More Stamina, a Gamified mHealth Solution for Persons with Multiple Sclerosis: Research Through Design

Guido Giunti, Vasiliki Mylonopoulou, Octavio Rivera Romero, Guido Giunti, Vasiliki Mylonopoulou, Octavio Rivera Romero

Abstract

Background: Multiple sclerosis (MS) is one of the world's most common neurologic disorders. Fatigue is one of most common symptoms that persons with MS experience, having significant impact on their quality of life and limiting their activity levels. Self-management strategies are used to support them in the care of their health. Mobile health (mHealth) solutions are a way to offer persons with chronic conditions tools to successfully manage their symptoms and problems. Gamification is a current trend among mHealth apps used to create engaging user experiences and is suggested to be effective for behavioral change. To be effective, mHealth solutions need to be designed to specifically meet the intended audience needs. User-centered design (UCD) is a design philosophy that proposes placing end users' needs and characteristics in the center of design and development, involving users early in the different phases of the software life cycle. There is a current gap in mHealth apps for persons with MS, which presents an interesting area to explore.

Objective: The purpose of this study was to describe the design and evaluation process of a gamified mHealth solution for behavioral change in persons with MS using UCD.

Methods: Building on previous work of our team where we identified needs, barriers, and facilitators for mHealth apps for persons with MS, we followed UCD to design and evaluate a mobile app prototype aimed to help persons with MS self-manage their fatigue. Design decisions were evidence-driven and guided by behavioral change models (BCM). Usability was assessed through inspection methods using Nielsen's heuristic evaluation.

Results: The mHealth solution More Stamina was designed. It is a task organization tool designed to help persons with MS manage their energy to minimize the impact of fatigue in their day-to-day life. The tool acts as a to-do list where users can input tasks in a simple manner and assign Stamina Credits, a representation of perceived effort, to the task to help energy management and energy profiling. The app also features personalization and positive feedback. The design process gave way to relevant lessons to the design of a gamified behavioral change mHealth app such as the importance of metaphors in concept design, negotiate requirements with the BCM constructs, and tailoring of gamified experiences among others. Several usability problems were discovered during heuristic evaluation and guided the iterative design of our solution.

Conclusions: In this paper, we designed an app targeted for helping persons with MS in their fatigue management needs. We illustrate how UCD can help in designing mHealth apps and the benefits and challenges that designers might face when using this approach. This paper provides insight into the design process of gamified behavioral change mHealth apps and the negotiation process implied in it.

Keywords: chronic disease; exercise; fatigue; mobile applications; multiple sclerosis; qualitative research; software design; telemedicine; user-computer interface; video games.

Conflict of interest statement

Conflicts of Interest: None declared.

©Guido Giunti, Vasiliki Mylonopoulou, Octavio Rivera Romero. Originally published in JMIR Mhealth and Uhealth (http://mhealth.jmir.org), 02.03.2018.

Figures

Figure 1
Figure 1
Phases of user-centered design. Green represents the areas covered in this study. Detailed results of our mobile health (mHealth) app review for multiple sclerosis and focus groups and interviews with stakeholders can be found in their respective studies.
Figure 2
Figure 2
Successive iterations on main screen design.
Figure 3
Figure 3
Final paper prototype design: (a) initial main screen; (b) new task input; (c) Stamina Credits assignment; (d) main screen with tasks; (e) edition and completion of tasks; (f) effort estimation; (g) effort recommendation; and (h) user profile.
Figure 4
Figure 4
Guiding design questions. GST: goal-setting theory; SDT: self-determination theory; TPB: theory of planned behavior; HBM: health belief model.
Figure 5
Figure 5
Usability errors and fixes. User control and freedom (left) and error prevention (right).

