Teknik och samh¨alle
Datavetenskap och medieteknik
Examensarbete 15 h¨ogskolepo¨ang, grundniv˚a
An Evalutation of Walk the ward: A Serious Game For
Rehabilitiation
En utv¨ardering av Walk the ward
Nicolai Jaynes
Examen: kandidatexamen 180 hp Huvudomr˚ade: datavetenskap
Program: datavetenskap och applikation-sutveckling
Datum f¨or slutseminarium: 2018-05-30
Handledare: Nancy Russo
Sammanfattning
Stora delar av v¨arlden har idag problem med en sjukv˚ard som inte l¨angre ¨ar h˚allbar resursm¨assigt. En v¨axande ¨aldre befolkning som har ned˚atg˚aende h¨alsa visar sig vara anstr¨angande f¨or sjukhus, b˚ade ekonomiskt och f¨or arbetarsb¨ordan f¨or de anst¨allda. F¨or att bek¨ampa dessa problem s˚a anv¨ands ”Serious games” f¨or att hj¨alpa patienter med rehabilitering. Serious games ¨ar en term som anv¨ands f¨or att beskriva spel vars huvudsyfte ¨
ar att hj¨alpa och utbilda m¨anniskor.
Denna studie ¨ar en utv¨ardering av ett serious game som heter ”Walk the Ward” och f¨ors¨oker skapa en f¨orst˚aelse f¨or vad som kan g¨ora detta, och andra serious games attraktiva f¨or en stor publik.
Studien presenterar ett antal aspekter som beh¨ovs f¨or att g¨ora ett serious game lockande. En unders¨okning utf¨ordes f¨or att f¨orst˚a vad m¨anniskor i olika ˚aldersgrupper hade f¨or upp-fattning av spelet. Resultaten av unders¨okningen analyserades f¨or att f¨orst˚a vad som kan f¨orb¨attras med spelet. Denna analys kan anv¨andas som underlag n¨ar man f¨ors¨oker skapa och utveckla nya serious games, som ska rikta sig till en stor publik.
Abstract
There is a global consensus that health care systems in large parts of the world are no longer sustainable and in need of change. A growing elderly population with declining health puts a strain on hospitals, both economically and workload wise for the staff. To combat this problem, ”Serious games” are used to make rehabilitation more effective and less costly. Serious games is a term used to describe any kind of game which aims to help and educate people as their primary goal.
This study is an evaluation of a serious game called ”Walk the Ward” and aims to create an understanding of what can make this game and other serious games appealing to a large audience.
This study presents a number of aspects that are needed to make a serious game appealing. A survey study was conducted to work out what opinion people of different age groups had about the game. These results were analyzed to gain an understanding of what improvements could be made to the game. The result can also be used a basis for making new serious games appealing to a large audience.
Contents
1 Introduction 1
1.1 Background . . . 1
1.2 Health promotion of Walk the Ward . . . 2
1.3 Purpose . . . 2
1.4 Research questions . . . 3
2 Previous Research 3 2.1 Video games and health . . . 3
2.2 Serious Games . . . 3
2.3 Serious Games for the elderly . . . 4
2.4 How to make serious games engaging . . . 4
2.4.1 Reward . . . 4
2.4.2 Difficulty/Challenge . . . 5
2.4.3 Feedback . . . 5
2.4.4 Choice/Interactivity . . . 5
2.4.5 Socialization . . . 5
2.4.6 Clear Goals and Mechanics . . . 5
3 Method 5 3.1 Method description . . . 6 3.2 Method discussion . . . 6 3.2.1 Chosen method . . . 6 3.2.2 Alternate method . . . 7 4 Result 7 4.1 Questionnaire statistics . . . 8
4.1.1 How much of a habit do you have of playing games on a mobile or tablet? . . . 8
4.1.2 How fun did you find the game to be? . . . 9
4.1.3 Were the instructions easy to understand? . . . 9
4.1.4 How interesting did you find the questions to be? . . . 10
4.1.5 How probable is it that you would play the game again? . . . 11
4.1.6 How would you grade the game on a scale of 1-5? . . . 11
4.2 User comments . . . 12
4.3 Observation . . . 13
5 Analysis 13 5.1 Current engaging aspects of the game . . . 13
5.2 Divisive opinions . . . 13
5.3 Divisive opinions between age groups . . . 14
5.4 Improvements . . . 14
6 Discussion 15 6.1 The potential of serious games . . . 15
7 Conclusions and further research 16
References 18
1
Introduction
1.1 Background
There is a global consensus that health care systems in large parts of the world are no longer sustainable and in need of change [1]. According to studies, the elderly population is dramatically increasing in developed as well as undeveloped countries [2]. As a con-sequence of aging, the body suffers a series of changes which can lead to declining health and the need for rehabilitation at a hospital [2]. Naturally, this puts a strain on hospitals, both economically and workload wise for the staff.
