Review Article
A Study of a Serious Game for Adolescents and Young Adults with Leukemia
Al-Anazi WK1, Alsuhebah AM2, Estanislao A2, Al-Jasser AM3, Al-Hashmi H2, Al-Anazi KA2*
1College of Computer and Information Sciences, Prince Sultan University, Riyadh, Saudi Arabia
2Department of Hematology and Hematopoietic Stem Cell Transplantation, King Fahad Specialist Hospital, Dammam,Saudi Arabia
3Department of Microbiology, Riyadh Regional Laboratory, Riyadh, Saudi Arabia
*Corresponding author: KA Al-Anazi, Department of Adult Hematology and Hematopoietic Stem Cell Transplantation, Oncology Center, King Fahad Specialist Hospital, Saudi Arabia
Published: 20 Mar, 2018
Cite this article as: Al-Anazi WK, Alsuhebah AM,
Estanislao A, Al-Jasser AM, Al-Hashmi
H, et al. A Study of a Serious Game for
Adolescents and Young Adults with
Leukemia. Clin Oncol. 2018; 3: 1440.
Abstract
Serious games sparked the possibility of promoting interactive technology in healthcare sector. The
design of serious games relies heavily on the experience of the targeted users. The aim of this study
is to design and evaluate suitable mechanics of a serious game for adolescents and young adults with
leukemia in Saudi Arabia. The study followed usability testing approach by evaluating low-fidelity
and high-fidelity prototypes. This study showed that the suitable mechanics in serious game design
for adolescents and young adults with leukemia were: mechanics of interaction and play experience
comprising of the story, different levels, and characters; mechanics of integrating knowledge and
learning including brief dialogues and alerts; and mechanics concerning patients' conditions and
constraints consisting of relaxing sound effects and pausing option.
Keywords: Serious Games; Usability Testing; Adolescents and Young Adults; Leukemia; Saudi Arabia
Introduction
Recently, serious games utilize game concepts in non-game context have gained attention in the
field of healthcare [1,2]. Game design appeals most to adolescents and young adults since they have
great exposure to technology than other age groups [3]. Leukemia treatment regimens are complex
and every patient follows specialized treatment plan. Adolescents and young adults with leukemia
find difficulty once diagnosed in adherence to treatment [4].
Designing serious games remains perplexing. Mechanics in serious games act as rules that
possess the ability to motivate users including point system, badges, leaderboard, narratives, and
avatars. There is a lack in the guidelines of designing mechanics that achieve the desired outcomes
of serious games for adolescents and young adults with leukemia [5].
Arising challenges in developing serious games in health have been found in many aspects
including: the experience and usability issues faced by participants; the inclusion of fun aspect in
designing serious games; a game design that is aligned with the targeted group preferences; the
patients' conditions and constraints; the psychological impact of the game; and the complexity of
requirements as well as the content design of such serious games [6–11].
Moneta’s [12] theory of flow is an essential game design principle to achieve a balance between
the player's current skill level and the game challenge level. Winn [13] proposed a framework of
Design, Play and Experience (DPE) that provides guidelines for serious game design which consisted
of learning layer, storytelling layer, gameplay layer, user experience layer, and technology layer.
Early user involvement eliminates ambiguities of understanding the unique requirements
of serious game design. The aim of the study is to choose suitable game mechanics to support
adolescents and young adults with leukemia in their serious game play experience. This was tackled
by identifying the requirements of intended users, developing two prototypes of a serious game, and
evaluating these prototypes.
Related Work
Stinson et al. [14,15] proposed a pain assessment mobile application, called Pain Squad app,
which keeps track of daily pain level for children and adolescents with cancer. The prototype
was refined based on feedback from low-fidelity and high-fidelity
testing stages resulting in early recognition of usability issues. Main
mechanics in this prototype involved progress bar, rewards, and
badges.
Fuchslocher et al. [16] designed Massively Multiplayer Online
Role Playing Game (MMORPG) that promoted social integration
among kids and adolescents with cancer during treatment. The
evaluation process consisted of Game Experience Questionnaire
(GEQ).Game mechanics consisted of the following: avatar, dialogues,
story, leaderboards, messaging system, and pausing option.
Peters et al. [9] suggested an alternative solution to patients'
written diaries that works as a remote data entry for reporting and
monitoring the health conditions of adolescents and children. User
Centered Design (UCD) approach was followed where experts
were involved in the design process. The game design consisted of
mechanics such as avatar, health bar, progress bar, and performance
graphs.
