Increasing motivation in eHealth through gamification

ICT solutions can help to alleviate the increasing demand for elderly care by e.g. enabling medical professionals to remotely provide care, and activating a healthier lifestyle which extends autonomy and independence of elderly [1].\ud We present an overview providing insights in current motivational approaches, addressing underlying theory from psychology, behavioural science and game design. In order to create sustained engagement, we should aim to address the intrinsic motivation of users and satisfy their psychological needs [6]. However, psychological and motivational aspects cannot be generically applied to individuals, and classifications of the user and its preferences are needed. Preliminary results indicate a link between personality and the preference for certain game elements

Online gaming and training platform against frailty in elderly people

Frailty, a condition associated with functional decline caused by insufficient mental stimulation, physical activity and healthy nutrition (Gomez et al., 2013), is a common occurrence among older adults. To counter this effect and decrease the risks for disability, dementia and hospitalisation, we developed a community-based service supported by technology called PERSSILAA (PERsonalised ICT Supported Services for Independent Living and Active Ageing). People who can particularly benefit from such a self-management service platform are in a so-called pre-frail state; declining but not yet in need of professional care. Since becoming frail is often going unnoticed by the person itself, the service starts with a screening process to identify the older adults with functional decline. They are offered a monitoring and training program that supports them in maintaining or improving on the three abovementioned dimensions of daily functioning. In addition, subjects with proper levels of functioning are also encouraged to use the service since by training in the different modules vulnerability for age related health decline can be prevented. To realise indispensable long-term engagement of the user to the service, an online gaming platform has been developed. Its user experience design relies on our previous research outcomes on gaming, gamification strategies and player motivation for the older adult (De Vette et al., 2015) to match the various preferences, abilities and prior game experience of this target group as well as possible. The game serves as an alternative interface to the standard way of exercising by providing access to the other modules from within the game environment. In the game, the player is an adventurer that is shipwrecked on an unknown island in a storm. A meaningful and motivating experience is created by reflecting the user’s performance on the training modules in the progression of the game. For example, every next level is opened after passing a predefined threshold of performance on the PERSSILAA services. Both in the Netherlands and in Italy, end-users have been involved in short evaluation cycles to quickly investigate and solve issues, thereby ensuring optimal acceptance and usability. In an ongoing evaluation study among long-term users, information is gathered on preference for game content, usability, clarity and accessibility through an online questionnaire, and provides direct input for further implementation. In addition, actual use is monitored objectively through data logs. The refinement of the game environment by means of new study outcomes and developments is an ongoing iterative process toward the realisation of an enjoyable game-based service platform for the older adult that is also employable in similar future services. Final evaluation results are expected end of 2016

Game-based design for eHealth in practice

Background: Games are increasingly used in eHealth as a strategy for user engagement. While these game-based applications receive attention in literature, there is an enormous diversity of end users and objectives targeted by eHealth. Identifying game content that drives and sustains engagement is therefore challenging. Future developments would benefit from more openness on the game design process and motivational strategies applied. Objective: Our objective was to provide insight in our approach in the development of game-based eHealth in practice. By means of a case study, PERSSILAA, we elaborate the entire game design process and show the motivational strategies applied, to aid researchers and designers of future game-based applications. PERSSILAA is a self-management platform which aims to counter frailty by offering older adults training modules in the domains of healthy nutrition, physical and cognitive training to maintain a healthy lifestyle. Methods: We introduce four phases in the process towards game-based eHealth: 1) end-user research, 2) conceptualisation, 3) creative design and 4) refinement. Results: A total number of 168 participants participated in end-user research (1), resulting in an overview of their preferences for game content and a set of game design recommendations. We found that conventional games currently popular among older adults do not necessarily translate well into engaging concepts for eHealth. Recommendations include: focusing game concepts on thinking, problem solving, variation, discovery and achievement, using high quality aesthetics. Stakeholder sessions with developing partners resulted in strategies for long-term engagement (2), using indicators of user performance on the platform's training modules. These performance indicators, e.g. completed training sessions or exercises, form the basis for game progression. Results from prior phases were used in creative design (3) to create the game "Stranded!". The user plays a shipwrecked person who has to gather parts for a life raft by completing in-game objectives. Iterative prototyping (4) resulted in the final prototype of the game-based application. A total number of 35 end users participated using simulated training modules. The online game-based application was used without reported errors for a six weeks. End users scored appreciation (74/100), ease of use (73/100), expected effectivity and motivation (62/100), fun and pleasantness of using the application (75/100) and intended future use (66/100) which implicates that the application is ready for use by a larger population. Conclusions: The study resulted in a game-based application for which the entire game design process within eHealth was transparently documented. We believe we have contributed to the transfer of knowledge on game design that supports engagement in eHealth applications. Our user evaluations indicate that results from end-user research and consequential strategies for long-term engagement led to game content that is engaging to the older adult end user.</p