A possible aid to this problem could be cost effective technological innovation. Some-thing which is useful in improving patient health and which doesn’t put a burden on the resources of hospitals, or the workload of the staff. A technology which could be useful for this purpose could be a game which promotes both exercise and intellection. This would strengthen both the patients physical and cognitive well being. A possible result of this could be lessened stays at hospitals for patients who use this kind of technology and therefore a release of hospital resources.
One such technology is a game entitled Walk the Ward. The first version was developed at Malm¨o University in 2015 and a new web-based version was developed in 2017. It is a tablet based, quiz-type game. The idea behind the game is that the player (a patient at a hospital) gets to answer different questions at stations located throughout the hospital ward where the patient is staying. At each station a QR-code can be found on a poster. A QR-code consists of black squares arranged in a square grid on a white background, which can be read by an imaging device such as a camera. This QR-code is to be scanned to retrieve a set of questions on the device. They player may chose a question from four different categories. The player receives points upon answering correctly. Besides the previous mentioned functionality, the amount of steps the patient takes while playing the game are recorded. The patient may play the game as much as he or she likes during their hospital stay, and when they are discharged the tablet can be reset so another patient can play the game.
The ambition behind the creation of the game is for it to be as engaging and as fun as possible for a patient. If people find the game appealing, it will be an excellent resource to promote daily health and exercise during a hospital stay. The promotion of health will not only consist in the patients stroll around the ward to find the QR-codes, but also in a set of physical exercises present in the game (as an alternative to answering questions) that the patient is encouraged to perform, with the assistance of a video which demonstrates the exercise.
A patient sitting idle and isolated in their room waiting for treatment, may also expe-rience social isolation and boredom. Walk the Ward has the potential to make patients more social when they are up and about, seeing other people and possibly even playing together with another patient, which may brighten their mood and general outlook. This has the potential to create a sort of fellowship between patients. The game also has the capacity to make a hospital stay less boring for a patient.
When a rehabilitation game is fun and introduces challenges that make repetitive tasks more engaging, a patients well-being is strengthened both physically and mentally [3]. This is precisely the style of game that Walk the ward aims at being.
1.2 Health promotion of Walk the Ward
Walk the Ward has the potential to promote health and rehabilitation in a big way. The physical movement aspect of the game Walk the Ward is, as the title alludes to, the major purpose the game. Additionally, there are a set of movement exercises in the game that can be done at each QR-code station. These exercises can be performed instead of answering a question.
According to Pate et al. it is recommended that each adult gets atleast 30 minutes of moderate-intensity physical activity on most, preferably all, days of the week [4]. Included in the definition of moderate-intensity physical activity, is walking briskly, atleast 3-4 miles per hour.
Research by Lee and Buchner supports walking as largely beneficial for public health. They mention that physical activity such as walking plays a substantial role in the man-agement of a large number of diseases and conditions such as: coronary heart disease, obesity, elevated cholesterol, type 2 diabetes, osteoarthritis, back pain, stroke. It is also mentioned that mental diseases such as anxiety disorders and depression can be managed through physical activity such as walking [5]. This means that playing Walk the Ward can be effective for managing a wide variety of diseases that a patient might be hospitalized for, if they play the game long enough each day and at a certain tempo. Lee and Buch-ner also mention geBuch-neral calisthenics as a viable exercise option, which suggests that the movement exercises in the game would also help manage symptoms of above mentioned diseases.
1.3 Purpose
The study intends to evaluate the game: Walk the Ward. The ambition is to determine whether the game is engaging for younger, as well as older age groups, or not. The reason for this is that the game will be more effective in helping additional patients if it is appealing to younger as well as older age groups. The findings in the study can later on be used as a guideline when making improvements of the game.
This document will also provide an inkling of how to make Walk the ward as enticing as possible to people. It will also indicate how to best design this genre of game as a whole.
An assessment of the first version of Walk the ward was done at the end of 2015 through early 2016 [6]. This assessment was however only done on eight patients above the age of 70 and was conducted by hospital staff. A short interview was conducted after the patients were discharged from the ward.
This paper aims to give a more complete assessment of the game than the above men-tioned one. The first version of the game was mostly geared toward older patients, while the current version aims to appeal to any person who might find themselves hospitalized. Therefore it is imperative to know about which opinions people from a wide variety of age groups have about the game. The game will also be tested on a larger amount of people than in the first assessment, and make use of a questionnaire to obtain quantifiable results considering peoples opinions about the game.
1.4 Research questions
This study aims at answering the following questions:
• What aspects of the game Walk the Ward are engaging for younger as well as older age groups?
• What, if anything, can be changed to improve the game and make it more attractive to play?
