Work-in-Progress: Health
CHI 2013: Changing Perspectives, Paris, France
Research-Derived Guidelines for Designing Toddlers' Healthcare Games Marikken Høiseth
Abstract
Department of Product Design,
This paper presents the development of a set of research-derived design guidelines for healthcare games and applications for toddlers (children aged 1-3 years). An initial set of best practices was first developed through a workshop with experts; and afterwards, by employing an affinity diagram constructed by a HCI researchers’ focus group, a revised set of best practices was obtained. This set of best practices was connected with gaming application design principles and translated into design guidelines. The results should be useful for designers and researchers who work with design and evaluation of healthcare games and applications for toddlers.
Norwegian University of Science and Technology (NTNU) Trondheim, NO-7491 Norway
[email protected] Michail N. Giannakos Department of Computer and Information Science, NTNU Trondheim, NO-7491 Norway
[email protected] Letizia Jaccheri Department of Computer and Information Science, NTNU
Author Keywords
Trondheim, NO-7491 Norway
Healthcare Games; Design Guidelines; Toddlers; Affinity Diagrams; Focus Groups
[email protected]
ACM Classification Keywords J.3 [Life and Medical Sciences]: Health; H.5.2 [Information Interfaces and Presentation]: User Interfaces, user-centered design; K.8.0 [Personal Computing]: General---games Copyright is held by the author/owner(s).
Introduction
CHI 2013 Extended Abstracts, April 27–May 2, 2013, Paris, France.
Healthcare games refer to digital games used in healthrelated contexts. Such games are typically developed in
ACM 978-1-4503-1952-2/13/04.
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order to inform patients about particular diseases, to serve as distraction while experiencing pain or discomfort, and to stimulate desired behavior and activities related to healthy lifestyles. Case studies from the early 80’s show that the medical field has a noteworthy history of embracing video games as a way to engage patients, and improve the health outcomes of a particular therapy [11]. Today healthcare games are designed, used, and researched on an extensive level [8, 12]. But even though toddlers represent a growing group of gamers, there is a lack of research focusing on design of healthcare games for this group.
Figure 1. Illustration of nebulizer treatment [1]
This work is part of a project called BLOPP (Norwegian acronym for Children’s pharmaceutical experiences) which aims to explore how design and technology can contribute to the motivation of children with respiratory diseases to take prescribed medication and stimulate child-caregiver interactions to increase medication adherence. Serious respiratory infections caused by respiratory syncytial virus or related viruses lead to hospitalization of many young children. The most common treatment is nebulizer treatment. Nebulizer treatment is suitable for young children because it does not require special breathing techniques. The treatment lasts for 5-10 minutes, which is a long time for children to sit still. The treatment is typically repeated every 2-4 hours. Patients receive medications through a mask that covers mouth and nose (Figure 1). The mask is attached to a nebulizer that converts the liquid medication into mist. Young children often resist nebulizer treatment. A combination of fear, pain and lack of understanding can cause children to resist medical treatment [9]. Much research has documented that young children are particularly vulnerable to experiencing emotional distress during hospitalization
[e.g. 15, 5, 19, 20]. Our user studies, which include semi-structured interviews with parents and nurses, indicate that the facial contact with the mask and the noise produced by oxygen-driven devices can be perceived as uncomfortable or fear-provoking aspects. Studies have shown that about 30% of young children are distressed during inhalation therapy [6]. In our efforts to investigate how interactive products and applications could be designed to motivate toddlers for medical treatment of respiratory diseases, we conducted a workshop with experts in order to capture their best practice experiences with regard to pediatric treatment. Next, we employed an affinity diagram technique in order to organize the data. As the final step of the process we used the structured data and derived guidelines for improving healthcare games and application for toddlers.
