=Paper=
{{Paper
|id=Vol-1857/gamifin17_p19
|storemode=property
|title=Usability of a Gamified Application to Promote Family Wellbeing in Child Health Clinics
|pdfUrl=https://ceur-ws.org/Vol-1857/gamifin17_p19.pdf
|volume=Vol-1857
|authors=Anni Pakarinen,Heidi Parisod,Iiro Linden,Minna Aromaa,Jouni Smed,Ville Leppänen,Sanna Salanterä
|dblpUrl=https://dblp.org/rec/conf/gamifin/PakarinenPLASLS17
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==Usability of a Gamified Application to Promote Family Wellbeing in Child Health Clinics==
https://ceur-ws.org/Vol-1857/gamifin17_p19.pdf
Usability of a Gamified Application
to Promote Family Wellbeing in Child Health Clinics
Anni Pakarinen, Heidi Parisod, Iiro Linden, Minna Aromaa,
Jouni Smed, Ville Leppänen and Sanna Salanterä
University of Turku
Finland
{anni.pakarinen, heidi.parisod, iiro.linden, minna.aromaa,
jouni.smed, ville.leppanen, sanna.salantera} @utu.fi
Abstract: The purpose of this study was to evaluate the usability of a gamified application (WellWe) among
public health nurses (PHN) and families with toddlers and preschool-aged children. A post-test design was used.
After providing access to WellWe and using it during one health visit in a child health clinic, data were collected
with structured system usability scale (SUS) from PHNs (n=5) and families (n=15). WellWe had satisfactory
usability with the total mean SUS-score of 65,2. The mean SUS-score was 71,5 among PHNs’ and 58,8 among
families’ evaluations. Most favorable evaluations concerned learning the use of WellWe and managing to use it
without technical support. The least favorable evaluations concerned users’ opinion on their feeling of confidence
when using the application and their willingness for frequent use. WellWe is considered moderately feasible with
respect to usability, but there is need for further improvements. Especially the functionality needs refinement,
different functions need integration and streamlining.
Keywords: Child, Family, Child health clinic, Wellbeing, Gamification, Usability testing
1. Introduction
Family provides an important context for child socialization, in which health-related behaviors are
shaped (Campbell & Hesketh, 2006, Dalton & Kitzmann, 2008, OECD 2013). Children’s wellbeing,
balanced growth and development depend on the wellbeing of their families (Moilanen, Räsänen,
Tamminen, Almqvist, Piha & Kumpulainen, 2010). Thus, interventions directed to the whole family
should be favored.
Interventions that emphasize family-centered approach facilitate detecting each family’s individual
needs and supporting their own resources in an empowering manner (Mikkelssen & Frederikksen
2011). Natural setting for the implementation of such interventions in Finland is the child health
clinics, which reach a wide range of families with children under school age, and, thus, play a
significant role in promoting the wellbeing of children and families (STM, 2009, Government Decree,
338/2011).
The use of health technology and the development of family-centered child health services have been
highlighted in political guidelines (Government Programme, 2015). Technological solutions and their
ease of use as well as independence of time and place attracts people of today and are ever more
present in everyday lives of families. New technology is evolving rapidly, providing the opportunity to
develop and implement innovative and child-friendly interventions (Baranowski, Buday, Thompson &
Baranowski, 2008, Quelly, Norris & DiPietro, 2015). Favorable findings from a recently published
review on digital interventions to promote children’s healthy nutrition and physical activity contributed
to the development and implementation of future digital interventions (Quelly et al., 2015).
Gamification, defined as “the use of game design elements in non-game contexts” (Deterding, Dixon,
Khaled & Nacke, 2011), can increase the enjoyment and engagement (Hamari, Koivisto & Sarsa,
2014), as well as enhance learning and at some extent also health behaviors among adults (Looyestyn
Kernot, Boshoff, Ryan, Edney & Maher, 2017). Among children, gamified approach showed to
increase the attractiveness of health interventions and to be potential in promoting their health (Parisod
et al., 2014). Our exploration on related work showed, that research on digital and gamified health
promotive interventions has evolved during recent years.