2
Previous Research
2.1 Video games and health
Griffiths [7] presents a number of different ways that video games can be beneficial and help rehabilitate patients suffering from both physical ailments or mental illness. Video games can assist patients in performing exercises that are normally seen as tedious and can aid in distraction of pain. In Griffiths’ study, it is also affirmed that video games can improve self-esteem, memory and mood.
Kato [8] reports that video games can be extremely beneficial in a health care setting and reports a significant amount of different uses. She mentions that one of the largest advantages of using a game for health care is the way in which it can make a mundane or repetitive task engaging and enjoyable.
When a patient in a long-term rehabilitation process has performed the same exercises hundreds of times they tend to become bored. It may then follow that the patients concentration on the therapy program dwindles. Thus the therapy loses its effectiveness, since rehabilitation results are better when patients are motivated [9].
2.2 Serious Games
The emergence of games that aim to help and educate people as their primary goal, has become so widespread that a separate term to describe this category of games has been coined: Serious games. The idea of serious games is to combine the fun and motivat-ing challenges of video games, with serious purposes like education, exercismotivat-ing, health, prevention and rehabilitation [10].
Bartolom´e et al. [11] identify three distinct groups of serious games for health, which are:
• Serious games for rehabilitation
• Serious games for educating/training professionals • Serious games for health prevention and education
This paper will focus on the group of serious games for rehabilitation, since this is the purpose of Walk the Ward. These games aim to help people during the rehabilitation process and make the exercises more easy and fun than with the traditional method.
2.3 Serious Games for the elderly
Although serious games can be used for a number of purposes and for a wide range of age groups, it is important to note that a big part of the future serious game market will be aimed towards the elderly. According to Marin, Navarro and Lawrence [2], this is due to the simple fact that studies show that the elderly population is growing in developed, as well as undeveloped countries around the world .
As the human body ages it can suffer a decline in mental and motor abilities. Diseases such as postural instability, balance disorders, and stroke are considered the main cause of disability among elders [12]. The decline of motor abilities has also been identified as a big problem among the elderly, due to it leading to potentially fatal falls [12]. Therefore even general purpose rehabilitation games must take the elderly into account in the design of the game, for the simple reason that a large amount of patients in need of rehabilitation will be the elderly.
Gerling et al. [13] presents several common impairments which can hinder an elderly person from being able to play a game, which should be taken into account when designing a serious game. An example is that visual and auditory impairments can make game play difficult. A solution to this can be large and well-defined symbols in combination with clear auditory feedback. Another example is a decline in cognitive ability. Instant feedback and very clear instructions are a solution to reduce the cognitive load [13].
2.4 How to make serious games engaging
Some researchers point out that serious games for health differ quite a bit from commercial video games regarding plot, activities and the reward you get from the game play [14] [15]. It is therefore imperative that programmers ensure that some sort of entertainment can be derived from the games. Serious games will be minimally beneficial if people are as bored by the games as they are by the traditional forms of therapy that do not include a video game.
Annema et al. [16] investigated the therapeutic use of video games for both mentally and physically impaired children. A central problem in the games appeared to be the amount of time spent on performing other actions than actually playing the game, such as configuring the game controls for each individual player and explaining how to play. Thus the amount of time actually spent on therapy was reduced. It is therefore recommended that a game used for therapeutic purposes should be as self explanatory as possible and easy to set up.
McCallum claims that the primary distinction between an ”activity for health” and a ”game for health” is related to the motivation and engagement of the participant. If a game is not engaging and enjoyable, it’s just an activity and hardly a game at all [17].
Lohse et al. [18] have written an extensive article about how to enhance engagement in physical therapy by using serious games. They present 6 factors that increase motivation via game-play. These factors will each be briefly explained in this section.
2.4.1 Reward
Getting some sort of reward from your game play will release the neurochemical dopamine and elicit feelings of pleasure and enjoyment. This will motivate a player to play the game
again. An example of a reward is points gained when you complete a task in a game. 2.4.2 Difficulty/Challenge
A player desires lower difficulty at the beginning of a game. As they get used to the game they crave more and more challenges. A good game tries to keep the difficulty level on par with the players current ability. If a game is too easy the player will be bored. If a game is too hard the player will be frustrated.
2.4.3 Feedback
Feedback is any information given to a user of a game about how a skill was performed and/or the effectiveness with which the skill was performed. Giving a player feedback about what to do following an error reduces cognitive load. Feedback can also serve as a motivator if it affirms that the player has done something right.
2.4.4 Choice/Interactivity
Giving the player a choice to chose their own path in a game gives him or her a feeling of ownership of the game. Another outcome is that it increases the desire for the player to play the game again, since there are multiple unexplored ways of beating the game, even though the player may have finished it once.
2.4.5 Socialization
Being a member of a social online community increases time spent playing a game. In rehabilitation games proximal socialization is a more viable scenario. Competing or coop-erating with another player is beneficial for motivation and engagement. Another person can furthermore be a valuable resource of encouragement and feedback.
