A Prototype Exercise-Empowerment Mobile Video Game for Children With Cancer, and Its Usability Assessment: Developing Digital Empowerment Interventions for Pediatric Diseases

Abstract

Background: 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 Empower Stars! mobile video game grounded in behavioral and exercise theories with the purpose of coupling physical exercise with empowerment over disease in children with cancer.

Methods: 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. Unity multiplatform technology provided animation and audiovisual features for immediate player feedback. Javascript, C#, Photoshop, Flash, and SketchUp were used for coding, creating graphical assets, Sprite sheets, and printing files, respectively. 3D-printed handles and case backing were used to adapt the iPad for physical exercise. Game usability, engagement, and enjoyment were assessed via a multilevel study of children undergoing cancer chemotherapy, their parents, and pediatric cancer health-care providers. Feedback crucial for ongoing game development was analyzed.

Results: A prototype Empower Stars! mobile video game was developed for children 7-14 years old with cancer. Active, sedentary, educational, and empowerment-centered elements intermix for 20 min of exercise within a 30 min "one-day treatment" gameplay session involving superheroes, space exploration, metaphorical cancer challenges, life restoration on a barren planet, and innumerable star rewards. No player "dies." Usability assessment data analyses showed widespread enthusiasm for integrating exercise with empowerment over cancer and the game itself. Favorite elements included collecting star rewards and planet terraforming. Traveling in space and the Healthy Food Choice game were least liked. The need for improved gameplay instructions was expressed by all groups. The usability study provided essential feedback for converting the prototype into alpha version of Empower Stars!

Conclusion: 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.

Keywords: digital health; electronic health; empowerment; exercise; mobile health; pediatric cancer; pediatric chronic disease; video game.

Figures

Figure 1

The prototype Empower Stars! video game usability assessment centered on a multilevel user approach that included children with cancer ages 7–14 years of age, one of their parents, and Pediatric Hematology-Oncology health-care providers.

Figure 2

The prototype Empower Stars! video game usability assessment design involved a single gameplay session by three distinct yet related study populations as previously detailed, and included collection and analysis of both quantitative and qualitative data.

Figure 3

The prototype Empower Stars! video game is grounded in behavioral, empowerment, exercise, and engagement theories. It serves as a promising prototype intervention that couples exercise with empowerment over a specific disease to positively influencing health, disease, and therapy understanding in children with cancer and other chronic pediatric diseases.

Figure 4

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.

Figure 5

Physical, educational, and emotional empowerment themes are prominent throughout the prototype Empower Stars! video game. These themes include exercising to become stronger; conquering Cercer crabs that are metaphoric for cancer; learning about cancer, treatment and supportive care via educational messages and educational mini-games; and restoring life a barren planet by creating clouds, running water, plentiful trees, and new life form, a process summarized as “terraforming.”

Figure 6

The programmable iPadAir accelerometer and gyroscopic motion features facilitate incorporation of specific upper extremity and trunk exercise motions for (A) exercise motions needed to overcome a specific mini-game challenge and (B) exercises for 30 s “power-ups” to provide the energy needed to continue gameplay, as illustrated in the Planet Puzzle mini-game sequences.

Figure 7

Educational empowerment is facilitated by (A) important on-screen health-related messages interspersed through the game and (B) mini-games that center on teaching important components of cancer patient care, like nutrition, that are preceded by simple graphic gameplay instructions.

Figure 8

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.

Figure 9

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 Empower Stars! video game. Emoji faces were used instead of five numbers to indicate the degree of subject agreement or disagreement with the statement made, as illustrated here in the section evaluating engagement.

Figure 10

Mean responses of 10 pediatric cancer children to questions related to usability, engagement, and enjoyment of the prototype Empower Stars! video game. Ratings from the Likert scale from each of the three areas assessed were transformed to a numerical scale of 1–5. The mean rating scores for each question in the categories of usability, engagement, and enjoyment were then plotted.

Figure 11

Mean responses of the 9 of 10 pediatric subjects who were able to rank-order two distinct picture scales. (A) Of the eight major game components, collecting the star rewards was the most liked (1) and traveling in space was the least liked (7). The Space Heroes and the important messages were tied for the fourth most liked. (B) Of the five distinct exercise mini-games, the Positron game was the most liked (1) and the healthy food choice game was the lease liked. The star exercise mini-game and the planet puzzle game tied for the second most liked.

Figure 12

Health-care providers and parents each completed a 10 question Likert scale, which contained five unique and five overlapping questions. (A) The mean ratings of health-care providers (n = 12) were above 3.5 in all categories, with the top-rated being liking the idea of integrating a cancer-focused video game into the overall therapy for a child with cancer. (B) The mean ratings of parents (n = 10) were somewhat lower though all still above 3.0. The top-rated statement identified their child is not being as physically active as before the diagnosis and initiation of cancer treatment, followed very closely by liking the idea of integrating a cancer-focused video game into the overall therapy for their child with cancer.

Figure 13

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.