GamiFIN Conference 2017, Pori, Finland, May 9-10, 2017 141
According to a recent review, digital health promotive interventions are feasible and acceptable
methods among children and families (Turner, Spruijt-Metz, Wen, Hingle, 2015). A web-based
nutrition-intervention showed high acceptability and usability among families with 8–12-year-old
children in US (Sze, Daniel, Kilanowski, Collins, & Epstein, 2015), a web-based dietary assessment
software was well accepted among 8–11-year-old children in Denmark (Biltoft-Jensen et al., 2014) and
a study of an eHealth tool to enhance parents’ motivation to support 5–17-year-old children’s healthy
behaviors (dietary, physical activity and sedentary behavior) is currently ongoing in Canada (Avis et
al., 2015). There is also evidence about the effectiveness of these gamified solutions. A gamified
approach to promote physical activity among 8–10-year-old children in UK (Coombes & Jones, 2016),
healthier nutrition among elementary school-aged children in US (Jones, Madden & Wengreen, 2014,
Jones, Madden, Wengreen, Aguilar & Desjardins, 2014, Joyner, Wengreen, Aguilar, Spruance, Morrill,
& Madden, 2017) and nutritional knowledge among 8–10-year-old children in Italy (Rosi et al., 2016)
showed positive outcomes.
In addition to these existing gamified interventions, several others are currently under development,
such as a family-based gamified healthy eating app for parents with over 5-year-old children in UK
(Curtis, Lahiri, & brown, 2015) and a gamified monitoring app to improve the snacking patterns of 14–
16-year-old children in Belgium (Lippevelde, 2016). As presented, gamified health promotive
interventions have targeted mostly at school-aged children. To our knowledge, there are no family-
based digital interventions for families with toddlers and preschool-aged children. Thus, there is lack of
digital interventions utilizing gamification among families with toddlers and preschool-aged children
and this area needs further exploration.
2. Description of the Development Process of WellWe
We developed a gamified WellWe-application to promote family wellbeing and to facilitate family-
centered health counseling in child health clinics. We targeted families with toddlers and preschool-
aged children.
The development of WellWe followed a typical iterative game development process (Novak, 2011). To
ensure sustainable implementation of WellWe, participatory design principles were followed. Health
care professionals were involved in each step of the development process. The development process
consisted of several key activities (see Fig 1). WellWe was developed in a multidisciplinary group with
representatives from the fields of nursing, medical, nutrition, physical activity and information
technology and graphical design.
First, the idea and concept of WellWe were created in a multidisciplinary group. The idea and concept
were based on previous evidence and theory, and supplemented with knowledge and experience from
experts in various fields of health. After this, an alpha version of WellWe was developed with experts
from the fields of information technology and graphics. Second, the alpha version of WellWe was
tested among healthcare professionals (n=26), targeting system quality (ease of use), content quality
(relevance and visualization). The data were collected through semi-structured group interviews after
the participants tested the application. Based on the testing, the application was improved and further
developed into beta version. Third, the beta version of WellWe was tested among healthcare personnel
from child health clinics (a medical doctor and PHNs) (n=5), targeting system quality (usability and
functionality), content quality (usefulness, understandability and visualization). The data were
collected through open group discussion after a demonstration of WellWe. During the third step, also
the comments about the visualization and understandability were acquired from the research group’s
and acquaintance’s children (n=3). Based on these steps, the prototype (the release candidate version)
of WellWe was finalized. The data reported in this article were collected during the testing session of
the release candidate version of WellWe. (Fig. 1)
GamiFIN Conference 2017, Pori, Finland, May 9-10, 2017 142
Figure 1. The development process of theWellWe application. Adapted from Novak (2011).
3. Description of WellWe Tool
WellWe was created as a responsive single-page application (SPA) to support as wide a variety of
target devices as possible. This also made the usage of the application simple for the users by removing
the need for any installation procedures; only an up-to-date browser and an Internet connection were
required. The client application was built with modern HTML5 technologies and frameworks (e.g.
AngularJS). The communication with the Node.js –based back end application was done as a RESTful
Web Service (Representational state transfer).
Gamified approach was applied to WellWe and implemented as a child-friendly theme (an amusement
park theme) and reward-like system (a balloon with a rhyme) in monitoring. WellWe includes four
parts: physical activity, nutrition, family resources and daily rhythm. In addition to the child-friendly
theme as a gamified element, we included reward-like system to monitoring. In WellWe, monitoring
means that families move cards (representing for example different nutritional items) relevant to their
behavior into the Ferris wheel and after each card move, a balloon with a rhyme (fact about healthy
behavior) appears to the screen. (Fig. 2). Families monitor their wellbeing by going through the four
parts before entering to the health visit in child health clinic. A session lasts around 15 to 30 minutes
depending on the individuals and whether the children are participating in the use of the application.
PHNs receive information on the families’ wellbeing through WellWe. The information about family is
also available in a statistical format (Fig. 3) and PHNs use this information in health counseling with
families. The aim of WellWe intervention is to promote family wellbeing and facilitate family-centered
health counseling in child health clinics.
Figure 2. The family user-interface of WellWe.