2.4.6 Clear Goals and Mechanics
Clear goals gives players reassurance and something to strive towards while playing a game. Poor or unclear instructions have a negative effect and can leave the player confused and frustrated, which ultimately leads to low motivation.
3
Method
The following section explains the method that has been chosen to perform the study. The first purpose of the study is to understand which aspects of the game are engaging for younger as well as older age groups. The best way to come to an understanding about this is to conduct a survey study. In that way one would gather enough data to come to a conclusion about the quality of the game.
The second research question explores whether or not anything needs to be improved about the game. The attitudes concerning the game are best gathered by systematically collecting data from subjects who can express their view on the game after trying it.
3.1 Method description
To conduct a survey study means to gather data from a large group of people or events and look for patterns in said data [19]. The goal of this is to be able to generalize the results to a larger group than the test group. This is normally managed through a quantitative approach, meaning that the result can be measured numerically. Normally it is assumed that the data will be gathered through a questionnaire. However, the data can be gathered in a number of different ways when using a the survey method, such as polls, interviews, observation and analyzing documents [19].
In this study, a questionnaire with predefined questions has been used to gather data concerning peoples attitudes towards the game.
Observation has also been used to a certain degree. The observation took place while the test subjects played the game and the questionnaire was filled out after the game had been played. The observation focused mostly on facial expressions and verbal reactions to different parts of the game.
3.2 Method discussion 3.2.1 Chosen method
The amount of participants needed in a usability test to reliably identify usability issues has been widely debated. Studies show that the percentage of identified issues tends to hit 100 at around 10 user tests [20]. In this study there was, however, different age groups that needed to be covered in the tests and compared to each other. Therefore, a number of approximately 25-30 people was deemed necessary to identify all possible issues with usability.
No discrimination of age was made when choosing subjects to try the game. This was because a person of any age may play the game in a hospital setting. However, a span of at least 50 years between the youngest and oldest person testing the game was regarded as necessary to cover a wide range of age groups.
When a test subject was done playing the game, he or she answered a series of questions on a questionnaire. Most of the answers were on a scale of 1 to 7, so as to make the results quantifiable. An example of a question that was asked is: ”How easy were the instructions to understand?”, where 1 is very hard and 7 is very easy. The complete set of questions used can be found in Appendix A. The questions were designed to match the aspects of how to make a game engaging, which is covered in section 2.4.
After the testing of the game was completed, the data was analyzed to find a pattern in the attitudes toward the game. These patterns indicate what future modifications and improvements should be made to the game.
Most of the tests were done in the home of the testers, since access to a hospital ward was not available. It should be acknowledged that the lack of a proper testing environment is a limiting aspect. The ideal would have been to test the game in its intended environment. However, it is hard to argue that a sick person and a healthy person would differ a lot in their enjoyment of a game. Therefore, the testimonials of the people who tried the game, should weigh just as heavy as if it were tested by people in a hospital ward.
Also, a majority of the testers did not have any physical impairments. This does of
course count as an additional limitation to the study, because the game won’t be tested exactly as it is intended to be used. However, this study aims to investigate the general appeal of the game, and not to give conclusive proof of whether or not the game will help combat illnesses (although some research regarding this can be found in section 1.2).
To resemble how the real game would be played, the QR-codes were placed at a distance from each other large enough to force the player to walk in between them. Immediately following the test, a questionnaire was filled in by the player.
3.2.2 Alternate method
A considered alternative to the chosen method was conducting interviews to discover what opinions people had about the quality of the game. The interviews would be semi-structured with a set of predefined questions that covered the most important information that needed to be gathered. The users would however be able to freely talk about other aspects of the game to if they wished. The reasoning for choosing a questionnaire instead of this approach, was because a questionnaire gives a more quantitative result, which makes it easier to identify problem areas of the game. Interview answers can be ambiguous depending on how specific the users answer is.
Instead, to give the test subject a chance to comment freely about the game, a section was added to the questionnaire where the user could write down their thoughts about what could be improved about the game. In that way the most important questions would be able to be quantified, as well as giving the user an opportunity to address other issues that were not included in the predefined questions.
4
Result
In this section the data gathered through the user tests will be presented.
The results will first be presented as a whole, meaning a bar chart showing all of the users results. Then, the answers will be split into age groups of:
• Below 15 • 15 - 30 • 30 - 50 • 50 and above
This distinction will be made so that an analysis can be made regarding different age groups and their opinions. The age spans were chosen to try to represent the age groups: very young, young, middle aged and old.
