Development of and adherence to a
computer-based gamified environment
designed to promote health and wellbeing
in older people with mild cognitive
impairment.
Mark SCASEa,1, Blessing MARANDUREa, Jennie HANCOXb,
Karl KREINERc, Sten HANKEd and Johannes KROPFd
a
Division of Psychology, De Montfort University, Leicester
b
Faculty of Medicine and Health Sciences, The University of Nottingham
c
Center for Health & Bioresources, Austrian Institute of Technology, Graz
d
Center for Health & Bioresources, Austrian Institute of Technology, Wiener Neustadt
Abstract. Background: The older population of Europe is increasing and there has
been a corresponding increase in long term care costs. This project sought to
promote active ageing by delivering tasks via a tablet computer to participants
aged 65-80 with mild cognitive impairment. Objectives: An age-appropriate
gamified environment was developed and adherence to this solution was assessed
through an intervention. Methods: The gamified environment was developed
through focus groups. Mixed methods were used in the intervention with the time
spent engaging with applications recorded supplemented by participant interviews
to gauge adherence. There were two groups of participants: one living in a
retirement village and the other living separately across a city. Results: The
retirement village participants engaged in more than three times the number of
game sessions compared to the other group possibly because of different social
arrangements between the groups. Conclusion: A gamified environment can help
older people engage in computer-based applications. However, social community
factors influence adherence in a longer term intervention.
Keywords. Psychology, aging, mobile application, eHealth.
1. Introduction
Gamification is defined as the use of game design elements in non-game contexts to
encourage users and to increase activity and participation [1]. Gamification has
become a popular technique for motivating people to accomplish tasks they might
otherwise either be reluctant to do or to persevere with [2]. This paper describes the
development of gamification techniques for a project designed to enhance the health
and wellbeing of individuals aged 65-80 with mild cognitive impairment and the
adherence to tasks during an intervention. The DOREMI project [3] (Decrease of
1
Corresponding Author: Mark Scase, Division of Psychology, De Montfort University, The Gateway,
Leicester, LE1 9BH, UK, E-Mail: [email protected]
cOgnitive decline, malnutRition and sedEntariness by elderly empowerment in
lifestyle Management and social Inclusion) brought together psychologists, clinicians,
economists and computer scientists to devise a series of activities for older people to
target health and wellbeing. These aspects include poor nutrition, sedentariness,
cognitive decline and social isolation as they all contribute to a poor quality of life and
result in increased spending on health and social care [4]. DOREMI delivered a
lifestyle intervention on a tablet computer and aimed to help participants improve their
nutrition and increase physical activity, socialization and cognitive function and so
encourage active ageing [5]. With tablet computer delivery participants can be
autonomous and reduce the burden on health care systems [6] and age-appropriate
gamification of applications can encourage participant involvement [7].
Although there are health related serious games [8] that have been produced [9-11]
there have been none that integrate all the areas of cognition, exercise diet and social
interaction for an older population [12]. Therefore this project built on pre-existing
solutions but made them specific for older people and integrated them into one
environment. To encourage participants to engage with the applications the technique
of gamification was used. Gamification of serious games can help motivate
participants and ultimately change behavior (e.g. change and improve diet [13]). The
process of gamification is rooted in the psychological theory of operant conditioning –
producing behavioral changes by rewarding some actions and punishing others [14].
Within the context of serious games, rewards for actions are generally used rather than
negative reinforcement. Examples of rewards include points and leader boards [10],
badges [15], progress monitoring (e.g. of a progress bar and tick chart) [16] and
feedback (e.g. an encouraging message after a user has completed a task) [17].
For the DOREMI project it was important that participants feel motivated to
engage with the technology. Motivation is at the heart of gamification [18-19] and is
linked to the theoretical approach underlying positive psychology and psychological
wellbeing—promoting a positive improvement in the lives of individuals [20].