Designing game-based eHealth applications: strategies for sustainable engagement of older adults

Digital healthcare applications, also called eHealth, can contribute to increasing the quality of healthcare and reducing the demand for care. A rapidly growing target group that can particularly benefit from eHealth is the older adult (65 years and up). It is of vital importance that these eHealth applications are used as they are intended: usually frequent and for a longer period of time. This so-called adherence leaves room for improvement, so that users can optimally benefit from the interventions offered. Games, or specific game elements, can be used in applications that have a primary goal other than entertainment for their natural power to engage people. This research describes how to deploy this strategy, to which refer to with ‘game-based design’, to engage users in productive activities, thereby meeting the demand for strategies to increase and improve the use of eHealth applications. The focus is mainly, but not exclusively, to address the older population. Research evolves around two lead incentives. Part one focused on a method to capture the elements of games that intrinsically motivate people to play, to investigate the elements that are motivating for elderly users, and how these can be translated into engaging design of gamified applications. A series of studies resulted in a practical tool for developers of gamified applications that enables assessment of any target group’s preferences: the 6D framework. Part two covered the development and evaluation of two gamified eHealth applications for the older adult, in which the results of the first section are applied. These studies provided insight in the development of game-based eHealth in practice. By creating transparency in this process and highlighting the rationale behind design choices and motivation strategies in game-based design, future and existing game-based applications can be optimised. By offering repeatable, practical methods, suitable content, principles and mechanisms can be selected and applied. A case study resulted in an effective, well-functioning and aesthetically attractive game-based eHealth application. Evaluations with end-users showed that the preferences as investigated with the 6D framework, and resulting strategies for long term engagement, have led to game content that engages the older adult user

A Game-Based, Physical Activity Coaching Application for Older Adults: Design Approach and User Experience in Daily Life

Objectives: In this article, we describe the design approach of a game-based, mobile coaching application for older adults (65-75 years) that aimed to stimulate physical activity (PA) in daily life. We evaluated older adults' experiences using this application compared with a standard coaching application in terms of engagement, motivation to be physically active, and in relation to the applied design features. Development and Design: An iterative design approach was followed to develop the game-based coaching application, called WordFit. Step count data (FitBit) were used for the crossword-inspired game. The standard coaching application (the ActivityCoach) displayed FitBit data. Materials and Methods: Participants were asked to use the ActivityCoach for 1 week first and then use WordFit for up to 3 weeks. Engagement was determined by logging actual use and motivation for PA by a daily in-app motivation question and step count data. Afterward, a semistructured interview was conducted. Results: Twenty older adults participated (71.0 ± 5.0 years). Of these, 16/20 actively used the ActivityCoach (13.1 ± 10.0 days) and 8/20 used WordFit (14.8 ± 9.5 days). For the latter, mean PA before WordFit use was 5852 ± 3652 steps/day, while mean PA using WordFit was 7236 ± 3335 steps/day. The interviews (n = 12) showed that step data and feedback on performance through the ActivityCoach/FitBit were prominent motivators for PA. WordFit was generally played as a stand-alone brain trainer. Cognitive challenge, in-game challenges, and challenges through emergent gameplay were important for engagement to use the game. Older adults did not play WordFit together. Discussion: WordFit was not seen as a tool to help improve PA behavior. Enjoyment of the game concept could be improved by providing older adults with new and nontraditional gaming concepts before assessing game preferences. Follow-up studies should be conducted in a target group that is known for low adherence rates and that can benefit from the intervention provided

