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 Table of Contents  
Year : 2019  |  Volume : 5  |  Issue : 1  |  Page : 30-36

Developing serious games to improve children's compliance in chronic illnesses: Input from two use cases

1 Imaginary Srl, Piazza Caiazzo, Milano, Italy
2 YOUSE GmbH, Florastrasse, Berlin, Germany

Date of Web Publication29-May-2019

Correspondence Address:
Luca Morganti
Piazza Caiazzo, 3, 20124, Milano
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/digm.digm_2_19

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Background and Objectives: Developing serious games (SGs) for children is challenging, especially when dealing with complex medical diagnosis. Enhancing children's compliance for the treatment of chronic conditions is a crucial challenge that requires caring about the engagement of users in the game experience already from the initial stages of the development. Materials and Methods: Participatory design is the methodological key to trace the right path toward an effective and easy-to-use game; specific methodological settings are necessary to collect meaningful feedback and guide the creation of the game. Our article reports the involvement of 14 young users in two different stages of the design and development of two SGs for chronic clinical conditions (Crohn's disease and cystic fibrosis). Results: Specific feedbacks were reported about game contents (e.g., the preference for anthropomorphic avatars) and technological issues (e.g., the need of a graphical tutorial). Conclusions: Using the same methodological approach in two different phases of the development allows to highlight children's perspective toward a technological solution addressing clinical compliance.

Keywords: Children, Crohn's disease, cystic fibrosis, participatory design, serious game, user.centered design eHealth

How to cite this article:
Morganti L, Ascolese A, Zettl A, Pannese L. Developing serious games to improve children's compliance in chronic illnesses: Input from two use cases. Digit Med 2019;5:30-6

How to cite this URL:
Morganti L, Ascolese A, Zettl A, Pannese L. Developing serious games to improve children's compliance in chronic illnesses: Input from two use cases. Digit Med [serial online] 2019 [cited 2023 Jun 8];5:30-6. Available from: http://www.digitmedicine.com/text.asp?2019/5/1/30/259307

  Introduction Top

Health care is strictly related to adherence to medical instructions and willingness to follow prescriptions: compliance is the related term that has been defined as the extent to which a person's behavior coincides with medical advice given.[1] In 1975, Becker and Maiman were already able to review about this topic, highlighting that many factors are implied in compliance, namely health beliefs, health-related motivations, and perception of psychological costs of the recommended actions, as well as the doctor–patient relationship.[2] Chronic illnesses require many daily actions which make it difficult to determine the exact compliance because multiple aspects would have to be checked continuously. Compliance has to be thought in a wider perspective focusing also on medication usage and related health behavior outside the clinic:[3] for example, daily nutritional regime may have a crucial role, as for fat intake in people with cystic fibrosis (CF).

Fielding and Duff[4] debate on the specific challenges regarding the compliance of children with chronic illnesses: first, they warn of talking about compliance as a unitary concept, especially when dealing with a complex subject like a family, composed of parents and children. They define a graph involving all the possible influencing factors, including socioeconomic factors, type of illness (e.g., impairment, length of time since diagnosis), and coping strategies both at children's and parents' level. Christophersen also wrote a guide about pediatric compliance, identifying the need of a daily support in clinical practice.[5] In two articles, Brownell and Cohen reviewed the adherence to dietary regimes providing both an overview of the research and ways to act effectively:[6] when dealing with nutritional issues, not involving medicine, the approach should target different levels, working on motivation enhancement, skill empowerment, and information. More recent studies focus on the compliance of children with chronic diseases, dealing with food intake: for example, Roma et al. found low compliance with a gluten-free diet and suggest a better education about the disease and an appropriate food labeling as a promising way to improve it.[7]

Technology may help increase compliance for children with chronic illnesses. A basic intervention for chronic pain has been tested by Palermo et al., who compared the use of an electronic diary with a paper-and-pencil diary. The authors found out that the eHealth solution led to greater compliance and accuracy in diary recording.[8] Still, similar interventions – trying to enhance compliance through mobile ecological momentary assessment (mainly collecting user data via mobile devices to track daily actions) – need to be improved. Wen et al. provided a meta-analysis reporting moderate but suboptimal compliance rates, especially noting high efficacy for reporting good practices to users.[9]