Background Several gaming techniques aim to enhance enjoyment and motivation in medical treatment [21]. For instance, tools for improving children’s acceptance of chemotherapy have been successfully applied. In the game Re-Mission the player wanders in a child's body to destroy cancer cells [10]. The game, which has been shown to support improved adherence, provides the player with opportunities to learn about the disease and how the treatment works [10]. Wind Runners is a game designed to encourage school-aged children who have been diagnosed with asthma to measure their peak expiratory flow on a daily basis [17]. Coyle and Doherty [2] describe a 3D computer game designed to enhance adolescent engagement in therapeutic discussion and how it was evaluated to have a positive impact on specific therapeutic issues. SilverCloud is a therapeutic
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platform based on HCI research which offers guided, online mental health interventions, and contains various design strategies to facilitate personal, supportive and social interaction [4]. It is widely accepted that the interactive and gameful potential afforded by games offer distinct advantages over conventional methods of health education [13]. A compelling interactive game can repeatedly expose players to essential content, as well as offer a social component that in turn can enhance motivation to improve health behavior [13]. The concept of “gamification” is also relevant as it refers to the idea of using game design elements in non-game contexts with the aim to motivate user activity [3].
Workshop with Experts Figure 2. The workshop with experts
Figure 3. The focus group and the affinity diagram development
The first step of our methodology was to record best practices/ideas from healthcare experts. To this end, an invitation was sent and the workshop was formed up. Five professionals from the sectors of healthcare and pedagogy (i.e., nurses, doctor, hospital clown, pedagogue) and five members from the BLOPP project (designers, HCI and health researchers) participated in the workshop (Figure 2). In selecting the participants, we focused on people’s professional expertise in the domains of health, children and design. Based on preliminary content analysis of the semistructured interviews with nurses and parents, conducted as part of the BLOPP project, four categories for idea grouping were proposed (prepare, motivate, distract, and reward). The participants worked in groups of three and brainstormed around their best practice experiences. Best practices/ideas were written or drawn on post-its and pinned to each category. The
workshop lasted for about 2 hours, and ended with a joint session wherein each group highlighted important aspects. At the end of the workshop session we had collected 175 best practices/ideas from experts with regard to medical treatment of toddlers.
Affinity Diagram within Focus Group Building on the results from the workshop with experts, a focus group consisting of five participants (PhD research students and academics from the domains of design, HCI and health) organized the best practices to greater detail by constructing an affinity diagram. Using a focus group enables a wide variety of collective views and often leads to results based on a consensus among participants [14]. Affinity diagramming is a technique used to organize large amounts of data through grouping related ideas or topics. Affinity diagrams enable identification of patterns and in that way also allow for better understanding of a problem [22]. The technique is considered useful for identifying and analyzing issues in gathered data [7]. The 175 best practices/ideas were translated into English, reprinted onto post-it notes and stuck onto the wall, so that they were visible to all team members (Figure 3). The participants were then asked to review and reposition the best practises within each category (prepare, motivate, distract, and reward) in order to construct sub-categories. This was an iterative process that consisted of adding or removing post-its until a pattern was discovered. Finally, the participants made headings for the constructed sub-categories.
Results and Design Guidelines As the best practices and ideas of the experts could be relevant for several purposes, it was considered useful
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Figure 4. The finalized affinity diagram: Overall best practices categorization
CHI 2013: Changing Perspectives, Paris, France
to sort them on a more general level to start with. Through the affinity diagram technique, we found that the best practices, within each original category, corresponded to three sub-categories: approach, settings, and means. Figure 4 depicts the affinity diagram, which represents the overall best practices categorization.
and the treatment. For instance, activities that allow children to do the procedure themselves on a doll or another character can familiarize them with the disease and prepare them for the treatment on their own terms. Support social/family-centered activities (Game play/mechanics or activity): Since toddlers are always together with caretakers, healthcare games and applications should support social activities. Contexts for collaboration can for instance be supported through multi-play functionality that enables parents, siblings or nurses to play together with the toddler.