References

    1. Browne P, Chandraratna D, Angood C, Tremlett H, Baker C, Taylor BV, Thompson AJ. Atlas of multiple sclerosis 2013: a growing global problem with widespread inequity. Neurology. 2014 Sep 09;83(11):1022–4. doi: 10.1212/WNL.0000000000000768.
    1. Goldenberg MM. Multiple sclerosis review. P T. 2012;37(3):175–184.
    1. Motl RW, McAuley E, Snook EM. Physical activity and multiple sclerosis: a meta-analysis. Mult Scler. 2005 Aug;11(4):459–63. doi: 10.1191/1352458505ms1188oa.
    1. Freal JE, Kraft GH, Coryell JK. Symptomatic fatigue in multiple sclerosis. Arch Phys Med Rehabil. 1984 Mar;65(3):135–8.
    1. Ponichtera-Mulcare JA. Exercise and multiple sclerosis. Med Sci Sports Exerc. 1993 Apr;25(4):451–65.
    1. Frau J, Coghe G, Lorefice L, Fenu G, Cadeddu B, Marrosu MG, Cocco E. Attitude towards physical activity in patients with multiple sclerosis: a cohort study. Neurol Sci. 2015 Jun;36(6):889–93. doi: 10.1007/s10072-015-2100-x.
    1. MacAllister WS, Krupp LB. Multiple sclerosis-related fatigue. Phys Med Rehabil Clin N Am. 2005 May;16(2):483–502. doi: 10.1016/j.pmr.2005.01.014.
    1. Kurtzke JF. Rating neurologic impairment in multiple sclerosis: an expanded disability status scale (EDSS) Neurology. 1983 Nov;33(11):1444–52.
    1. Krupp LB, LaRocca NG, Muir-Nash J, Steinberg AD. The fatigue severity scale. Application to patients with multiple sclerosis and systemic lupus erythematosus. Arch Neurol. 1989 Oct;46(10):1121–3.
    1. Chalder T, Berelowitz G, Pawlikowska T, Watts L, Wessely S, Wright D, Wallace EP. Development of a fatigue scale. J Psychosom Res. 1993;37(2):147–153.
    1. Trisolini M, Honeycutt A, Wiener J, Lesesne S. MSIF. 2010. [2018-02-12]. Global economic impact of multiple sclerosis .
    1. Lorig KR, Holman H. Self-management education: history, definition, outcomes, and mechanisms. Ann Behav Med. 2003 Aug;26(1):1–7.
    1. Schulman-Green D, Jaser S, Martin F, Alonzo A, Grey M, McCorkle R, Redeker NS, Reynolds N, Whittemore R. Processes of self-management in chronic illness. J Nurs Scholarsh. 2012 Jun;44(2):136–44. doi: 10.1111/j.1547-5069.2012.01444.x.
    1. Mirkovic J, Kristjansdottir OB, Stenberg U, Krogseth T, Stange KC, Ruland CM. Patient insights into the design of technology to support a strengths-based approach to health care. JMIR Res Protoc. 2016 Aug 24;5(3):e175. doi: 10.2196/resprot.5906.
    1. Anderson RM, Funnell MM. Patient empowerment: myths and misconceptions. Patient Educ Couns. 2010 Jun;79(3):277–82. doi: 10.1016/j.pec.2009.07.025.
    1. Whittaker R. Issues in mHealth: findings from key informant interviews. J Med Internet Res. 2012;14(5):e129. doi: 10.2196/jmir.1989.
    1. Jahns RG, Houck P. Research2guidance. 2013. [2018-02-12]. Mobile Health Market Report 2013-2017 .
    1. Giunti G, Guisado-Fernandez E, Caulfield B. Connected health in multiple sclerosis: a mobile applications review. 2017 IEEE 30th International Symposium on Computer-Based Medical Systems (CBMS); June 22, 2017; Thessaloniki, Greece. IEEE; 2017. pp. 660–665.
    1. Noar SM, Benac CN, Harris MS. Does tailoring matter? Meta-analytic review of tailored print health behavior change interventions. Psychol Bull. 2007 Jul;133(4):673–93. doi: 10.1037/0033-2909.133.4.673.
    1. Ludden G, van Rompay TJ, Kelders SM, van Gemert-Pijnen GE. How to increase reach and adherence of web-based interventions: a design research viewpoint. J Med Internet Res. 2015 Jul 10;17(7):e172. doi: 10.2196/jmir.4201.