Serious games (SGs) could be a means of tackling the various aspects related to compliance, such as fostering motivation, skill empowerment, and education. SGs are computer games, aiming not only at entertaining the player, but also at exploiting the entertaining qualities for training, education, and health.[10] They are an example of positive technologies, an digital solution that shapes new opportunities for individual and collective learning and training, capable of supporting health and well-being.[11],[12] Connolly et al.'s systematic review analyzed 129 papers investigating computer games with respect to learning, skill enhancement, and engagement, highlighting that the most frequently occurring outcomes and impacts were knowledge acquisition/content understanding and affective and motivational outcomes.[13] Based on this common assumption that SGs work both on changing cognitive processes and affecting motivation, Wouters et al. compared them to conventional instruction methods, finding out that SGs are more effective in terms of learning and retention, even if they are not more motivating. They also identified factors that increase SGs' effectiveness such as multiple training sessions and multiplayer modalities.[14]

Based on these premises, SGs have all the characteristics required to positively affect the compliance of children with chronic illnesses. For this reason, we developed two SGs for children with two different kinds of chronic diseases, CF and Crohn's disease (CD). Compliance is a key issue for these clinical conditions because daily nutritional advice has to be followed for an effective health management. Gudas et al. identified knowledge about the disease as a beneficial factor for compliance.[15] Targeting young children seems promising, as Llorente et al. found therapeutic adherence to worsen with age and disease severity.[16] Lakatos[17] reported nonadherence in over 40% of patients with inflammatory bowel diseases (IBDs) that include CD as a chronic condition. a self-management package incorporating enhanced patient education is specifically requested by the author. In addition, in his work about compliance for IBDs, Kane[18] reported the problem of bad information when dealing with CD, an issue affecting 78% of patients.[19]

Watters et al. reported the effectiveness of SGs in eHealth in a framework that includes motivation for compliance as a key factor in their SG usage for chronic diseases.[20] they identified developmental issues such as personalization of games, based on the child's interest or specific illness and strategies to maintain novelty and interest in the treatment over time. To reach these goals, the best methodological approach when creating a SG is the user-centered design, “a broad term to describe design processes in which end-users influence how a design takes shape” as stated in the Encyclopedia of Human Computer Interaction[21] after the initial idea of Norman and Draper.[22] The number of user-centered design studies is increasing, and many of them demonstrate the practical advantages of this approach in eHealth,[23],[24] also when dealing with children.[25]

In this article, we report two cases of how participatory design applies to the development of eHealth solutions to enhance the compliance of children facing chronic illnesses such as CD and CF.

  Materials and Methods Top

The development of each game needs to focus on a specific target, and it deals with selected content. Still, the methodological approach is common, and it aims at involving users along the whole process. We report two use cases in order to highlight the peculiar type of user involvement and the related study design. The main phases of the development of a digital SG are as follows:

  1. Definition of the concept, mainly focusing on the content to be conveyed and the target of users
  2. First iteration with users, checking the technological level of the target and their way to manage the specific content
  3. Development of the prototype, integrating ideas and suggestions to create a playable version of the game
  4. Second iteration with users, identifying possible barriers for game experience and collecting specific hints on how to complete the following versions toward the first beta release.

In this article, we report the first iteration for CD and the second iteration for CF, both conditions with children suffering from chronic illnesses. Accordingly, two different samples were involved, focusing on the target identified during the definition of the two concepts. The CD sample was composed of four children (three females and one male) ranging from 9 to 12 years. The CF sample was composed of ten users, belonging to three age groups, related to the three different versions of the game that were originally planned: two children from 2 to 7 years old (one male and one female), three children from 8 to 11 years old (three males), and five teenagers from 12 to 16 years old (two males and three females).

The game related to CD was developed as a mobile app with the aim of increasing kids' knowledge about their pathology, to help them recognize symptoms, to choose adequate food for their meals, and to manage social situations where they usually feel embarrassed.