The amount of people from the tests in each of the above mentioned age groups are as follows:
• Below 15 = 4 • 15 - 30 = 12
• 30 - 50 = 5 • 50 and above = 4
4.1 Questionnaire statistics
The questionnaire (which can be found in its complete form in Appendix A) consisted of six multiple choice questions on a scale of 1 - 7. The scale was used to be able to simply quantify the results. A value of 1 meant that the user was as dissatisfied as possible with the aspect of the game that the particular question referred to. A value of 7 meant that the user was very satisfied. And a value of 4 signified ”average”. When analyzing the results it was then simple to identify which aspects of the game users found positive and which ones they found negative. If a majority of the test subjects answered below 4 on a question, it would be a safe bet that this part of the game needs some further work. If a majority answered above 4, it is probable that this aspect of the game is strong. The results of each question will be presented in bar charts below. The Y-axis shows the amount of people who answered the different numeric values on the X-axis.
4.1.1 How much of a habit do you have of playing games on a mobile or tablet?
The first question alludes to how big the participants habit is of playing games on a mobile or a tablet. The value 1 represents very little experience, while the value 7 represents a very large experience. As can be seen in the above graph, the results varied quite a bit. This means that the assessments of the game can be useful for both the experienced and the inexperienced tablet and mobile gamers, because users all across the experience range have tested the game. It should however be emphasized that the majority (64%) of the testers had an above average habit. Having a certain habit of playing mobile and tablet games can indicate that these players have a more critical eye, due to the high standard of games they are used to.
4.1.2 How fun did you find the game to be?
This question asked the user how fun their overall experience of the game was, which gave an indication of how engaging the current iteration of the game was. The value of 1 was defined as ”Not at all fun” and the value 7 was defined as ”Very fun”.
48% of the test subjects found the game to be below average in entertainment value, while 32% found it above average.
The most commonly picked value was a 2, which 38% of the users picked. This value indicates that these users found the game to have an almost non existent amusement level. 4.1.3 Were the instructions easy to understand?
Here, a value of 1 indicates ”Very hard” and a value of 7 indicates ”Very easy”. The results of this question indicated that the current amount of instructions in the game were enough for the user to understand what to do, and how to play the game. A
whole 84% of users thought the instructions were very easy or on the brink of very easy to understand. Only 8% found the instructions to be below the value of 4, which indicates ”Pretty easy”.
This question can be directly tied together with the ”Clear Goals and Mechanics” aspect of making a game engaging, mentioned in section 2.3.6, where it is recognized that unclear instructions can lead to confusion, frustration and ultimately low motivation [18].
4.1.4 How interesting did you find the questions to be?
The question of how interesting the questions of the game were to the test participants was the most divisive.
40% of the test participants found the questions to be below average in interest level, while 36% found them to be above average.
The most commonly chosen value was a 4, with 24% participant choice, which indicated an average interest level.
This question was asked to the participants because the questions are the very core of the game. If players don’t find the questions interesting enough, they will not be excited to play the game.
4.1.5 How probable is it that you would play the game again?
Over half (52%) of the test subjects answered that there was a below average proba-bility that they would play the game more than one time.
40% of the test subjects expressed that there was an above average probability that they would play the game more than one time.
A whole 28% answered with a value of 1, meaning that it’s not at all probable that they would play the game more than once.
This question was included because creating the desire to play the game more than once is crucial if any health benefits are to be obtained from the game. Research on the amount of walking exercise needed for noticeable health benefits are presented in section 1.2.
4.1.6 How would you grade the game on a scale of 1-5?
Finally the users were asked to give a final grade to the game on a scale of 1-5. This question was asked to get an idea of how good the quality the users found this iteration of the game to be overall.
The most common answer was a 3, meaning an average game, with 36%.
32% of users found the game to be below average quality, while an equal amount found the game to be above average in quality.
4.2 User comments
A section of the questionnaire was dedicated to letting the user comment in free text, about what, if anything, could be made better about the game. Some of the most common feedback regarding the game will be presented in this section.
More than 80% of the users testing the game commented on inadequate feedback to the user. Many of the users felt that there was missing a clear flow in the game, and got stuck in certain situations because of the game not giving clear instructions on how to proceed. This might sound as a contradiction to the question in the questionnaire about if the instructions were easy to understand, which most users answered with a 6 or a 7. However, that question was about the instructions on how to play the game and what the object of the game was, which were presented in the beginning of the game.
Users also reported that the flow of the game could be made better if there were less situations in which there were a multiple choice selection. An example of this was the many choices of categories after scanning a QR-code. A better alternative would have been to give the user a random question directly after the scanning of the QR-code, many users felt.
Another prevalent comment regarding feedback to the user was in relation to the game including sounds as an indication of what your action has resulted in. A couple examples of this could be a positive ringing noise when a question was answered correctly or a more negative sounding buzzer when a question was answered incorrectly.
These comments can be directly tied together with the previous mentioned article by Lohse et al. [18] about what makes a game engaging. The users felt that the cognitive load was too large when the instructions about how to proceed were unclear and they had to figure out by themselves what to do to continue the game. Furthermore, the lack of positive and motivating feedback upon answering a question correctly made the game seem dull and unrewarding to some players.
