Edited by: Frederick Robert Carrick, Bedfordshire Centre for Mental Health Research in Association with the University of Cambridge (BCMHR-CU), United Kingdom
Reviewed by: Joav Merrick, Ministry of Social Affairs, Israel; Tim Takken, University Medical Center Utrecht, Netherlands
Specialty section: This article was submitted to Child Health and Human Development, a section of the journal Frontiers in Pediatrics
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Medical advances continue to improve morbidity and mortality of serious pediatric diseases, including cancer, driving research addressing diminished physical and psychological quality of life in children with these chronic conditions. Empowerment enhances resilience and positively influences health, disease, and therapy understanding. We describe the development and usability assessment of a prototype
Academic faculty, health-care providers, and community video game developers collaborated in this project. The iPadAir was selected as a delivery platform for its accelerometer and gyroscope features facilitating exercise design.
A prototype
Adapting exercise empowerment-promoting video game technology to mobile platforms facilitates usability and widespread dissemination for children with cancer. We discuss broader therapeutic applicability in diverse chronic pediatric diseases, including obesity, asthma, cystic fibrosis, diabetes, and juvenile idiopathic arthritis.
Recent advances in pediatric medicine have resulted in markedly improved patient survival, thus increasing prevalence of those living with diverse serious and previously often fatal pediatric chronic diseases, including cardiac, pulmonary, renal, autoimmune disorders, and cancer (
Consider pediatric cancer as an illustrative example. Dramatic improvement in 5-year survival from 28% in 1960 to currently over 75% drives research to improve physical and psychological QOL from diagnosis through survivorship (
Video game technology and digital health [electronic health (eHealth) and mobile health (mHealth)] are emerging as effective empowerment-promoting tools by improving one’s understanding of health, disease, and treatment options (
With these challenges and concepts in mind, we have been developing a video game technology that couples physical exercise with mental empowerment directed at simultaneous improvement of physical strength and endurance, and psychologic QOL of pediatric oncology patients (
Before developing the prototype
Discussions involving children with cancer and their parents, nurses, child life specialists, psychologists, physical therapists, social workers, pediatric oncology physicians, and video game developers confirmed interests to develop of an exercise–empowerment video game for children with cancer. Given the overwhelming support, the first iteration of an exercise–empowerment video game, The Patient Empowerment Exercise Video Game (The PE Game) was created (
Thus, our efforts were shifted toward developing a disease-specific video game promoting physical activity, empowerment, and behavioral change in pediatric cancer patients using a mobile tablet platform. This would facilitate broader technology dissemination in a relatively easy and affordable manner to children with cancer, and potentially other chronic pediatric diseases. Based on the aforementioned experiences, our efforts shifted toward developing a video game promoting physical activity, empowerment, and behavioral change in pediatric cancer patients using a mobile tablet platform. In collaboration with a local youth media organization, the prototype
The game was designed using Unity Multiplayer game engine (
The multidisciplinary team collaborated to create an imaginative story line that included metaphorical mini-game exercise challenges, educational and psychosocially empowering experiences. Audiovisual and kinetic feedback and rewards were designed to enhance enjoyment and immersion. Design elements deemed crucial to facilitate game flow during gameplay were: imaginative stories and graphics embodying empowerment over cancer; avoidance of violence and negative, death-related themes; clear instructions; and inclusion of fun, engaging, and non-repetitive exercise elements of ample intensity to raise heart rate. The unique power bar handles and backing were designed and produced using a 3D printer and then affixed to a commercially available iPad case to accommodate diverse physical exercises while simultaneously providing iPad device protection.
The driving hypotheses for assessing the prototype
The prototype
The prototype
Five-item Likert scales with end anchors were used to assess child, parent, and provider opinions regarding usability, enjoyment, and engagement. Ratings from the Likert scale were recorded and transformed to a numerical scale of 1–5. Tests for significant difference in ratings were assessed by a two-sided Wilcoxon–Mann–Whitney test. SAS (SAS Institute, Cary, NC, USA) was used for statistical comparisons. GraphPad Prism (GraphPad Software, La Jolla, CA, USA) was used to generate the accompanying figures.