    1. Schnall R, Rojas M, Bakken S, Brown W, Carballo-Dieguez A, Carry M, Gelaude D, Mosley JP, Travers J. A user-centered model for designing consumer mobile health (mHealth) applications (apps) J Biomed Inform. 2016 Apr;60:243–51. doi: 10.1016/j.jbi.2016.02.002.
    1. De Vito Dabbs A, Myers BA, Mc Curry KR, Dunbar-Jacob J, Hawkins RP, Begey A, Dew MA. User-centered design and interactive health technologies for patients. Comput Inform Nurs. 2009;27(3):175–83. doi: 10.1097/NCN.0b013e31819f7c7c.
    1. Maguire M. Methods to support human-centred design. Int J Hum Comput Stud. 2001 Oct;55(4):587–634. doi: 10.1006/ijhc.2001.0503.
    1. Brown 3rd W, Yen PY, Rojas M, Schnall R. Assessment of the Health IT Usability Evaluation Model (Health-ITUEM) for evaluating mobile health (mHealth) technology. J Biomed Inform. 2013 Dec;46(6):1080–7. doi: 10.1016/j.jbi.2013.08.001.
    1. Localytics Info.localytics. [2017-12-13]. 23% of Users Abandon an App After One Use .
    1. Perez S. Techcrunch. 2016. [2017-12-13]. Nearly 1 in 4 people abandon mobile apps after only one use
    1. Deterding S, Dixon D, Khaled R, Nacke L. From game design elements to gamefulness. MindTrek '11 Proceedings of the 15th International Academic MindTrek Conference: Envisioning Future Media Environments; September 28-30, 2011; Tampere, Finland. Gamification: Using Game Design Elements in Non-Game Contexts. Proc 2011 Annu Conf Ext Abstr Hum Factors Comput Syst (CHI 2011). 2011; 2011. pp. 9–15.
    1. Lister C, West JH, Cannon B, Sax T, Brodegard D. Just a fad? Gamification in health and fitness apps. JMIR Serious Games. 2014;2(2):e9. doi: 10.2196/games.3413.
    1. Cugelman B. Gamification: what it is and why it matters to digital health behavior change developers. JMIR Serious Games. 2013;1(1):e3. doi: 10.2196/games.3139.
    1. ISO . International Organization for Standardization. Geneva, Switzerland: International Organization for Standardization; 2010. Mar, Ergonomics of human-system interaction - Part 210: human-centered design for interactive systems; pp. 1–32.
    1. Pruitt J, Adlin T. The Persona Lifecycle: Keeping People in Mind Throughout Product Design (The Morgan Kaufmann Series in Interactive Technologies) USA: Morgan Kaufmann Publishers Inc; 2006.
    1. Johnson CM, Johnson TR, Zhang J. A user-centered framework for redesigning health care interfaces. J Biomed Inform. 2005 Feb;38(1):75–87. doi: 10.1016/j.jbi.2004.11.005.
    1. Pressman RS. Software Engineering A Practitioner's Approach 7th Ed. Singapore: McGraw-Hill; 2010.
    1. Mayhew DJ. The Usability Engineering Lifecycle: A Practitioner's Handbook for User Interface Design (Interactive Technologies) 1st Ed. Burlington, MA: Morgan Kaufmann; 1999. Sep,
    1. Sharp H, Rogers Y, Preece J. Interaction Design: Beyond Human-Computer Interaction 2nd Edition. Hoboken, NJ: Wiley; 2007.
    1. Herring SR, Chang CC, Krantzler J, Bailey BP. Getting inspired!: understanding how and why examples are used in creative design practice. CHI '09 Proceedings of the SIGCHI Conference on Human Factors in Computing Systems; April 04-09, 2009; Boston, MA, USA. ACM; 2009.
    1. Kinzie MB, Cohn WF, Julian MF, Knaus WA. A user-centered model for web site design: needs assessment, user interface design, and rapid prototyping. J Am Med Inform Assoc. 2002;9(4):320–30.
