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.