The children’s assessment also contained two visual ranking scales for ranking of likability of (1) the eight main game environments and characters and (2) the five exercise mini-games and games. Mean scores were determined for each scale.
Each study participant was also asked to complete a simple open-ended questionnaire entitled “The Three Things” to provide feedback regarding the three things they liked the best, the three things they liked the least, and the three things they would change about the video game. Answers that appeared at least two times were compiled and presented in a summary table.
The prototype
The prototype
There are five environmental settings in this imaginative space exploration story. The game begins at the “Space Station,” where the Space Explorer Hero avatar, customizable for gender, prepares for the journey by completing two different exercise mini-game challenges and one nutrition education exercise mini-game challenge. The Space Explorer Hero then boards the spaceship and begins “the Space Flight” that involves an exercise mini-game where the space ship must be maneuvered through rings of stars, where additional star reward are earned. The space ship then stops at “the Outer Planet Puzzle” where the Super Hero meets up with Keemo, the Super Buddy avatar with multiple mobility options, each of which is needed to overcome different game obstacles at various time points during gameplay (Figure
Together, the Space Explorer Hero avatar and the companion super buddy Keemo overcome many obstacles on their space mission to restore life to the barren planet and conquer the Cercer crabs before safely returning to the space station. The Space Explorer Hero is customizable for gender, and Keemo has multiple mobility options, all of which are used during gameplay to overcome different obstacles during the mission.
Game activity-associated empowerment themes are integrated throughout the game, and center on overcoming diverse obstacles metaphoric for pediatric cancer challenges (Figure
Physical, educational, and emotional empowerment themes are prominent throughout the prototype
Physical exercise movements are designed to increase upper extremity and trunk strength, flexibility, and mobility, while being fun, natural, and comfortable (Figures
The programmable iPadAir accelerometer and gyroscopic motion features facilitate incorporation of specific upper extremity and trunk exercise motions for
Educational empowering content addresses such questions like: “What is cancer?” “What is chemotherapy?” “What is radiation therapy?” “What are treatment side effects?” “How can I improve my nutrition during my cancer treatment?” and “How can I help myself get stronger and healthier?” This content was presented in two different formats in the prototype
Educational empowerment is facilitated by
Two light weight, high density ergonomically designed side handles and a rectangular shaped backing plate were printed at the University of Utah 3D printing facility. These were then securely affixed to a commercially available iPadAir case to promote motion/sensor accuracy in addition to providing iPad protection during physical exercise (Figure
The light weight, high density bi-handled casing support pieces were created using a 3D printer and then affixed to a commercially available iPad case. This adapted casing facilitates active exercise while simultaneously protecting the iPadAir.
The questions asked to the children pertained to their relationship to cancer-related effects and to their experience playing the game with respect to usability, engagement, and enjoyment (Figure
For pediatric subjects, three 5-point Likert scale assays, each consisting of five questions, were used to asses usability, engagement, and enjoyment of the prototype
Mean responses of 10 pediatric cancer children to questions related to usability, engagement, and enjoyment of the prototype
Results of the Picture Tool assay showed that the two favorite game components were collecting star rewards and terraforming the planet. Traveling in Space from the space station to the planet was the least favorite game component. The two most liked exercise mini-games were the Positron Planet Core Game and the Collecting Stars Exercise Game, while the least liked exercise mini-game was the Healthy Food Choice exercise game (Figures
Mean responses of the 9 of 10 pediatric subjects who were able to rank-order two distinct picture scales.
The prototype
Health-care providers and parents each completed a 10 question Likert scale, which contained five unique and five overlapping questions.
Five questions were asked to both health-care providers and parents of the children with cancer. Ratings were transformed to a scale of 1–5, and significant differences were assessed with a two-sided Wilcoxon–Mann–Whitney test. The “+” signs in the box-and-whiskers plots indicate the mean response of each group, box extends from the 25th to 75th percentiles, and a vertical line (when visible) drawn at the median response level.