The technological solution related to CF was developed within the framework of a European project (MyCyFAPP). The aim was to develop a mobile app for the management of the disease in connection with a game app about nutritional education. The target of the game is to engage kids in the care of an avatar and to make them play specific mini-games with informational content about nutrition and healthy lifestyle. The game merges the need to convey knowledge about the disease and the need to simulate the care for the nutritional and health status of the avatar. A particular focus was put on the importance of recognizing the nutrients in food, in order to make children aware of fat intake, which is related to CF and important for their medicine intake.

Crohn's disease

Users were involved in the preliminary phase dealing with the design of the game environment and the characters. A focus group was conducted to interview children, in order to collect their spontaneous feedback. The setting was a room with different tools put on the tables (e.g., pens, pencils, markers, and scissors) to make the participants comfortable in the unusual setting and to help them share their ideas, for example, in the form of drawings. A semi-structured schedule was previously created for the focus group, in order to select the themes to be involved and to be able to present them in the best way to involve children into the activity. For the discussion, the following four topics were chosen: personal technological habits (best game and device management), avatar features, environmental characteristics, and suggestions about gameplay. For this last issue, preliminary graphical concepts were shown in order to test the pleasantness of different styles and to offer stimuli for discussion and users' ideas.

Cystic fibrosis

Users were involved in the testing phase of the first prototype of the game. Individual meetings were scheduled in order to gain feedback through semi-structured usability tests with semi-structured interview elements, based on usability, user experience, and perception of different features; spontaneous feedback was collected through the method of think aloud and was recorded with the help of audio registration. The track of the testing session was as follows: general look and feel, avatar appreciation, environment appreciation, navigation mode, and game session (access, instruction, and gameplay). In this phase of the development, the availability of the prototype allowed to provide the following series of tasks that users had to face while playing the game: navigation through the environment, playing with a specific and customizable avatar, and playing a mini-game [Table 1].
Table 1: Methodological issues

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The UNICEF guidelines based on the UN Convention on the Rights of the Child have been followed for the development of the research materials, and the parents of all the participants signed a consent agreement. Interviews were transcribed in order to collect and organize suggestions and feedback [Figure 1] and [Figure 2].
Figure 1: Specific phase of children's involvement in Crohn's disease game

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Figure 2: Specific phase of children's involvement in cystic fibrosis game

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  Results Top

The data collected were gathered both from verbal transcription and the observations by the researchers of the focus group and the usability tests.

Game for Crohn's disease

Technological habits

All the children (four out of four) were reported to have daily access to tablets, mainly belonging to parent or older siblings. Two types of games were reported as preferred, namely shooting games (three children) and games where players take care of animals (one child) (“I like games with dogs just because of dogs in them”).

Avatar features

Two children suggested using virtual children or in general anthropomorphic creatures because of the type of interaction they would like to have (“I would like to chat with the avatar” and “an avatar should keep company and someone I can play with”). One child suggested using an animal (“penguin with a blue ribbon”) and the last one suggested a fantasy character (“a yellow alien”). A warm interaction is also required when thinking about possible activities for the avatar: taking care of it and play together are reported (“I take care of my avatar and let him play”).

Environmental characteristics

All the children (four out of four) identified fantasy environments with a quiet atmosphere that allows a safe exploration (“I will send my avatar there because he likes exploring”). While evaluating the preliminary graphical concepts, human characters were evaluated as more realistic so that only one child would prefer them, whereas the other three children rated it unfit to the fantasy environment. The need to explore the world would benefit of the chance to meet unusual creatures, positively rated by all the children (“it is cute because it is a mix between a monkey and a dog” and “I like funny and lovely creatures”) [Figure 3].
Figure 3: Game environment created by a user for Crohn's disease game

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Suggestions about gameplay

The game should also provide dresses, food, toothbrush, torch, and games for the avatar objects. all the children asked for them. In addition to this, three children asked for a medal (“it brings me luck and it identifies me”), one child asked for specific tools for exploration (binoculars and a camera), and one asked for money (“I can buy everything with them”).

Game for cystic fibrosis

General look and feel

The two youngest users (4–7 years old) liked the pleasantness of the colors and the objects of the game; three children belonging to 8–11 years old suggested adding interactive objects. One child from the oldest range (12–16 years old) rated the rhythm of music to be “too calm.”