Optimal intrinsic motivation and immersion in the task is achieved when there is a
balance between participant ability and task challenge. This state has been termed
“Flow” [21] and departures from it can induce participant boredom (if the task is too
easy) or anxiety (if too difficult). As well as having optimal task difficulty it is
important that gamification is relevant and appropriate for the target participants.
Successful gamification enhances self-belief in a participant’s ability to perform a task,
also known as self-efficacy [22]. Individuals with high self-efficacy towards a
behavior are more motivated to complete that behavior than individuals with low selfefficacy. It has also been found that health choices are dependent on self-efficacy [23].
Another way to ensure effective gamification is to have a user-centered design.
This design process captures characteristics of the population for whom the system is
being produced. User-centered design is an iterative process and has been applied
previously for health, education and for older people [24-25].
The aims of this study were two-fold: first to design a gamified environment
through which applications could be delivered to promote cognition, exercise, social
interaction and healthy eating; and second to test the adherence to this technology
solution through an intervention where older people were asked to play the serious
games over a 47 day period. Given the design need for age-appropriate gamification
for health interventions we first investigated the preferences of individuals through a
series of focus groups. In the intervention that then followed, the adherence to
technology was assessed both quantitatively by measuring the amount of engagement
with the tablet delivered applications and also qualitatively by interviewing participants
and assessing their experiences. We were particularly interested in whether adherence
in older people depended on factors such as the housing arrangements of the
participants. We therefore assessed two groups of older people. One group was living
independently in a retirement village that had communal areas for social interaction and
the other group was spread across a large city. Consequently, our research questions
were as follows:- 1. What are the levels of adherence to a purpose developed and age
appropriate gamification-based intervention in older adults? 2. What factors influence
adherence to such an intervention by older adults?
2. Methods
2.1. Development of gamified environment
Three focus groups were conducted as part of an iterative user-centered design process
in the development of serious games and gamification to encourage better nutrition,
increased physical activity, social interaction and cognitive function. Participants were
recruited with normal or mild cognitive impairment as assessed by the mini mental
state examination (MMSE) [26] or the Montreal Cognitive Assessment (MoCA) [27].
The first focus group consisted of nine people (5 male; mean age=77.0, SD=7.47; mean
MMSE=29.3, SD=1.00). The purpose of this group was to elicit information on the
experience of participants about games and gaming for health together with their
motivations. The second focus group consisted of five people (1 male; mean age=74.6,
SD=5.46; mean MoCA=22.8, SD=1.64). Themes defined in the first round of focus
groups were presented to participants with suggestions for the gamification of these
themes. The third focus group consisted of four people (1 male; mean age=78.5,
SD=1.91; mean MoCA=22.0, SD=2.45). This group further refined the themes from
the second focus group and obtained participant views on gamification together with
the display of game progress. The groups were facilitated by two psychologists and
each session lasted between 50 and 70 minutes. The recordings were transcribed and
analyzed thematically.
2.2. Intervention and adherence to protocol
Following the development of the gamified environment an intervention was conducted
where the adherence to the DOREMI protocol was assessed. Participants aged 65-80
years old with mild cognitive impairment were recruited to be part of the intervention.
There were two groups of participants different to the participants involved in the focus
groups. One group were based in a retirement village and consisted of 11 people (1
male; mean age=75.4, SD=5.14; mean MoCA=26.0, SD=2.28). The other group were
living separately across a large city and consisted of 13 participants (1 male; mean
age=74.9, SD=3.68; mean MoCA=24.4, SD=1.19). All participants were living alone.
Within the gamified environment on the tablet computer there were four separate
areas. The area to promote cognition consisted of four games: Find it—where
participants searched on the screen for elements as quickly as possible; Match it—a
game where participants were asked to memorise and then match pairs of cards; Solve
it—a multiple choice game of mathematics where participants solved equations; and
Complete it—where participants found missing pieces from a photograph. These
games promoted attention, praxis, memory and executive function. The exercise area
consisted of a series of videos of age-appropriate exercises and stretches that
participants could view and copy. The area to promote social interaction gave
participants challenges to interact with other people eg go for a walk and visit a friend
and also to encourage others enrolled in the intervention by giving “well done”
comments. The area to promote healthy eating asked participants to keep a food diary
and were given electronic feedback on possible future healthy meal choices.