A few users also mentioned the idea of having a high score system to make the game more competitive. A result of having a high score system, they believed, would be a willingness to play the game several times, in order to get the highest score. This criticism can also be directly tied to the aforementioned article by Lohse et al. [18]. A high score system would satisfy both the reward aspect (since the feeling of being the best at something triggers dopamine release in the brain) and the aspect of having a clear goal to strive for (which is becoming the player with the highest score at the hospital).
A few of the test subjects also made remarks about the user interface being bad-looking. These users speculated that the game would be more alluring at first glance if some of the elements, such as fonts, color schemes and buttons, were more aesthetically pleasing.
4.3 Observation
The observations that were made during the testing of the game resulted in a few common reactions among a majority of testers.
The first was that almost all test subjects reacted enthusiastically when the concept of the game was explained, before they actually had played the game. This suggests that the idea behind the game does sound appealing to most people.
The second was that most of the test subjects commented verbally on almost every part of the game with a positive tone of voice, even if the comment was about that they found something about the game that needed to be improved.
The third and final most common reaction to the game was a loss of interest when the questions that suggested the player to perform a physical exercise came up. This is probably part of the limitation that the game was not tested on people that were in actual rehabilitation, which made them uninterested in performing an activity which would not help them much.
5
Analysis
The following section will present an analysis of the collected data and carve out the current engaging aspects of the game, and what improvements can be made to the game. The test subjects varied widely in experience range as far as playing games on a mobile or tablet. This means that the feedback from these users can be valuable for both experienced and inexperienced mobile and tablet gamers.
5.1 Current engaging aspects of the game
The only question of the questionnaire that had an overwhelming positive response was ”Were the instructions easy to understand?”. This means that the game was successful in explaining what it was about and how to play. Players will therefore not be confused about how to proceed from the get go, which, as referred to in section 2.3.6, can leave a player confused and frustrated. The clear instructions will make it easier to get people to get started playing the game for the first time, since there will be no confusion about what to do. There was however a certain confusion among users at different points in the game. The most prominent was concerning a lack of instructions about how to proceed after answering a question, which many users mentioned in their comments.
Most users did also express that they liked the idea of the game and that they believed that it would be successful with some modifications.
5.2 Divisive opinions
The most divisive question of the survey was ”How interesting did you find the questions to be?”. This implies that the questions which people find interesting are very much a personal preference. It is hard to satisfy all people, because what interests people varies very widely. A solution to this could be to expand the amount of subjects and questions, but ultimately it must be accepted that not everyone will find the questions exciting enough for them. However, more than half (60%) of the participants did find the questions to be averagely interesting or above (that is to say, gave the game a rating of at least 4 out
of 7 on this question). With an expansion of subjects and questions, this number might increase, which would make the game appealing to a larger audience.
5.3 Divisive opinions between age groups
As can be seen in the bar charts, there seems to be a quite clear difference in opinions of the game between the different age groups. The very young age group (under 15 years old) and the old age group (over 50 years old) gave a better average rating to the game on almost all questions than the other two age groups. The middle aged age group (30 - 50 years old) seemed to be a bit more divided on most questions, while the young age group (15 - 30) had the most negative stance towards the game on most questions. This is a signal that the current iteration of the game does not appeal equally to people of different ages.
5.4 Improvements
The first aspect of the game that is in need of improvement is the replayability aspect. As presented in section 4.1.5, over half (52%) of the test subjects answered that there was a below average probability that they would play the game more than once. And almost 1/3 (28%) answered that it was not probable at all that they would play the game more than once. With these results in hand, we can clearly see that modifications should be made to make the game exciting enough to play more than once. There should also be enough content so that it is not exhausted after playing only once. To make the game more exciting, enhancements could be made to satisfy the in section 2.3 mentioned factors that make a game engaging. The game could offer more rewards to elicit feelings of pleasure and enjoyment. As some users mentioned in their comments, a high score system could be implemented to give the game a competitive feature. Competing with others to get the highest score could motivate players to replay the game to collect more points.
Another feature which could be implemented to increase replayability is difficulty levels. As mentioned in section 2.3.2, a player desires a difficulty level that is lower in the beginning of the game, which gradually gets harder. With difficulty levels there would be a desire to replay the game to beat the current difficulty level of the game and uncovering a bigger challenge at the next difficulty level. ”Leveling up” also gives a rewarding feeling. A majority of the testers (17/25) answered with an average rating of 4 or below when answering the question ”How fun did you find the game to be?”. This is another major sticking point that needs to be corrected if the game is to become popularized. As previ-ously mentioned, the game just becomes another boring rehabilitation activity if it isn’t enjoyable, so a certain degree of this is of the utmost importance if the game is to fulfill its purpose effectively. Once again, the in section 2.3 mentioned aspects that make a game more engaging and fun should be considered when making this aspect of the game stronger.