    1. Lim YK, Stolterman E, Tenenberg J. The anatomy of prototypes. ACM Trans Comput Hum Interact. 2008 Jul 01;15(2):1–27. doi: 10.1145/1375761.1375762.
    1. Wong YY. Rough and ready prototypes. Posters and short talks of the 1992 SIGCHI conference on Human factors in computing systems - CHI '92; May 03-07, 1992; Monterey, CA, USA. 1992. p. 83.
    1. Sefelin R, Tscheligi M, Giller V. Paper prototyping - what is it good for?: a comparison of paper- and computer-based low-fidelity prototyping. CHI EA '03 CHI '03 Extended Abstracts on Human Factors in Computing Systems; April 05-10, 2003; Ft. Lauderdale, Florida, USA. 2003.
    1. Lathan CE, Sebrechts MM, Newman DJ, Doarn CR. Heuristic evaluation of a web-based interface for internet telemedicine. Telemed J. 1999;5(2):177–85. doi: 10.1089/107830299312140.
    1. Jaspers MW. A comparison of usability methods for testing interactive health technologies: methodological aspects and empirical evidence. Int J Med Inform. 2009 May;78(5):340–53. doi: 10.1016/j.ijmedinf.2008.10.002.
    1. Nielson J, Mack RL. Usability Inspection Methods. New York, NY: John Wiley & Sons; 1994.
    1. Kushniruk AW, Patel VL. Cognitive and usability engineering methods for the evaluation of clinical information systems. J Biomed Inform. 2004 Feb;37(1):56–76. doi: 10.1016/j.jbi.2004.01.003.
    1. Miller AS, Cafazzo JA, Seto E. A game plan: gamification design principles in mHealth applications for chronic disease management. Health Informatics J. 2016;22(2):184–93. doi: 10.1177/1460458214537511.
    1. Kappen DL, Orji R. Gamified and persuasive systems as behavior change agents for health and wellness. XRDS: Crossroads ACM Mag Stud. 2017 Sep 14;24(1):52–55. doi: 10.1145/3123750.
    1. Deterding S, Dixon D, Khaled R, Nacke L. From game design elements to gamefulness: defining “gamification”. 15th International Academic MindTrek Conference: Envisioning Future Media Environments; September 28 - 30, 2011; Tampere, Finland. New York, NY, USA: ACM; 2011. pp. 9–15.
    1. King D, Greaves F, Exeter C, Darzi A. 'Gamification': influencing health behaviours with games. J R Soc Med. 2013 Mar;106(3):76–8. doi: 10.1177/0141076813480996.
    1. Zichermann G, Cunningham C. Gamification by Design: Implementing Game Mechanics in Web and Mobile Apps. Sebastopol, California, USA: O'Reilly Media; 2011.
    1. Reaves B, Read JL. Total Engagement: Using Games and Virtual Worlds to Change the Way People Work and Businesses Compete. Boston, MA: Harvard Business Press; 2009.
    1. Baranowski T, Buday R, Thompson D, Lyons EJ, Lu AS, Baranowski J. Developing games for health behavior change: getting started. Games Health J. 2013 Aug;2(4):183–190. doi: 10.1089/g4h.2013.0048.
    1. Janz NK, Becker MH. The health belief model: a decade later. Health Educ Q. 1984;11(1):1–47.
    1. Ajzen I. The theory of planned behavior. Organ Behav Hum Decis Process. 1991 Dec;50(2):179–211. doi: 10.1016/0749-5978(91)90020-T.
    1. Locke EA, Latham GP, Smith KJ, Wood RE, Bandura A. A Theory of Goal Setting & Task Performance. New York, NY: Pearson College Division; 1990.
    1. Ryan RM, Deci EL. Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. Am Psychol. 2000 Jan;55(1):68–78.
    1. Wood RE, Mento AJ, Locke EA. Task complexity as a moderator of goal effects: a meta-analysis. J Appl Psychol. 1987;72(3):416–25.