The timeline of the intervention phase consisted of participants receiving
personalized face-to-face training on how to use the tablet computers, the apps and the
gamified environment over a 17 day period. Following this training phase there was an
intervention period of 47 days where participants were asked to use the tablet
computers in their homes independently. Participants were encouraged to engage with
the DOREMI application five days a week. Technical support was available for the
participants. For those participants living in the retirement village the support was
available face-to-face. For the other participants the support was available via
telephone. The tablets were connected via WiFi to a central server and the amount of
time participants spent using the DOREMI apps to promote cognition and exercise was
recorded. After the intervention there eight participants were interviewed about their
experiences of using the tablets. The interviews were recorded, transcribed and
analyzed thematically.
2.3. Post-Intervention Participant Interviews
An interview schedule was developed in order to glean participants’ perspectives of
their experience of taking part in the project. The schedule was designed so as to elicit
specific and detailed responses, with interviews lasting an average of 35 minutes. The
interviews were transcribed verbatim and analyzed using thematic analysis. This
allowed for the identification of common themes emerging in the participant responses.
An inductive approach was utilized, meaning the identified themes were purely data
driven. Steps in thematic analysis were followed as previously detailed [28]. This
involved the reading and re-reading of the transcripts, followed by the generation of
codes. The participant responses were then classified according to these codes, after
which codes were collapsed to form themes.
3. Results
3.1. Gamified environment
In the first focus group some participants reported that they played cognitive games to
keep their brains active but they did not play classes of games for other health benefits.
A theme that emerged was the importance of social interaction as participants felt that
loneliness and isolation were a risk factor with age. Participants were positive about
gamification concepts such as rewards for completing stages within games.
The second focus group introduced participants to a prototype gamified
environment of walking a dog along a path, a theme derived from feedback from the
first focus group. Participants said they liked to travel and build collections to remind
them of where they had been. They said that keeping motivated was an important
factor in persevering with a task.
The third focus group combined feedback from the first two to present a gamified
environment to participants. A scenario was presented where game progress was
represented as walking a dog through a European city people were visiting. At points
along the path landmarks were reached. At these landmarks a virtual postcard would
be collected that would be inserted into an album.
The final gamified environment incorporated suggestions from the three focus
groups (see Fig. 1). Progress was visualized by a dog walking a path through a city
with the collection of postcards along the way to build an album. As participants
completed the path for one European city they would then progress to another city and
collect postcards of well known landmarks there. Participants could also view a
graphical representation of their progress in the four separate game areas of the
application.
Figure 1. The gamified environment illustrating the path the dog will follow through the city. At certain
points on the path landmarks will be reached where users collect postcards illustrating those landmarks
3.2. Adherence to intervention
Following the intervention phase 435 distinct sessions on the tablet computers were
recorded for all participants with the number of sessions per participant varying
considerably from 2 to 59 sessions of engagement with the cognitive games and/or
exercise area. An independent-samples t-test was conducted to compare the number of
sessions between the two groups of participants. This test choice was due to the
presence of two independent groups, and the t-test’s ability to compare two means
There was a significant difference in the mean number of sessions for retirement
village participants (mean=29.1, SD=14.8) and those living separately (mean=8.8,
SD=7.5), adjusted t(14.3)=4.1, p=0.001. These results suggest that community living
tends to promote adherence to the tablet-delivered intervention. The session length
whilst participants interacted on the tablet computers ranged from 32 to 13611 seconds.
An independent-samples t-test was conducted to compare the participant mean session
length between the two groups of participants. There was no significant difference in
the mean participant session length between the retirement village participants
(mean=1707, SD=1040) and those living separately (mean=1747, SD=1436), t(22)=0.07, p=0.94. The results suggest that there was no difference between the groups in
how long they spent on the tablet computers in each session.