Responses from children, parents, and health-care providers to this open-ended questionnaire yielded very useful information. In general, the prototype
Ten children, 10 parents, and 12 health-care providers completed “The 3 things…” simple sentence completion tool after playing or observing their child play
The 3 things I liked most | The 3 things I did not like | The 3 things I would change | |
---|---|---|---|
Children | The Star Rewards The exercises The characters The cancer facts The story It was fun It was something new |
Characters were too cartoony Exercises were too hard It was hard to know what to do sometimes Instructions were not good |
Add more detailed instruction Add more levels Add more cancer crabs Add more actions for the heroes Add more actions for the crabs Add more characters Add more music choices |
Parents | Physical exercise and game interactions Idea of teaching about cancer Mind stimulation and education The handles The exercises Helps kids see cancer can be destroyed |
Hard to understand at times Instructions not very clear Had to be able to read to play |
Improve the instructions Make attack on cancer more direct Emphasize the exercises more Make goals to be accomplished clearer More celebration |
Health-care providers | The idea of empowerment over cancer Incorporating the education elements How interactive the game is Portability You have to move to play The storyline and characters |
Hard to understand at times Some levels were long and repetitive Music was the same throughout Game objectives sometimes not clear Not enough levels Did not understand the terraforming tools |
Clarify and expand the instructions Add more education, including radiation and surgery Emphasize the exercises more Add more animation to crabs and superheroes Make the awards more distinctive Add more ethnicity choices to characters |
Video games provide a fun, appealing format that captivates a player’s mind and body, regardless of age. The concept of empowering children to fight their cancer using an activity-promoting video game that directly couples physical exercise with personal empowerment over cancer
This concept was first explored in The PE Game. The PE Game prototype was built on a PC communicating with Sony PS3 running Sony’s Move.me software and was designed to be played within a small hospital inpatient room. It consisted of a series of discrete metaphorical mini-games centered on overcoming cancer-related challenges, and integrated physical exercise with promoting teamwork, a fighting spirit, and a sense of personal empowerment in children with cancer (
The multilevel usability assessment of the prototype
Health-care providers were particularly keen on the idea of incorporating cancer education and empowerment and exercise in a portable disease-specific video game. Parents also liked the education, the exercises, and that the game actually helped show their children that cancer can be destroyed, with some wanting an even more direct and less metaphorical attack on cancer. The most striking significant difference between parents and health-care providers was in response to the question of whether the game would help children understand cancer better, with a mean rating difference of 1 level higher in providers. This may reflect the providers’ comprehension of cancer facts being provided in the game which was not as well taken in by the parents. In general, the overall lower rating of parents may also potentially reflect an understandably more pessimistic reflection on rating anything. Ideally, future surveys would include a few sample questions not related to cancer which could assess such a general difference in this group.
Playing commercially available video games can decrease chemotherapy-associated nausea in oncology patients when used as distraction therapy (
An estimated twenty percent of children are affected by some type of chronic disease. In contrast to the treatment of acute self-limited illness, children with chronic diseases have a more prominent role in directing their own care, with parental guidance, and in making ongoing changes in how they live their lives, particularly as they transition into adulthood (
Diverse pediatric chronic diseases share similar psychosocial targets for empowerment intervention, and potential exercise benefits that could be addressed with disease-specific exercise–empowerment interventions like the prototype
Chronic pediatric illness (reference) | Psychosocial targets for empowerment intervention | Benefits and safety of physical exercise |
---|---|---|
Obesity ( |
Exercise and diet non-compliance Social isolation Low self-esteem Limited self-management |
Improved HR-QOL Improved cardiopulmonary status Improved self-efficacy Decreased comorbid chronic diseases |
Asthma ( |
Medication non-adherence Limited disease understanding Limited self-management |
Improved quality of life (QOL) Improved therapy compliance Reduced disease symptoms Safety concern: asthma exacerbation |
Cystic fibrosis ( |
Therapy program non-adherence Limited disease understanding Limited self-management |
