) stress-relieved status (Figures 3^-4). Detecting a participant’s stress level directly from the smartwatch on their wrist on the spot would be more accurate. However, to do so would require making a stressful situation for prototype testing. To avoid ethical issues, static prototypes were substituted for actual measurements, showing stress variations. We prepared high-fidelity smartphone prototypes (Figures 5–8), one for each stress category, with Adobe XD indicating step-by-step stress-relieving guidance. We describe the detailed user interfaces in the following section (Section 4.2).

Figure 4 Participants Taking Prototype Testing

• For Physical Stress with Lack of Movement

Once a participant’s physical stress is detected, a stress-detection interface appears on the watch (Figure 3). Then, a paired smartphone application launches and urges users to start relaxing their stress (Figure 5). A step-by-step guide to relieve physical stress includes taking a deep breath, moving the body for a minute, stretching for a minute, and then sitting.

Figure 5 Physical Stress Relieving User Interface

• For Psychological Stress with Fear from Uncertainty

Once a participant’s psychological stress is detected (Figure 3), a paired smartphone application launches, urging the user to follow a step-by-step guide to relieve their psychological stress (Figure 6). Instructions include clearing their minds, taking a deep breath, starting mindfulness meditation, followed by more diaphragmatic breathing.

Figure 6 Psychological Stress Relieving User Interface

• For Psychosocial Stress with Loneliness and Social Isolation

Once a participant’s psychosocial stress is detected (Figure 3), a paired smartphone application launches and urges the user to follow a step-by-step guide to relieve psychosocial stress (Figure 7). The steps include bringing back users’ precious memories with family, friends, and pets from traveling, special anniversaries, and reminding users that they are not alone. In addition, they can make a video call or send messages to stay connected.

Figure 7 Psychosocial Stress Relieving User Interface

• For Psycho-spiritual Stress with Limitations for Faith Community Routine

Once a participant’s psycho-spiritual stress is detected (Figure 3), the paired smartphone application urges users to follow a step-by-step guide to relieve their psycho-spiritual stress (Figure 8). Guidelines include commencing prayer with ambient sound, suggesting religious phrases, and sharing feelings and thoughts with the faith community.

Figure 8 Psycho-spiritual Stress Relieving User Interface

The case study procedure designed as a within-subject experiment (Figure 9). In the initial stage, we introduced the purpose of the case study and the procedures. In the next stage, we asked participants to measure stress degrees with the PSS-14 questions when encountering stressful situations. In the following stage, prototype testing was conducted to relieve detected stress with guidelines on paired smartphones. Then, participants answered the same PSS-14 questions to measure any changes in stress degrees. In the last stage, participants answered all demographic questions.

Figure 9 The Case Study Procedure