Kato et al. [17] developed a serious game which promotes
adherence to treatment for adolescents with leukemia and measured
its effectiveness for improving positive behaviors for this age group.
Avatar, dialogues, health bar, and story were examples of the main
mechanics incorporated in the design.
Figure 1
Method
Usability testing was followed in this study [18–20]. Usability
testing for serious games undergoes a cycle of:
Initial study consists of defining an initial idea about the overall
concept and identifies a brief game description. Initial study gathered
insights about five patients game preferences by questionnaires and
one physician's recommendations in creating the content of the game
using a semi-structured interview.
Low fidelity design and usability testing revolves around
generating game concept and game goals. A paper-card prototype
was evaluated in low-fidelity stage by two physicians in a session and
follow-up interview.
High fidelity design and usability testing where the actual code
and design of aesthetics is generated. This stage is concerned about
the development of high fidelity prototype which was accomplished
using several software and hardware tools. High-fidelity testing was
conducted in order to evaluate the game experience by patients.
Participants and Settings
In a high-fidelity study, a total of 29 participants (18 adolescents
and young adults with leukemia) and medical and nursing team in
charge of leukemia patients (five physicians and six nurses) were
involved in the study. The study was conducted in the department of
adult hemato-oncology and stem cell transplant department at King
Fahad Specialist Hospital (KFSH) in Dammam, Saudi Arabia. KFSH
is one of the leading hospitals that provide stem cell transplantation
in the Eastern region in Saudi Arabia.
Figure 2
Figure 3
Materials
A mobile-based prototype and questionnaires were used in this
study. The mobile-based prototype was developed as 2D actionadventure
for Android mobile devices in Arabic (Figure 1). The
name of the game was Brave Ranger where this game aimed to take
the player in an adventure throughout different levels of leukemia
treatment plan. High-fidelity prototype was designed using Unity
game engine and Adobe Illustrator.
High fidelity study included information sheet, consent form, and
questionnaires. The questionnaires consisted of two parts which were:
Game Engagement Questionnaire (GEQ) questions: The ingame
GEQ was adopted due to patients conditions in order to have
a brief questionnaire as recommended by the physicians [21,22].
Brockmeyer [23] GEQ was designed using Likert five points scale
(extremely = 4, fairly = 3, moderately = 2, slightly = 1, and not at all =
0). In-game GEQ consisted of items that measures seven dimensions
which were the variables of the study including: competence, sensory
and imaginative immersion, flow, tension, challenge, negative affect,
and positive affect (Table 1). Other gameplay and mechanics
questions: choosing the preferred mechanics; selecting mechanics
that caused issues and dislikes; reaching the end of the game; and
providing future suggestions.
Procedures and Analysis
Patients and medical and nursing team were asked to use the prototype and to complete the questionnaire afterwards. The score of each variable was derived from calculating the average of the two items. This was done after calculating the percentage of responses for these items in the 5-Likert scale.
Table 1
Findings
The initial study gave an insight about the serious game design
based on requirements gathered from the patients and their
physicians. The patients preferred playing games in Arabic language.
Patients were frequent players who preferred sophisticated games
with an adventure and clear gameplay. The patients' player types
were achievers, socializers, and explorers while their favorite game
platform was PlayStation then Android and IPhone.
Boosting patient's positivity and avoiding mention sad and
terrorizing events were considered in the design. The three main
levels in the game as suggested by the physician were diagnosis stage,
control stage, and cure stage. The serious game story began with a
character (a brave ranger) who discovered the existence of monstrous
cells and acquires certain abilities to eliminate them throughout the
levels.
Level 1 (Diagnosis Stage): The first level showed the beginning
of the appearance of cancer cells. The player met the medical team
as characters that were not controlled by the player at the end of the
level. The medical team provided an armor (chemotherapy armor)
that helped the player in second level.
Level 2 (Control Stage): The player fought cancer cells and
defended cancer cells attacks wearing the chemotherapy armor. An
alert message was triggered by the player at a certain point during
the gameplay which showed an advice for the player. At the end of
the level, the player interacted with the medical team and received an
armor upgrade and a new ability.
Level 3 (Cure Stage): The player was able to eliminate a powerful
type of cancer cells instantly by a stem cell transplant ability.
Low fidelity resulted in an inclusion of a pause button in the game
considering the requirements of patients' condition. Dialogues were
shortened and level names were stated clearly at the beginning of
every level.