Avatar appreciation

The two youngest users asked for further items (e.g., caps, glasses) and extra powers as possible add-ons. One of them asked about putting the soccer shirt of his favorite player on as reward. Children aged 8 to 11 years showed a global appreciation (“the avatar is beautiful. it looks like Shrek!”), and one of them specifically asked about the size of the paws as a valuable feature. In general, they focus on body parts (“I like avatar's teeth.... but not too sharp!”). Users ranging from 12 to 16 years old appreciated the avatar because of its happy and positive nature and its clumsy way of moving that make it realistic instead of computerized. The three female users asked for dresses or flowers.

Environment appreciation

Focusing on the environment, younger users also asked for additional elements (fishes, cliffs, and small animals), with one of them specifically asking for a house for the monster. The three males ranging from 8 to 11 years old asked for more natural objects (colorful trees and crabs). Oldest users (especially the two males) rated the environment too fantastic, asking for more realism.

Navigation mode

The execution of game tasks with the prototype was good, with all the ten users immediately being able to move throughout the environment and play the game. Small issues were related to the different outcomes of touching game elements: a child from the youngest group insisted on touching the sun even if it does not lead to an animation like other items do.

Game session

All the ten users succeeded in finding the mini-games and play, with a little assistance for the children of the youngest group. These two children also had difficulties in understanding the labels on the fruit, but they got the overall goal of the game (“bring the right food so that the monster stays fit”). The three children from the 8 to 11 years old group reported difficulties in understanding all the simultaneous changes of some game elements (lower volume, smirk of the monster not clear, and falling leaves not recognized as timer); still, they started appreciating the need for intelligence and attention to solve the game (“I like it because I need to stay focused”). Observing the interaction of older children with the game, they seem not to care about specific game elements, but just playing and trying to find the best solutions through trials and mistakes to infer rules. A child asked for the possibility to set the difficulty by autonomously choosing a level. In general, the prototype looks a little bit boring to younger users who expect more interactions with other characters and animations [Figure 4].
Figure 4: Screenshot of the game prototype for the testing of cystic fibrosis game

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[Table 2] reports the main issues highlighted on the common themes related to the basic game characteristics.
Table 2: Main findings from child users

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  Discussion Top

This article aims to expose and compare two possible ways of involving children in the development of a SG that is aimed at helping them to manage their chronic disease in order to enhance their compliance. The use cases highlighted the possibility to involve young users in two different and specific phases of a game development: the preliminary definition of the game (CD) and the first testing with a prototype (CF). In both situations, useful feedback was collected which can guarantee that the future game will be directly connected to the needs and expectations of real users. The focus group for the CD game defined a clear structure for the environment and the avatar: the need to explore a land with an anthropomorphic friend is the main idea gathered; the idea of taking care for an avatar in daily activities; and the request for objects related to daily activities stresses the similarity between the needs of children and the ones they think their avatar will have.

On the other hand, the hints for CF game were more specific due to the fact that users expressed ideas starting from an initial concrete experience: A detailed feedback is a clear guide for the next steps of the development, for example, focusing on the creation of a house for the avatar, additional game elements that make the environment more interactive, and a tutorial for a better understanding of the mini-games for younger players.

The methodology adapts to the developmental needs: for the definition of the idea of the game, it is better to define a focus group where ideas can come from the children's interaction and each one then can be immediately checked to state the level of general consensus. When testing a prototype, individual settings allow to focus on the children's interaction with the game, in order to collect specific feedback and not to affect the game experience of other users, with feedback coming from a single performance.

The main limitation of this article is that results gathered from our cases may not be valid with other targets due to the small size of user samples, which is necessary to the type of investigation adopted. From this perspective, specific results might lack of scientific validity; still, repeating the methodology highlighted here allows integrating children's hints along the development of a game.

  Conclusion Top

Compliance is a crucial issue dealing with the involvement of the patient in the therapeutic plan. When dealing with a technological solution to enhance it, a methodological approach that collects specific inputs directly from the users throughout the different phases of the development is the best way to proceed. Children can be involved in this process by creating specific settings that allow them to express freely and evaluate their technological needs.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.


We thank the users who participated during the workshops and evaluations, but also the Health Professionals (HPs) who helped us recruiting the participants.

Financial support and sponsorship

Part of this work was funded by the H2020 EU project MyCyFAPP, grant agreement 643806.

Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2]

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