Below follows a list of possible features that could be added to the game for the purpose of making it more fun based on user comments and reactions to the game:
• Create a more guided flow in the game to lift cognitive load from player.
• Introduce sounds and animation to indicate if the player has done something cor-rectly or wrong in the game.
• Give motivating feedback.
• Implement a high score system to make the game competitive. • Add a larger variety of questions and subjects.
• Polish the graphical user interface to make the game more alluring and professional looking.
6
Discussion
6.1 The potential of serious games
In this study previous research has been presented which shows that serious games have great potential to help sick people, both mentally and physically. They also have the potential to aid hospitals economically and their staff when it comes to their workload. Of course, creating sustainable health care is a complex problem which demands a lot of resources and can’t be solved by the use of serious games alone. However, serious games could be one of many contributions which pushes the development of sustainable health care in the right direction.
Some examples of how serious games can aid in health care are:
• Giving bored patients something exciting to do instead of bothering overworked staff • Make a patient healthy enough to get home faster
• Combating social isolation when patients have to stay in single rooms • Stimulating and increasing a patients mental well being
6.2 Challenges when creating serious games
The big challenge ahead has been shown to be how to make these kinds of games appealing for people in need of treatment, so that they are widely used and actually contribute to the health care system.
The major hurdle when creating these types of games is how to make the game enjoy-able to play, while at the same time fulfilling the purpose of rehabilitating a patient. The serious game Walk the Ward, which this study has focused on, has a clear idea of how to combine the two by encouraging the player to get up and walk around, at the same time as they are playing an intriguing game.
The findings of the study indicates that although an idea is solid and exciting for most in theory, many finer details need to be attended to if a game like this is to be engaging for a majority of people in practice. People of different ages find different things intriguing which means that it is very difficult to create a game which captures everyones attention. This could perhaps mean that completely different games need to be created for different age groups, based on what they find exciting about a game. In the case of Walk the Ward it could reasonably mean that the player enters their age before playing and the type of questions and overall feel of the game is modified thereafter.
A probable reason for the variance of opinion about the game between the very young and old age groups compared to the young and middle aged age groups is the amount of time spent playing normal video games. Since the young and middle aged age groups most likely have a larger amount of experience with normal video games, Walk the ward might pale in comparison. Very young and old people however usually haven’t been spending as much time playing video games in their lifetime, which might give them a lower threshold for feeling entertained by a game.
What has been made clear in this study is that people demand something which captures their attention and does not leave them bored too fast. Something that motivates them and leaves them with a better feeling about themselves than before playing. To create this type of game one needs to take many aspects into consideration. There needs to be lots of content so a game feels fresh and new each time you play. There needs to be sounds and sights which captures peoples attention. There needs to be a sense of accomplishment when doing something correctly, some kind of reward for doing a good job.
This study does presents a number of solutions to the problems one might face when designing and creating a serious game. These solutions come directly from people of a wide variety of ages who have tried a serious game and got to comment about it themselves. These solutions can be used and built upon when creating and improving serious games.
7
Conclusions and further research
The first research question of this study asked what aspects of the game Walk the Ward were engaging for younger as well as older age groups. The result of the questionnaire shows that the only aspect of the game which all age groups found positive was the simple and clear instructions.
The result of the other questions showed that people under 15 years of age and over 50 years of age found the game engaging. This means that future iterations of the game should take into consideration what people in the age span between 15-50 find engaging about a game, if one wants to appeal to a larger audience with this game.
To discover what people in the age span between 15-50 find exciting about a game, a more detailed study could be made on this group in future research. Perhaps another test run could be made, followed by a semi-structured interview to determine in more detail what this age span feels that the game is lacking. It should be mentioned that this age group might find the game better if some of the changes suggested in this study were to be implemented in the next version of the game.
The second research question asked about what, if anything, could be changed to improve the game and make it more attractive to play. The result of the questionnaire showed that quite a few aspects of the game is in need of improvement.
Many players found the game to be below average in entertainment value. A majority of these negative scores were given by people in the age span of 15-30 years old. Suggestions about how to make the game more entertaining presented in the analysis section, as well as a more focused study on what this age group finds entertaining, can be used to improve this part of the game.
A lot of people also found the questions to be uninteresting. As mentioned previously in this study, it is tough to satisfy everyone when it comes to this aspect of the game, since
people differ widely in what they find interesting. The only way to improve this aspect of the game is to try to add as wide a variety of questions as possible to the game.
Another aspect in need of improvement is the replayability aspect of the game. Once again, the negative result on this question was largely due to the scores from people in the age span of 15-30 years old. Just as with improving the entertainment value of the game, suggestions from the analysis section and a study focusing on this age group, could be used to improve this part of the game.