Thematic analysis of the interviews after the intervention revealed a number of
points. Participants spoke positively about their experience of taking part in the project.
Some spoke about how it made them feel better (physically) and others spoke about the
benefits of learning new things “You’re never too old to learn, that’s very true, and
you know you got to be open to being forward thinking...because some things, you
know, this digital age... and all this technology that's coming across, I mean it’s
fantastic...” (participant E02). Participants said they had enjoyed the project and how it
fitted into their current lifestyle “Well, there wasn’t a lot really. I know it was... most of
it was easy, you know... so it didn’t take any of my time...really anymore than it should.”
(participant E01). Some participants enjoyed the social aspects of the project,
particularly those living in the retirement village. They liked meeting and interacting
with others on the project “Well the strengths were you all get round a little group
…and that that you know you can really cope with each other, which is nice, you know.”
(participant E02). There were some negative aspects of the project. Participants spoke
of technical issues which could be frustrating. However, the participants living in the
retirement village stated that these technical issues were mitigated by the ease of
availability of help to resolve the issues “…we had DC [technical support person]
readily available” (participant E06). Some participants found the project intrusive in
terms of the tasks they were asked to perform. However, for most participants the
positive aspects of the project mitigated what they were asked to do “Very interesting,
sometimes stressful, sometimes frustrating, ummm sometimes I felt it was a bit intrusive
ummm... challenging... ummm but of course, I think it’s been very
interesting...err....and I think one of the things that’s really carried it for me of course
has simply been the people involved” (participant E06).
4. Discussion
Iterative user-centered design has been an effective technique for developing games
and a gamified environment. This approach of gathering information and preferences
from an older population can result in a gamification model that the target participants
feel comfortable with, can engage with and will motivate them to persevere during an
autonomous intervention. From testing participants with tablet computers we found
that older people with no previous experience very quickly learned how to use these
devices. However, with age-related visual decline [29] and manual dexterity [30]
usability issues of interface designs need to be considered carefully. Successful
gamification should use the three principles of: providing meaning to participants;
enabling mastery to maintain Flow; and ensuring autonomy so users can participate
freely [31].
Results from the intervention suggested that the gamified environment had worked
well to motivate the older people to engage with the applications. A mean session time
of approximately 28 minutes demonstrated that the participants were using
applications. Some participants informally reported that the environment was highly
engaging and they could play for hours (perhaps accounting for some session times
being over 3 hours. There was no significant difference between the mean session time
of the two groups possibly suggesting that gamification promoted engagement equally
well in the two groups and was independent of the participant location. Computerised
training has been used with older adults in several other studies but there has been little
emphasis on age-appropriate gamification as a motivating factor [32]
There was a very significant difference in the number of sessions between the two
groups. Participants in the retirement village engaged with more than three times the
number of sessions as those participants living spread across a city. A number of
factors emerged that could help explain this very large difference. The participants in
the retirement village got to know each other as the intervention progressed (they
previously were not acquainted). There was a bonding and sense of community
between these participants that helped encourage them to engage. The social
interaction element in enhancing wellbeing in older adults has previously been reported
[33]. Furthermore, technical support was available face-to-face and participants felt
they were not on their own and help was easily available. It is important to
acknowledge that all participants had mild cognitive impairment which could have
caused mild memory losses. As such, those taking part in their own homes without a
social community of fellow participants might have forgotten to use the tablet
computers regularly.
These results are consistent with previous results that suggest older people in
general have less technical confidence when using technology [34]. Training older
people with technology helps improve their self-confidence [35]. Furthermore, mobile
applications have been demonstrated to help enhance the health of older people and
maintain social relationships [36-37]. However, as our study has suggested, the faceto-face social element of older people engaging in technology is crucial for participants
to help them return and re-start a gamified session [33].
Acknowledgments. This study is part of the EU Framework 7 DOREMI project, Grant
agreement - 611650 http://www.doremi-fp7.eu/
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