Engaging elderly people in telemedicine through gamification

BACKGROUND: Telemedicine can alleviate the increasing demand for elderly care caused by the rapidly aging population. However, user adherence to technology in telemedicine interventions is low and decreases over time. Therefore, there is a need for methods to increase adherence, specifically of the elderly user. A strategy that has recently emerged to address this problem is gamification. It is the application of game elements to nongame fields to motivate and increase user activity and retention. OBJECTIVE: This research aims to (1) provide an overview of existing theoretical frameworks for gamification and explore methods that specifically target the elderly user and (2) explore user classification theories for tailoring game content to the elderly user. This knowledge will provide a foundation for creating a new framework for applying gamification in telemedicine applications to effectively engage the elderly user by increasing and maintaining adherence. METHODS: We performed a broad Internet search using scientific and nonscientific search engines and included information that described either of the following subjects: the conceptualization of gamification, methods to engage elderly users through gamification, or user classification theories for tailored game content. RESULTS: Our search showed two main approaches concerning frameworks for gamification: from business practices, which mostly aim for more revenue, emerge an applied approach, while academia frameworks are developed incorporating theories on motivation while often aiming for lasting engagement. The search provided limited information regarding the application of gamification to engage elderly users, and a significant gap in knowledge on the effectiveness of a gamified application in practice. Several approaches for classifying users in general were found, based on archetypes and reasons to play, and we present them along with their corresponding taxonomies. The overview we created indicates great connectivity between these taxonomies. CONCLUSIONS: Gamification frameworks have been developed from different backgrounds-business and academia-but rarely target the elderly user. The effectiveness of user classifications for tailored game content in this context is not yet known. As a next step, we propose the development of a framework based on the hypothesized existence of a relation between preference for game content and personality

The 6D Framework: An Evidence-Based Tool for Designers of Game-Based Applications

In an effort to improve engagement to ‘serious’ game-based applications, we aim to create a framework that enables game designers to identify their target audience’s key motivations to play. We developed the 6D framework: a classification for game content and a survey to assess user preferences for this content. In this study, we 1) refined and validated the framework and 2) demonstrated the framework in practice. Three rounds of expert panel sessions resulted in a revised version of the framework's classification and survey, of which content validity was checked. In an online study, 102 respondents filled in the framework’s survey resulting in profiles of their game preferences as well as a practical example of insights gained from applying the framework. We found an average 76% match in comparing the profiles of the user with the user’s top ranked games. This study resulted in a hands-on method for game-based application developers

Healthcare recommendations from the Personalised ICT Supported Service for Independent Living and Active Ageing (PERSSILAA) Study

In the face of demographic ageing European healthcare providers and policy makers are recognising an increasing prevalence of frail, community-dwelling older adults, prone to adverse healthcare outcomes. Prefrailty, before onset of functional decline, is suggested to be reversible but interventions targeting this risk syndrome are limited. No consensus on the definition, diagnosis or management of pre-frailty exists. The PERsonalised ICT Supported Service for Independent Living and Active Ageing (PERSSILAA) project (2013-2016 under Framework Programme 7, grant #610359) developed a comprehensive Information and Communication Technologies (ICT) supported platform to screen, assess, manage and monitor pre-frail community-dwelling older adults in order to address pre-frailty and promote active and healthy ageing. PERSSILAA, a multi-domain ICT service, targets three pre-frailty: nutrition, cognition and physical function. The project produced 42 recommendations across clinical (screening, monitoring and managing of pre-frail older adults) technical (ICT-based innovations) and societal (health literacy in older adults, guidance to healthcare professional, patients, caregivers and policy makers) areas. This paper describes the 25 healthcare related recommendations of PERSSILAA, exploring how they could be used in the development of future European guidelines on the screening and prevention of frailty