    1. Werrij M, Ruiter R, van 't Riet J, de Vries H. Message framing. In: Abraham C, Kools M, editors. Writing Health Communication: An Evidence-Based Guide. London, UK: SAGE Publications Ltd; 2012.
    1. Giunti G, Kool J, Rivera-Romero O, Dorronzoro-Zubiete E. Exploring the Specific Needs of Persons with Multiple Sclerosis for mHealth Solutions for Physical Activity: Mixed-Methods Study. JMIR Mhealth Uhealth. 2017;6(2):e37. doi: 10.2196/mhealth.8996.
    1. Hamilton AD, Brady RR. Medical professional involvement in smartphone 'apps' in dermatology. Br J Dermatol. 2012 Jul;167(1):220–1. doi: 10.1111/j.1365-2133.2012.10844.x.
    1. Ventola CL. Mobile devices and apps for health care professionals: uses and benefits. P T. 2014 May;39(5):356–64.
    1. O'Neill S, Brady RR. Colorectal smartphone apps: opportunities and risks. Colorectal Dis. 2012 Sep;14(9):e530–4. doi: 10.1111/j.1463-1318.2012.03088.x.
    1. Wong SJ, Robertson GA, Connor KL, Brady RR, Wood AM. Smartphone apps for orthopaedic sports medicine - a smart move? BMC Sports Sci Med Rehabil. 2015;7:23. doi: 10.1186/s13102-015-0017-6.
    1. Connor K, Brady RR, De Beaux A, Tulloh B. Contemporary hernia smartphone applications (apps) Hernia. 2014 Aug;18(4):557–61. doi: 10.1007/s10029-013-1130-7.
    1. Marrie RA, Salter AR, Tyry T, Fox RJ, Cutter GR. Preferred sources of health information in persons with multiple sclerosis: degree of trust and information sought. J Med Internet Res. 2013;15(4):e67. doi: 10.2196/jmir.2466.
    1. Colombo C, Mosconi P, Confalonieri P, Baroni I, Traversa S, Hill SJ, Synnot AJ, Oprandi N, Filippini G. Web search behavior and information needs of people with multiple sclerosis: focus group study and analysis of online postings. Interact J Med Res. 2014;3(3):e12. doi: 10.2196/ijmr.3034.
    1. Cafazzo JA, Casselman M, Hamming N, Katzman DK, Palmert MR. Design of an mHealth app for the self-management of adolescent type 1 diabetes: a pilot study. J Med Internet Res. 2012 May 08;14(3):e70. doi: 10.2196/jmir.2058.
    1. Dicianno BE, Henderson G, Parmanto B. Design of mobile health tools to promote goal achievement in self-management tasks. JMIR Mhealth Uhealth. 2017 Jul 24;5(7):e103. doi: 10.2196/mhealth.7335.
    1. Prescott S, Fleming J, Doig E. Goal setting approaches and principles used in rehabilitation for people with acquired brain injury: a systematic scoping review. Brain Inj. 2015;29(13-14):1515–29. doi: 10.3109/02699052.2015.1075152.
    1. Playford ED, Siegert R, Levack W, Freeman J. Areas of consensus and controversy about goal setting in rehabilitation: a conference report. Clin Rehabil. 2009 Apr;23(4):334–44. doi: 10.1177/0269215509103506.
    1. Levack WM, Weatherall M, Hay-Smith EJ, Dean SG, McPherson K, Siegert RJ. Goal setting and strategies to enhance goal pursuit for adults with acquired disability participating in rehabilitation. Cochrane Database Syst Rev. 2015 Jul 20;(7):CD009727. doi: 10.1002/14651858.CD009727.pub2.
    1. Rose A, Rosewilliam S, Soundy A. Shared decision making within goal setting in rehabilitation settings: a systematic review. Patient Educ Couns. 2017 Jan;100(1):65–75. doi: 10.1016/j.pec.2016.07.030.
    1. Tur C. Fatigue management in multiple sclerosis. Curr Treat Options Neurol. 2016 Jun;18(6):26. doi: 10.1007/s11940-016-0411-8.