Improved pulmonary function and fitness Improved HR-QOL Improved therapy compliance Safety concern: shortness of breath |
Chronic renal disease ( |
Medication non-adherence Limited disease understanding Limited self-management Social isolation; low self esteem |
Improved therapy compliance Improved bone health Improved growth/development Improved HR-QOL |
Congenital heart disease ( |
Limited disease understanding Limited self-management Feelings of fear, uncertainty Medication non-adherence |
Improved cardiovascular status Improved muscle strength Improved HR-QOL Safety concern: heart strain with exercise |
Diabetes ( |
Medication non-adherence Limited disease understanding Limited self-management Self-esteem, depression |
Improved glycemic control Improved HR-QOL Improved weight control Safety concern: induced hypoglycemia |
Epilepsy ( |
Medication non-adherence Limited disease understanding Sense of hopelessness Depression, anxiety |
Improved HR-QOL Improved depression Improved self-esteem Safety concern: exercise induced seizure |
Juvenile idiopathic arthritis ( |
Fear of uncontrolled pain Social isolation Low self-esteem Therapy program non-adherence |
Increased range of motion Increased bone mineralization Improved HR-QOL Reduced joint inflammation and pain |
Obesity is a complex multifactorial chronic disease of increasing prevalence that also greatly increases risk for other chronic diseases, including depression, type 2 diabetes, obstructive sleep apnea and hypertension While hereditary factors, ethnicity and particular socioeconomic and sociocultural conditions exacerbate the risk and severity of obesity, some modifiable personal behaviors, like physical exercise expenditure, sedentary and screen time, and dietary intake, also play a significant role in disease severity (
Health-promoting interactive technologies show significant potential for effecting behavioral change and promoting disease self-management by education and active patient involvement directed at understanding health, disease, and treatment (
Video games are also finding their place in the management of specific mood disturbances. Adults with depression randomized to treatment with add-on video game therapy showed significantly fewer depressive symptoms at 1 month compared with the control group (
Several challenges to successful development and widespread dissemination of video games for positive health-care behavioral currently exist (
It is encouraging that the U.S. Food and Drug Administration recently cleared digital therapeutic technologies, including BlueStar® (WellDoc, Baltimore, MD, USA), a mobile platform promoting self-management in diabetes, the mobile medical app reSET™ (Pear Therapeutics, Boston, MA, USA) for the treatment of substance use disorder, and the Jintronix Rehabilitation System® (Montreal, QC, Canada). Significant improvement in attention was seen in children with attention deficit hyperactivity disorder (ADHD), after 4 weeks of playing EVO (Akili Interactive, Boston, MA, USA), an iPad-based intervention designed for children with ADHD (
One attractive development pathway for the prototype
Creating hope, improving QOL, reducing stress, and increasing one’s sense of control over the seemingly uncontrollable are all important components of patient empowerment over disease. The prototype
The Usability Assessment study was reviewed and approved by the University of Utah Institutional Review Board and classified as a Minimal Risk Study. Before study participation, signed assent forms from all participating subjects ages 7–14 years and signed parental permission forms from their respective parents, and signed consent forms were obtained for all adult study participants. There were no subject withdrawals.
CB and GB conceived of this project and defined the prototype
CB and GB are co-inventors on two issued US patents 9,569,562 and 9,747,423 “Disease Therapy Game Technology.” These patents are related to the exercise–empowerment video game technology and are owned by the University of Utah. The remaining coauthors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
CB and GB express appreciation for institutional funding from the Department of Pediatrics and the Tech Ventures at the University of Utah. We also thank the ALSAM Foundation for supporting IP summer research internship, and Hunter Robinette, Krzysztof Szewczuk, and Adam Kochanski for help in creating and assembling 3D-printed iPad case components. CM expresses appreciation for funding from the Intermountain Healthcare and Primary Children’s Hospital Foundations, the University of Utah Department of Pediatrics, and the Division of Hematology/Oncology. Finally, we express our appreciation to the children, their parents, and the Pediatric Oncology Team health-care providers at Primary Children’s Hospital and University of Utah Department of Pediatrics for their respective participation in the Usability Assessment. GB and CB would like to thank all friends and the children with cancer and their families who inspired this project.
QOL, quality of life; The PE Game, the Patient Empowerment Exercise Game; eHealth, electronic health; mHealth, mobile health; ADHD, attention deficit hyperactivity disorder.