The findings of high fidelity evaluation showed that the majority
of the participants were males. GEQ variables which are immersion,
positive affect, and competence had the highest scores. Tension and
negative effect were found to be the least in the game. The participants
were strongly interested in the story and felt successful when playing
the game. A fair level in the flow of the game was stated by the
respondents. Competence was higher than challenge element in the
game. Although the participants found that the game carried some
element of challenge, they did not put a lot of effort in the game
(Figure 2).
The preferred game mechanics were characters and multiple
levels while alerts and sound effects were least chosen by the
respondents (Figure 3). The majority of the reported issues were in
jump command. There were minor issues experienced in movements,
enemies, and sound. All of the participants successfully completed
the game. Suggestions for future improvements included adding
difficulty levels and improve the knowledge aspect in the game.
Discussion
The initial study was the first step in designing a serious game
tailored for specific users. Bartle’s [24] model gave an insight in
incorporating desired game mechanics that were closer to the player
types. The existence of game world (gameplay) was suitable for the
respondents' player types including achiever, explorer, and socializer.
These player types required interaction and acting features in a world
[13,25]. It was noticed that game genres chosen by the respondents
including role-playing and action-adventure consisted of a gameplay
design. This entails that serious game with a gameplay rather than a
mobile application with gamification elements should be pursued in
the design [13].
Flow dimension which was the attribute of measuring the level
of engagement was fair in this study similar to Fuchslocher et al.
[16]. However, competence scores were found higher than the flow
of the game which implied that participants were highly skilled in
playing the prototype. As a result, the participants' competence
scores affected the challenge dimension where the game experience
had fallen under the category "easy" according to Moneta's [12]
theory of flow. Suggestions for achieving the desired balance could
include difficulty levels since the participants were skilled players and
it was requested by them in high-fidelity study. This point might be
supported by the guidelines of designing serious games to adolescents
and young adults where they thrive for challenge in using games [26].
Tong et al. [6] found that the game was too easy for the participants
which showed similar outcomes in this paper. Suggestions by Tong et
al. [6] included using different levels ranging from easy to challenging
in order to cover different aspects of skills. The majority of the
participants in this study were males and this was similar to the study
conducted by Kato et al. [17]. The results could follow the suggestions
of Nielsen et al. [27] and Tondello et al. [11] which highlighted that
males were motivated by higher challenge levels and competitive play
more than females when playing games.
Designing the learning layer was found challenging in DPE
model. As Graafland et al. [28] stated, early involvement of medical
team was necessary for validation purposes, but it was vital in creating
the concept of game design especially for complex and varying
treatment plans for leukemic patients. Gathering requirements and
designing content were found challenging and this highlighted a
similar aspect reported by Peters et al. [9]. Another challenging aspect
was conveying knowledge using dialogues game mechanic since most
of the respondents requested to increase the level of knowledge in
this game. Winn et al. [13] showed that having a balance between
story and learning sides of DPE storytelling layer in serious games
was difficult to be achieved. The heterogeneity of cancer diagnosis
and treatment plans was noticed as a challenging factor in this
study which resembled the points raised by Kato et al. [17]. In user
experience layer, jump control caused the majority of the issues and
dislikes in high fidelity study.
The participants of the study found the concept of serious
games appealing and encouraged future implications in the patient
management. The study showed an immersive experience where
characters and different levels reflecting disease stages were the main
factors that contributed to this experience as selected by participants.
Different levels could be incorporated to show variation of levels in
gameplay mapped with distinct treatment stages. Ease of control
and story came next according to patients' responses. A convenient
approach was followed in presenting the story and content of the
disease for patients in the serious game according to the physician's
recommendations. Although death was a critical element of game
design, this was approached by having the player being respawned
(recreated) immediately after losing without displaying "you lose"
message.
Furthermore, the design of serious games in healthcare is critical
and may trigger unpleasant feelings for the patients. According to
Baranowski et al. [7], there were concerns regarding the psychological
impact since game mechanics affect the player's real life activities.
Graafland et al. [28] and Majeed-Ariss et al. [29] urged the need of the
involvement and the approval of physicians and nurses in order to
validate the safety and the privacy of the patients. This study involved
both medical and nursing team similar to other studies [9,14,16,17].
Arabic language was the main language of the prototype. This
result imposed similarity of designing games based on the preferred
language of participants which were found in adopting German
language in studies done in Austria and Germany [9,16].