    1. Hourihan SJ. Managing fatigue in adults with multiple sclerosis. Nurs Stand. 2015 Jun 24;29(43):51–8. doi: 10.7748/ns.29.43.51.e9654.
    1. Gaber TA, Oo WW, Ringrose H. Multiple sclerosis/chronic fatigue syndrome overlap: when two common disorders collide. NeuroRehabilitation. 2014;35(3):529–34. doi: 10.3233/NRE-141146.
    1. Sharp M, O'Sullivan D. Mobile medical apps and mHealth devices: a framework to build medical apps and mHealth devices in an ethical manner to promote safer use - a literature review. Stud Health Technol Inform. 2017;235:363–367.
    1. Rigby S, Ryan RM. Glued to Games: How Video Games Draw Us In and Hold Us Spellbound (New Directions in Media) Santa Barbara, CA: Praeger; 2011.
    1. Head KJ, Noar SM. Facilitating progress in health behaviour theory development and modification: the reasoned action approach as a case study. Health Psychol Rev. 2014;8(1):34–52. doi: 10.1080/17437199.2013.778165.
    1. Resnicow K, Vaughan R. A chaotic view of behavior change: a quantum leap for health promotion. Int J Behav Nutr Phys Act. 2006;3:25. doi: 10.1186/1479-5868-3-25.
    1. Sniehotta FF. Towards a theory of intentional behaviour change: plans, planning, and self-regulation. Br J Health Psychol. 2009 May;14(Pt 2):261–73. doi: 10.1348/135910708X389042.
    1. Schaalma H, Kok G. Decoding health education interventions: the times are a-changin'. Psychol Health. 2009 Jan;24(1):5–9. doi: 10.1080/08870440903126348.
    1. Landers RN, Bauer KN, Callan RC. Gamification of task performance with leaderboards: a goal setting experiment. Comput Human Behav. 2017 Jun;71:508–515. doi: 10.1016/j.chb.2015.08.008.
    1. Nielsen J. Finding usability problems through heuristic evaluation. CHI '92 Proceedings of the SIGCHI Conference on Human Factors in Computing Systems; May 03-07, 1992; Monterey, CA. 1992. pp. 373–380.
    1. Nielsen J. Usability Inspection Methods. New York, NY: John Wiley & Sons; 1994. Heuristic evaluation.
    1. Zanniera C, Chiasson M, Maurera F. A model of design decision making based on empirical results of interviews with software designers. Inf Softw Technol. 2007;49(6):637–53. doi: 10.1016/j.infsof.2007.02.010.
    1. Hanus MD, Fox J. Assessing the effects of gamification in the classroom: A longitudinal study on intrinsic motivation, social comparison, satisfaction, effort, and academic performance. Comput Educ. 2014;80(2015):152–61.
    1. Hamari J, Koivisto J, Sarsa H. Does gamification work? -- A literature review of empirical Ssudies on gamification. 2014 47th Hawaii International Conference on System Sciences (HICSS); January 6-9, 2014; Waikoloa, HI, USA. 2014.
    1. Hamari J. Transforming homo economicus into homo ludens: a field experiment on gamification in a utilitarian peer-to-peer trading service. Electron Commer Res Appl. 2013 Jul;12(4):236–245. doi: 10.1016/j.elerap.2013.01.004.
    1. Riley WT, Rivera DE, Atienza AA, Nilsen W, Allison SM, Mermelstein R. Health behavior models in the age of mobile interventions: are our theories up to the task? Transl Behav Med. 2011 Mar;1(1):53–71. doi: 10.1007/s13142-011-0021-7.
    1. Nielsen J. Enhancing the explanatory power of usability heuristics. CHI '94 Proceedings of the SIGCHI Conference on Human Factors in Computing Systems; April 24-28, 1994; Boston, MA, USA. 1994.

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