Children with exercise-induced asthma face several challenges in their daily life, which can improve by proper self-management practices. AIRplay combines biomedical sensing with gamified environments to improve physical conditioning and self-management of asthma among children aged 7 to 9 years old. The goal is to develop a proof-of-concept of coaching application that monitors physical activity of a young asthma patient, provide feedback based on this activity data, and integrates this application with an interactive playground to improve fitness. We discuss three areas where we can improve the current management of asthma among children based on literature and interviews with health care professionals. We present the coaching application and the interactive playground game, followed by a discussion where we discuss the current proof-ofconcept using the Persuasive Design Model (PSD). We also foresee some challenges for future development and research.
Asthma is the most common chronic disease in childhood. In the Netherlands the
number of people with asthma is well over 443.000 and is steadily increasing [
From interviews with medical experts (three pediatricians with experience in the care
of asthmatic patients) and from the literature we identified three main areas where
technology could be used to improve the current management of asthma among children.
The informal semi-structured interviews were performed in several iterations, three
meetings were accompanied with presentations to explain the problem areas, care
challenges, and opportunities for technological enhanced asthmatic care. First, there is the
importance of the physical conditioning of the children. Systematic- and meta-analysis
of the literature showed no consensus whether children with asthma are differently
engaged in physical activity than children without asthma [
A second area is the use and adherence to medication. Adherence to medication
preventing asthma symptoms has been associated with better disease control. Non- or
suboptimal adherence is associated with poorer disease control and increase in asthma
morbidity and mortality [
Studies examining adherence rates with preventive medication by asthmatic children
have reported average adherence rates of 50% to 77% [
The third area identified in which technology can support self-management of
asthma relates to the social, emotional, and mental aspects. Children with asthma do
feel they are different (less popular) and lonely because of their disease and the
medication they have to take. They experience limitations during (sport) activities with peers
and are being bullied, left out and not believed by their peers [
In childhood asthma there is critically low treatment adherence and there is treatment failure which is resulting in high costs and low Quality of Life (QoL). Self-management is needed for optimal asthma control (and life-long health consumption). Current healthcare is not sufficiently supporting children in acquiring self-management skills because of lack of support by health professionals and a lack of insight among parents and children.
Initial studies on technology-based interventions to promote self-management of
asthma focusing on education and medication adherence among the pediatric
population have suggested promising results [
The AIRplay project aims to improve the physical conditioning of children with asthma (7-9 years old) by combining mobile monitoring of daily physical activity with behavior change strategies in gamification elements. That is to say, that we focus on the identified problem areas of physical conditioning and social/emotional aspects, and at least for now not focus on medication adherence. This in short is the context of our AIRplay project: a collaboration between healthcare professionals (Medisch Spectrum Twente and Ziekenhuisgroep Twente) and researchers from the University of Twente in the fields of biomedical signals and human computer interaction.
Pervasive technology makes it possible to track physical activity, using affordable sensors that can be worn throughout the user’s daily life. In combination with tablets and other mobile devices that provide visual feedback, this allows for improving insight into children’s own behavior. In order to persuade children to change their behavior, improving their insight and also encouraging physical activity, we incorporate several coaching and gamification elements into a combination of pervasive technologies.
We are currently working on an implementation of these technologies, consisting of
three elements 1) a simple wearable physical activity sensor, 2) a tablet application, and
3) an interactive playground. With this combination we go beyond the screen, unlike
other exertion games we attempt to change behavior beyond the game play itself (cf
[
For one, in this project we choose to both address healthy children and children with asthma together, in a similar manner. We view that children with asthma should not be stigmatized but should be included in social play behavior (according to their capabilities), and preferably be challenged to increase their amount of play with others, which in turn can help to improve their emotional and mental aspects.
We also target improvement of the fitness of the children. Each child will be provided with a personal daily physical activity goal, in the form of a to be attained number of steps for that day. The target number of steps will be tailored based on their capabilities, and the amount of steps counted by the sensor is send to the tablet application.
The application will show which percentage of their goal they reached, and in this
way tries to stimulate to move more and increase their fitness. A ranking between
children will be made based on this percentage. Another element we are incorporating, is
to reward children with additional abilities in another game, that is physically present
in their world. This game is played on an interactive playground that could be placed
at a school. This playground, consists of an interactive floor projection of about 5 by 5
meter, that responds to players positions as measured by top-down Kinects, see Figure
1. This system was provided to us and allows users to walk in and play without
additional calibration or devices, for more detail on the system we refer to [
The application will also provide useful information and tips regarding the medication, but only for the children with asthma. This could increase the awareness about their medication, and in this way also help to improve adherence and use of medication. 3
We created a game on the playground where children have to use their projected avatar on the floor to either tag an opponent or to catch an opponent, see Figure 2 for a depiction of the game mechanics.