The approach sub-category was defined by the focus group as all the attitudes and acts that professionals should aim to perform in order to contribute to a successful treatment. For example, the importance of viewing the child as an expert was emphasized. The settings sub-category includes all the preconditions that help children enroll with the treatment more willingly. Supporting a correct sitting posture of the child, and a safe and playful room are some of the most important best practices within the settings subcategory. The best practices referring to concrete methods and materials (e.g., dolls, pictures, books, films) were organized under the means sub-category.
Use stories that confirm togetherness (Narrative): Healthcare games and applications should convey to the toddler that they share the treatment with someone else. The toddler can for instance perform the treatment together with a character that also performs the treatment. Stories can confirm togetherness by addressing specific emotions.
Throughout this process a set of design guidelines have been derived. In order to investigate how the best practices could be specifically relevant for healthcare games and applications, the affinity diagram was used to connect the best practices to four central gaming application “design” components: game play/mechanics or activity, narrative, characters, and curriculum [16]. Next, we present seven design guidelines by giving a brief description and some illustrative examples.
Use repetitive elements (Narrative): Healthcare games and applications should offer repetitive elements to support predictability and the establishment of rituals. Repetitive elements, which in turn may facilitate repetitive actions, can be important for the toddlers’ interest in the gaming application. Examples of repetitive elements include images, sounds, and rhythms that familiarize the toddlers with the gaming application.
Provide treatment-relevant play activities (Game play/mechanics or activity): Healthcare games and applications should provide relevant play activities so that toddlers can explore various aspects of the disease
Use elements that have potential as meaningful rewards (Narrative): In order to motivate toddlers for medical treatment, healthcare games and applications should offer elements that are perceived as
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meaningful rewards. For example, digital objects such as stickers, diplomas, or points that can be collected during a period of time may serve as rewards. Mix reality and fantasy (Characters): Healthcare games and applications should provide a mix of reality and fantasy in order to communicate on toddlers’ terms. For instance, characters may imitate the body language and linguistic communication styles of toddlers to appear more recognizable. Fantasy characters may have magical or mysterious qualities. Provide practical and informative information (Curriculum): Healthcare games and applications should offer practical and informative information in order to empower toddlers and their caregivers. For example, general information about the disease and the treatment can be explained by combining visualizations and verbal language. A concept prototype of a healthcare game developed to improve toddlers’ experiences with nebulizer treatment in a hospital setting has been developed as part of the BLOPP project (Figure 5). The application consists of two parts: the information part, in which the toddler and the parent can familiarize themselves with the treatment and different aspects of being at the hospital through an interactive story; and the treatment part, which is intended for play during the actual nebulizer treatment and seeks to provide toddler and parent with a shared focus [1].
Conclusions and the Way Ahead Figure 5. A prototype application developed for toddlers’ nebulizer treatment, top: [1], bottom: [18]
This paper presents an initial attempt to exploit knowledge from experts in healthcare and model this knowledge into useful guidelines for designers and
developers who aim to address children as potential users of healthcare games and applications. Our research is characterized by a close collaboration between designers, HCI practitioners/researchers, healthcare experts (doctors and nurses) and the parents of young children. The study described in this paper has led to a set of research-derived guidelines for designing healthcare games and applications for toddlers. The guidelines were backed by addressed experts’ best practices and has been exposed to several stages of validation and organization (affinity diagram, focus group), which should provide some assurance of their validity. Based on this, seven design guidelines have been proposed. There are inevitably some limitations to the present study. Probably the main limitation is the absence of the toddlers’ voices in this work. Our future research will concentrate on further refinement of the proposed guidelines by inviting toddlers and caretakers to test concept prototypes of healthcare games and applications in realistic treatment situations. The guidelines will also be further evaluated in terms of other existing guidelines for healthcare games and gaming applications for related user groups. Furthermore, healthcare application designers and developers should evaluate the proposed guidelines in order to ensure their understanding and seek suggestions in phrasing them.
Acknowledgements The authors would like to express their gratitude to all of the participants for volunteering their time and contributing with their expertise. We also thank funders and partners of the BLOPP project. Our very special thanks go to J. Asheim, O. Alsos and E. Bergene.
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