Low fidelity provided an early discovery of new mechanics
(e.g. pause button) and enhancements of existing mechanics (e.g.
dialogues). A pause button was added in order to ensure the continuity
of play since patient condition might change suddenly and the patient
loses progress in the gameplay. Kato et al. [17] recommended a smaller
version of the game to be designed for patients who have advanced
conditions or those who were not able to withstand longer times of
play. Similarly, this prototype was brief taking into consideration the
condition of the patient. As Tong et al. [6] stated, this study followed
the recommendations of the physician in testing the prototype using
portable devices that were easily carried in hospital settings.
The least selected game mechanics were alerts and sound effects.
Sound effects act as an important mechanic in game development
which ensures a complete immersive experience [30]. It is important
to understand the culture when designing games for specific users.
Some patients may not prefer to listen music during difficult
times including sickness. This indicated that sound effects must be
incorporated wisely for the targeted users such as including mute
option in the game design.
The findings of Fuchslocher et al. [16] pointed out that there was
a strong social and online community support whereas the results of
this study revealed that it was least suggested as future improvement.
The findings of this study may agree with several studies which
showed that adolescents do not prefer to have a game with mandatory
online community support but may be an optional choice for them
[3,26,31].
Game mechanics of the serious game were designed and
evaluated for adolescents and young adults with leukemia in Saudi
Arabia pursued the requirements of three purposes: (1) mechanics
for interaction and play experience were: story, different levels, and
characters; (2) mechanics for integrating knowledge and learning
were: brief dialogues and alerts; and (3) mechanics concerning
patients' condition and constraints were: relaxing sound effects and
pause option.
Conclusion
Designing appropriate serious games in health for targeted users
remains challenging. This study tackled the process of the design and
the evaluation of a serious game for adolescents and young adults
with leukemia in Saudi Arabia.
The methodology of the study consisted of the following usability
testing approach which had three major parts of this study which
are: initial study, low fidelity, and high fidelity. The mechanics of the
serious game covered the three following purposes: interaction and
play experience, knowledge and learning, patients' condition and
constraints.
Understanding participants' requirements were necessary in
the process of discovering suitable game mechanics. This study has
a specific time-frame with a small sample size. The inclusion of a
larger sample size can uncover new insights for future improvements.
Future studies can explore more mechanics in the serious game based
on the targeted group preferences. There is a need to tailor challenge
aspect in order to provide a better flow and a better experience such
as adding difficulty levels.
Acknowledgment
The authors extend their thanks to the medical and nursing team at the Oncology Center, King Fahad Specialist Hospital in Dammam, for their support and dedication. The authors are grateful to the patients who participated in this study and wish them quick recovery and cure.
References
- Lombriser P, van der Valk R. Improving the Quality of the Software Development Lifecycle with Gamification. 2011.
- Cannon-Bowers J, editor. Serious Game Design and Development: Technologies for Training and Learning. 1st ed. Hershey PA: IGI Global; 2010.
- McCloskey M, Loranger H, Nielsen J. Designing for Young Adults (Ages 18-25). Fremont CA.
- Ameringer S, Elswick RK, Shockey DP, Dillon R. A pilot exploration of symptom trajectories in adolescents with cancer during chemotherapy. Cancer Nurs. 2013;36(1):60–71.
- Baranowski MT1, Lieberman PD2, Buday R3, Peng W4, Zimmerli L5, Wiederhold B6, et al. Videogame Mechanics in Games for Health. Games Health J. 2013;2(4):194-204.
- Tong T, Sieminowski T, Sieminowski T. Case Study: A Serious Game for Neurorehabilitation Assessment. Procedia Comput Sci. 2015;69:125–31.
- Baranowski T, Blumberg F, Buday R, DeSmet A, Fiellin LE, Green CS, et al. Games for Health for Children—Current Status and Needed Research. Games Health J. 2016;5(1):1-12.
- Katz D, Dalton N, Price B. Failing the challenge: Diabetes apps & longterm daily adoption. In: 8th International Conference on Advanced Technologies & Treatments for Diabetes. Paris: Centre for Research in Computing. 2015.
- Peters K, Kayali F, Lawitschka A, Silbernagl M, Ruth-Mateus-Berr, Martinek D, et al. INTERACCT: Remote data entry system with gameelements for young leukaemia patients. In: 2015 17th International Conference on E-health Networking, Application & Services (HealthCom). MA: IEEE;2015;369-74.
- Birk M V., Friehs MA, Mandryk RL. Age-Based Preferences and Player Experience: A Crowdsourced Cross-sectional Study. In: Proceedings of the Annual Symposium on Computer-Human Interaction in Play - CHI PLAY ’17. 2017;157-70.