There is a ‘safe house’ that is located in a corner, and switches to another corner every 10 seconds. This ‘safe house’ can be used to take a break from the game, players cannot get caught or tagged whilst inside, this might allow a child (especially those useful for those with asthma) to take a deep breath or even take medication, if necessary. In order to materialize reaching their daily physical activity goals, children are rewarded by unlocking additional levels in the playground game, for instance a level where both teams are able to catch each other. 3.1
Playground Play Sessions About 80 children played with the playground game in four iterations. In total in the first and second iteration combined about 60 children (6-12 years old) participated as part of field trip of their primary school to the university premises. In the first iteration children were slightly older (10-12 years old) than during the second iteration (6-10 years old). The third iteration involved 7 healthy children (7-9 years old) and the fourth and last iteration included 8 children with asthma (7-12 years old), playing in the playground. During the four sessions children showed evidence of physical fatigue, as could be witnessed by their red faces and fast breathing rate. The children did have trouble understanding the game, and additional explanation was given during the games. Nonetheless, children very much liked to play in the playground, as they often asked us to play again, and as was witnessed by the remarks made during the game. 4
Although we did not explicitly start with using a framework like Persuasive Systems
Design [
For the Primary Task Support principles it is clear that we used reduction, tailoring,
personalization, self-monitoring, and rehearsal. Regarding the principle of tunneling,
we do not yet specify how the activity goals will be changed over time, and how the
hints will be used from a more holistic point of view about medication intake.
Furthermore, steering behavior in the playground –changing in-game behavior in a more
directed way with the introduction of new game elements– could also be used as an
interesting tunneling approach to further improve physical activity [
Many principles regarding Dialogue Support are also taken into account to some
extend: suggestions, similarity, liking, and the social role. Other elements also provide
interesting possible additions. Praise, although the winning team of the playground
game is always shown and praised, the app could use some more praising elements
when a user reaches a personal goal. Rewards, we tried to provide meaningful rewards
by having impact (unlocking levels) in a game separate from the app, akin to an
approach applied for digital games were achievements in one game resulted in rewards
for another [
Regarding System Credibility Support elements the systems clearly has a level of trustworthiness, expertise, authority, third-party endorsements, and surface credibility (mainly due to the help of the health care professionals involved in the project). The principle of real-world feel suggests it would be worthwhile to also include possibilities to contact the doctors about tips in the app. Although some third-party endorsements are inevitably linked with the cooperation of doctors in the project, more endorsements for instance of patient interests groups, and the hospitals (e.g. logos) could be helpful for the persuasive power and implementation of the system. The principle of verifiability suggests that further information and sources could be provided in the form of links, for instance regarding the hints or the level of the set personalized goals.
The systems also include many Social Support principles, mainly due to the ranking system and social play aspects: social learning, social comparison, cooperation, competition, and recognition. The latter could also be improved by creative appraisal of behavior similar to achievements in popular games: ”Great you are this week’s busy boots boy” or by using our contacts to show images, videos, and quotes of well-known sport heroes. Regarding social facilitation as well as normative influence, it is also interesting that we plan to place a playground at the hospital waiting room, where multiple children with asthma can play the game together, perhaps even together with parents and a passing-by doctor, which might help to increase the norm for amount of activity.
We can conclude that the PSD framework can efficiently be used for providing many
valuable suggestions, even when an app is linked to a playground. Once we incorporate
some of these suggestions, we still remain with the challenge to evaluate the level of
success in a more summative way based on actual use. For instance, the scope of the
project does not allow for doing a more thoroughly planned RCT, or doing the required
long term study (e.g. 3+ months). At the same time we expect that the novelty, and
tendency of children seen previous research to be positive during evaluations, will be
of influence and that for this and other reasons the long term adherence could drop
compared to results from simple user tests. A challenge of the multi-disciplinary work
is that we need to design both creative solutions while addressing appropriate targets.
All members of the team should work closely together in order to provide valuable,
new, and refreshing persuasive technologies. Furthermore, as is suggested with the PSD
model, to do so not only the medical professionals need to understand aspects of
technological concepts, the HCI professionals also need to understand the user and context
of use. Another challenge beyond the design and showing some scientific proof will be
to actually incorporate into daily practice. Several possible advantages could help to
facility this process such as an entertaining and social environment to stimulate activity
while providing opportunities for automatic behavior analysis (cf [
In this paper we present our work on the AIRPlay project. The goal of the project was to develop a proof-of-concept which combines a coaching application that is able to monitor physical activity of a young asthma patient, provide feedback based on this activity data, and integrates this application with an interactive playground. The integration of the coaching application with the interactive playground allows us to create a fun way in which children can interact with the system to improve the current management of asthma among children. The AIRPlay proof-of-concept can be improved by implementing knowledge from the field of persuasive technology and behavior change support systems in a more structured way. The PSD model can be used to improve or add features to the system to maximize the impact of the system on the management of asthma among children or to apply and translate the concept into applications for other (chronic) conditions. Interesting topics to explore are the way how knowledge from these fields can help to evaluate the system and to design a next version of the AIRPlay system.