GamiFIN Conference 2017, Pori, Finland, May 9-10, 2017 143
Figure 3. The professional user-interface of WellWe.
4. Aim
The purpose of this study was to evaluate the usability (SUS) of WellWe among PHNs and the families
with 1.5- and 4-year-old children. The data presented in this paper is part of a larger feasibility study.
5. Methods
5.1 Study Sample and Procedures
A post-test design (Fig. 4) and purposive sampling were used. After the study was approved by the Ethics
Committee of the University of Turku, Finland (6/2015/26) and relevant permissions were retrieved from
the Social and Health Board, five child health clinics from Southwest Finland were recruited to the study.
Participation was voluntary and after signing informed consents, PHNs (n=5) were instructed to the study
procedures. Families were recruited through the PHNs by sending all the eligible families (n=109) an
information letter. Eligibility criteria for families were as follows: Ability to communicate in Finnish
GamiFIN Conference 2017, Pori, Finland, May 9-10, 2017 144
language; participation in the regular 1.5 or 4- year health visit in one of the five child health clinic during
the data collection time (October to November 2015). Families were provided instructions for the access to
WellWe in the information letter, and all the families who registered into WellWe (n=25) were sent an
online link to the consent sheet and SU scale (Webropol). Because of low participation rate through online
survey, paper-based questionnaires were sent to the registered families by post. Eventually 15 families
participated into the study. PHNs were asked to fulfill the paper-based SU scale after few health counseling
sessions.
Figure 4. The study design.
5.2 Outcome Measures
Usability of WellWe was measured with System Usability Scale (SUS), which has proved to be a valid
and reliable tool to evaluate the usability of products, systems and services. It has been used in many
studies and can be applied to a wide range of technologies. It consists of ten statements (items) to
which respondent answers according to own perception using 5-point Likert scale ranging from 1=
“strongly disagree” to 5= “strongly agree”. SUS scores in total have a range of 0 to 100 (100 being the
best possible score). (Brooke, 1996.)
5.3 Data Analyses
Descriptive statistics were used to estimate the mean values for each item in SU scale using IBM SPSS
version 23. Usability scores were calculated from mean values using specific SUS-calculation formula
in Excel (Brooke, 1996). Two of the participants had to be excluded because of missing answers in
SUS. In this study, we followed adjective ratings for SUS-scores as reported in (Bangor, Kortum &
Miller, 2009).
6. Results
6.1 Usability (SUS)
PHNs’ and families’ combined evaluation of the usability of WellWe was satisfactory with the mean
SUS-score of 65,2. The usability was found good among PHNs evaluations (mean SUS-score 71,5) and
satisfactory among families’ evaluations (mean SUS-score 58,8). Specifically, both PHNs and families
felt that most people could learn to use the application quickly, it could be used without technical
support and its use does not require learning a lot of things beforehand. In contrast, both PHNs and
families did not feel very confident using the application. Conflicting evaluations were found in some
items, while PHNs giving favorable evaluations and families being of the opposite opinion. (Table 1)
GamiFIN Conference 2017, Pori, Finland, May 9-10, 2017 145
Table 1. Usability of WellWe evaluated with SUS (Brooke, 1996).
PHNs FAMILIES COMBINED
*) (N=5) (N=13) (N=18)
USABILITY STATEMENTS/ITEMS
MEAN MEAN MEAN
(SD) (SD) (SD)
3.2 1.77 2.5
1. I think that I would like to use this application frequently
(0.447) (0.832) (0.985)
1.8 2.30 2.13
2. I found the application unnecessarily complex
(0.837) (1.251) (1.150)
3.8 3.31 3.51
3. I thought the application was easy to use
(1.095) (1.315) (1.247)
4. I think that I would need the support of a technical person 1.20 1.85 1.75
to be able to use this application (0.447) (1.405) (1.237)
5. I found the various functions in this application were well 3.60 2.85 3.20
integrated (0.894) (0.987) (0.998)
6. I thought there was too much inconsistency in this 2.00 2.62 2.40
application (1.224) (1.464) (1.464)
7. I would imagine that most people would learn to use this 4.40 4.08 4.49
application very quickly (0.548) (1.320) (1.150)
2.60 3.15 2.70
8. I found the application very awkward to use
(1.140) (1.519) (1.414)
3.40 2.92 2.93
9. I felt very confident using the application
(0 .548) (1.256) (1.110)
10. I needed to learn a lot of things before I could get going 2.20 1.46 1.74
with this application (1.095) (0.967) (1.029)
*)
Scoring: 5=strongly agree and 1=strongly disagree.