In conclusion, an improved version of the game with the aid of the suggestions in this study should be created. In addition, a new study that especially takes into consideration what people in the age span of 15-30 as well as 30-50 years old find engaging about games, should be conducted. If these two steps are taken, the game will get closer to appealing to a large age span of people and could be a great resource for hospitals that decide to use it.
References
[1] C. Fern´andez-Llatas, A. Martinez-Romero, A. M. Bianchi, J. Henriques, P. Carvalho, and V. Traver. Challenges in personalized systems for personal health care. In 2016 IEEE-EMBS International Conference on Biomedical and Health Informatics (BHI), pages 356–359, Feb 2016.
[2] Jaime A. Garcia Marin, Karla Felix Navarro, and Elaine Lawrence. Serious games to improve the physical health of the elderly: a categorization scheme. In in: CEN-TRIC 2011 The Fourth International Conference on Advances in Human-Oriented and Personalized Mechanisms, Technologies, and Services, pages 64–71.
[3] N. A. Borghese, R. Mainetti, M. Pirovano, and P. L. Lanzi. An intelligent game engine for the at-home rehabilitation of stroke patients. In 2013 IEEE 2nd International Conference on Serious Games and Applications for Health (SeGAH), pages 1–8, May 2013.
[4] Pate RR, Pratt M, Blair SN, and et al. Physical activity and public health: A recommendation from the centers for disease control and prevention and the american college of sports medicine. JAMA, 273(5):402–407, 1995.
[5] I-Min Lee and David M Buchner. The importance of walking to public health. Medicine and science in sports and exercise, 40(7 Suppl):S512—8, July 2008.
[6] Russo N, Eriksson J, Mugelli SH, and Marin J. Small steps: Improving healthcare with local innovation. 2016.
[7] MD Griffiths. The therapeutic value of videogames. In J Goldstein and J Raessens, editors, Handbook of computer game studies, pages 161–171. MIT, Boston, 2005. [8] Pamela M. Kato. Video games in health care: Closing the gap. Review of General
Psychology, pages 113–121, 2010.
[9] A. Jaume i Cap´o and A. Samˇcovi´c. Vision-based interaction as an input of seri-ous game for motor rehabilitation. In 2014 22nd Telecommunications Forum Telfor (TELFOR), pages 854–857, Nov 2014.
[10] Josef Wiemeyer and Annika Kliem. Serious games in prevention and rehabilitation— a new panacea for elderly people? European Review of Aging and Physical Activity, 9(1):41–50, Apr 2012.
[11] N. A. Bartolom´e, A. M. Zorrilla, and B. G. Zapirain. Can game-based therapies be trusted? is game-based education effective? a systematic review of the serious games for health and education. In 2011 16th International Conference on Computer Games (CGAMES), pages 275–282, July 2011.
[12] S. T. Smith, A. Talaei-Khoei, M. Ray, and P. Ray. Electronic games for aged care and rehabilitation. In 2009 11th International Conference on e-Health Networking, Applications and Services (Healthcom), pages 42–47, Dec 2009.
[13] Kathrin Maria Gerling, Frank Paul Schulte, Jan Smeddinck, and Maic Masuch. Game design for older adults: Effects of age-related changes on structural elements of digital games. In Marc Herrlich, Rainer Malaka, and Maic Masuch, editors, Entertainment Computing - ICEC 2012, pages 235–242, Berlin, Heidelberg, 2012. Springer Berlin Heidelberg.
[14] V. Janarthanan. Serious video games: Games for education and health. In 2012 Ninth International Conference on Information Technology - New Generations, pages 875– 878, April 2012.
[15] G. P. Tolentino, C. Battaglini, A. C. V. Pereira, R. J. d. Oliveria, and M. G. M. d. Paula. Usability of serious games for health. In 2011 Third International Conference on Games and Virtual Worlds for Serious Applications, pages 172–175, May 2011. [16] Jan-Henk Annema, Mathijs Verstraete, Vero Vanden Abeele, Stef Desmet, and David
Geerts. Videogames in therapy: A therapist’s perspective. In Proceedings of the 3rd International Conference on Fun and Games, Fun and Games ’10, pages 94–98, New York, NY, USA, 2010. ACM.
[17] Simon McCallum. Gamification and serious games for personalized health. Studies in health technology and informatics, 177:85—96, 2012.
[18] Keith Lohse, Navid Shirzad, Alida Verster, Nicola Hodges, and H F Machiel Van der Loos. Video games and rehabilitation: using design principles to enhance engagement in physical therapy. Journal of neurologic physical therapy : JNPT, 37(4):166—175, December 2013.
[19] B.J. Oates. Researching Information Systems and Computing. SAGE Publications, 2006.
[20] Thomas Tullis and William Albert. Measuring the User Experience: Collecting, An-alyzing, and Presenting Usability Metrics. Morgan Kaufmann Publishers Inc., San Francisco, CA, USA, 2008.