- Tondello GF, Wehbe RR, Orji R, Ribeiro G, Nacke LE. A Framework and Taxonomy of Videogame Playing Preferences. In: Proceedings of the Annual Symposium on Computer-Human Interaction in Play - CHI PLAY ’17. 2017;329-40.
- Moneta GB1, Csikszentmihalyi M. The effect of perceived challenges and skills on the quality of subjective experience. J Pers. 1996;64(2):275-310.
- Winn BM. The Design, Play, and Experience Framework. In: Handbook of Research on Effective Electronic Gaming in Education. Hershey, New York: IGI Global; 2007.1010-24.
- Stinson JN, Jibb LA, Nguyen C, Nathan PC, Maloney AM, Dupuis LL, et al. Development and testing of a multidimensional iPhone pain assessment application for adolescents with cancer. J Med Internet Res. 2013;15(3):1-15.
- Stinson JN, Jibb LA, Nguyen C, Nathan PC, Marie A, Dupuis LL, et al. Construct validity and reliability of a real-time multidimensional smartphone app to assess pain in children and adolescents with cancer. Pain. 2015;156(12):2607–15.
- Fuchslocher A, Gerling K, Masuch M, Kramer N. Evaluating social games for kids and teenagers diagnosed with cancer. In: Serious Games and Applications for Health (SeGAH), 2011 IEEE 1st International Conference. Braga: IEEE; 2011:1-4.
- Kato PM, Cole SW, Bradlyn AS, Pollock BH. A Video Game Improves Behavioral Outcomes in Adolescents and Young Adults With Cancer: A Randomized Trial. Pediatrics. 2008:122(2):e305-17.
- Olsen T, Procci K, Bowers C. Serious Games Usability Testing: How to Ensure Proper Usability, Playability, and Effectiveness. In Springer Berlin Heidelberg. 2011:625-34.
- Gould JD, Lewis C. Designing for usability: key principles and what designers think. Commun ACM. 1985;28(3):300-11.
- Ramadan R, Widyani Y. Game development life cycle guidelines. In: Advanced Computer Science and Information Systems (ICACSIS), 2013 International Conference. Bali: IEEE. 2013:95-100.
- Nordin AI, Denisova A, Cairns P. Too Many Questionnaires: Measuring Player Experience Whilst Playing Digital Games. Seventh York Dr Symp Comput Sci Electron. 2014;69:69-73.
- Norman KL, Lindgaard G, Kirakowski J. GEQ (Game Engagement/ Experience Questionnaire): A Review of Two Papers. Interact Comput. 2013;25(4):278-83.
- Brockmyer JH, Fox CM, Curtiss KA, Mcbroom E, Burkhart KM, Pidruzny JN. The development of the Game Engagement Questionnaire?: A measure of engagement in video game-playing. J Exp Soc Psychol. 2009;45(4):624-34.
- Bartle R. HEARTS, CLUBS, DIAMONDS, SPADES: PLAYERS WHO SUIT MUDS. J MUD Res. 1996;1(1):1-39.
- Hunicke R, Leblanc M, Zubek R. MDA: A Formal Approach to Game Design and Game Research. In: Workshop presented at FuturePlay 2005 International Academic Conference on the Future of Game Design and Technology. East Lansing. 2005:1-5.
- McCloskey M, Loranger H, Nielsen J. Teenagers (Ages 13–17) on the Web. Fremont CA.
- Nielsen J. Games User Research: What’s Different? 2016.
- Graafland M, Dankbaar M, Mert A, Lagro J, De Wit-Zuurendonk L, Schuit S, et al. How to systematically assess serious games applied to health care. JMIR serious games. 2014;2(2):e11(pp. 1-10).
- Majeed-Ariss R, Baildam E, Campbell M, Chieng A, Fallon D, Hall A, et al. Apps and Adolescents: A Systematic Review of Adolescents’ Use of Mobile Phone and Tablet Apps That Support Personal Management of Their Chronic or Long-Term Physical Conditions. J Med Internet Res. 2015;17(12):e287.
- Lane N, Prestopnik NR. Diegetic Connectivity: Blending Work and Play with Storytelling in Serious Games. In: Proceedings of the Annual Symposium on Computer-Human Interaction in Play. New York, NY: ACM;2017:229-40.
- Hutton A1. The private adolescent: privacy needs of adolescents in hospitals. J Pediatr Nurs. 2002;17(1):67-72.