7. Discussion and Conclusions
The purpose of the present study was to explore the feasibility from the perspective of usability of
WellWe among PHNs and the families with 1.5- and 4-year-old children. According to the results the
usability of the WellWe was satisfactory. The usability was found good among PHNs’ evaluations and
satisfactory among families’ evaluations. Some evaluations were found even conflicting and opposite,
with PHNs giving more favorable evaluations. This may have been due to the WellWe- training,
which PHNs received before the use of WellWe. In addition, some of the PHNs were also involved in
the development process, and thus, may have better understanding as regards to the use and purpose of
WellWe. This may have caused the results to be biased towards too positive. Ideally, SUS should be
used after the respondent has tested the system being evaluated, but before any conversations take
place (Brooke, 1996). More research is needed with non-contaminated participants to gain more
reliable results about the usability.
Favorable evaluations were given related to the learning to use WellWe without any technical support
by both, the PHNs and families. This finding is partly in contradiction with the most unfavorable
evaluations given by both. Participants did not feel confident using WellWe, nor were eager to use it
frequently. The lack of confidence may refer to imprecise user instructions and those need to be
reviewed and clarified. Other possible reasons may be inexperience in using digital devices and
uncertainty of the reasons for using WellWe. Also, difficulty to implement new methods fluently into
GamiFIN Conference 2017, Pori, Finland, May 9-10, 2017 146
ones working routines from the PHNs point of view, may decrease the confidence, but also the
eagerness of using WellWe frequently. Lack of time introducing new technologies and hectic everyday
life with small children may decrease the willingness to use WellWe frequently.
Since families thought the functions in WellWe were not well integrated and its use was seen
somewhat awkward, the system needs refinement and different functions need better integration and
streamlining. This may also be the question of gamified elements implemented in WellWe. Since we
aimed at attracting small children with a child-friendly theme, it may have caused some adults feeling
of awkwardness, especially in situations where children were not participating to the use of WellWe.
This may have influenced to the fluent use of WellWe, for example by slowing down the monitoring.
Which, in turn, may have caused a feeling of less successful integration of different functions and an
unpleasant experience for parents. If gamified elements have hindered the functionality of WellWe,
this needs to be addressed in the future development of it.
Gamified elements need reflection also from the perspective of the children, since optimally WellWe is
used together with the children. In this study half of the participated children were 1,5-year-old
toddlers and their participation in these kinds of activities is limited. On the other hand, rest of the
children were 4-year-old preschoolers and their participation is often dependent on the attractiveness of
the activity. The question is, was WellWe enough fun and playful to foster their participation. Thus,
gamified elements need reviewing. We also need to think the optimal and relevant target group for
WellWe. It may be better to target preschoolers, instead of toddlers. On the other hand, tailoring the
user interface according to the users, may be of interest. We could implement WellWe with three
different user interface modes, for parents alone, for parents with toddlers and parents with
preschoolers. This general localization idea increases the possibility to adapt WellWe also into
different contexts and cultures in the future. All in all, unfavorable evaluations from the families may
be due to the fact that the families, were not involved to the development process until the feasibility
study.
This study had some limitations. The low participation rate and small sample size decrease the
generalizability of the results, but this is usually the case in usability studies. Low participation rate
may have skewed the results. Families participating to these kinds of studies are usually from higher
sosio-economical groups. They may have thought that they do not need these kinds of interventions,
and thus, their perceptions may have been less favorable. Families, who might have benefitted from
such interventions, usually do not attend to the studies. Another limitation was that some of the PHNs
were also involved in the development process of WellWe. This may have caused the results to be too
favorable from PHNs point of view. Finally, we did not collect any demographic data from the
participants other than the ages of the children, which prevented us from performing comparative
analyses to make more in-depth interpretations of the results. But, since we aimed to test the usability
of the released candidate version of WellWe, these results may be considered sufficient enough to give
us directions for further development.
As a conclusion, our findings suggest that there is need to further develop WellWe to enhance its
usability. The key improvement needs, emerging from the usability evaluations, concern refining the
functionality, unifying the content and functions and streamlining the system, families use while
monitoring their wellbeing. Also, instructions and gamified elements need reviewing. These
improvements are important in the light of facilitating the implementation of WellWe into health
services. These findings may also be used when developing future digital solutions into health services;
especially the involvement of end-users should be taken into consideration already from the beginning
of the development process.
Acknowledgements
The authors thank the public health nurses, parents and children who participated to the study. We also
thank graphic designer Sara Suvanto for her contributions in the visual design of WellWe. The
conducting of the study was financially supported by the Juho Vainio Foundation, Finland.
GamiFIN Conference 2017, Pori, Finland, May 9-10, 2017 147
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