Childhood obesity is one of the biggest paediatric public health concern, affecting more than one in three schoolaged children in countries like Spain, Brazil and Greece. This paper describes the gamification approach used in the OCARIoT project in order to promote a long-term behavioral change towards healthy habits in children between 9 and 12 years old. This gamification approach has been designed and validated following a user centricapproach, with a gender-balanced population of around 100 children aged 9 to 12, in four schools in Spain, Greece and Brazil.
INTRODUCTION
Bad long-term habits in eating and lack of physical activity
causes an energy imbalance between consumed and
expended calories. This is the primary cause of obesity.
Therefore, obesity is largely preventable by making
healthier eating choices and exercising regularly1. In the
case of children, childhood obesity is one of the biggest
health problems worldwide and the major paediatric public
health concern, affecting around 224 million school-age
children in the world2. Its prevalence has shot up since 1980
even tripling in many European countries. Childhood
obesity already affects more than one in three school-aged
This paper provides a detailed description on how we have
designed and validated the gamified app following a user
centric-approach and based on a gamification strategy
developed ad-hoc to the OCARIoT’s target group to
motivate and engage them while they acquire healthy
habits.
3 www.oecd-ilibrary.org/docserver/health_glance-2015-en.pdf
The final implementation is still ongoing and will be
validated to support a clinical study that will be performed
in three pilot sites in Europe and Brazil following standard
methodologies already adopted in similar studies [
several times a day; Lots of fruit and vegetables;
sugary and industrial drinks; Get active each day: at least 1 hour of physical activity every day; Limit screen time: sedentary time is associated with an increased risk of becoming overweight; Sleep quality: associations between short sleep duration in early childhood and obesity are consistently encountered.
Using as basis these recommendations and with the support of health professionals, we have also defined a set of KPIs to validate scientifically the outcomes of the project. These KPIs will be measured with the final version of the gamified app ready for the last piloting phase: Reduction rate of obesity childhood >=50%; Improvement of adherence to suggested healthy activities >=60%; Increment of physical activity for end-users >=50% Satisfaction from end-users >=95% USER-CENTRIC DESIGN The aim of OCARIoT is to educate and empower children to become the protagonists of changes in the family environment. That is why we have applied a user-centric approach, involving children from the beginning in the definition of the gamification strategy and gamified app design.
The validation and assessment approach during the design stage of the gamified app has focused on the technical usability, engagement and acceptance from the User Experience (UX) and User Interface (UI) perspectives. A set of validation workshops with children have been done with the two releases of the gamified app design. The next
5 https://kidshealth.org/en/parents/overweight-obesity.html sections provide details about the different steps and results during the design process of the gamified app.
All the procedures followed in the project were in accordance with the ethical standards of the OCARIoT Ethics Board (national and international) and with the Helsinki Declaration of 1995, as revised in 2008. The parents and/or legal representatives of children has signed a consent form for participating in the project.
INITIAL DESIGN OF THE OCARIOT EXPERIENCE The goal of the gamification strategy is to promote children between 9 and 12 years old to acquire healthy habits in the nutritional and physical activity areas while engaging them using fun and easy mechanisms. The expected results aimed to be achieved are: Children embracing healthy habits. Children acquire knowledge about healthy habits and understand how to apply them in their daily life.
Make the learning process about healthy habits as memorable as possible while using the app.
Although the target audience are children between 9 and 12 years old, families, educators and health professionals also play a very important role, promoting the use of the application among children, participating in some activities and setting example in feeding, physical activity and healthy lifestyle. This will clearly reinforce each of the activities proposed by the app while achieving the proposed goal.
During this gamification strategy design and according to the motivators of the target group, we identified four core elements to be integrated in the OCARIoT gamified experience: The storytelling and the world where the experience takes place. Considering the requirements previously collected from the pilot sites and the differences between age ranges (mainly between children aged 9-10 years and 11-12 years) about their preferences and what they like, we designed 5 potential worlds and storytelling (story 1: ninja warriors; story 2: classical mythology; story 3: secret agents; story 4: sci-fi; story 5: superheroes). The coach avatar represents the mentor who challenges children with healthy activities while providing guidance during the whole experience. We designed 19 potential models covering humanoid, pet or monster appearance and combining cartoon and realistic art styles. The items for personalization will be used by children to personalize their mentor. Different types of potential predefined candidates were developed (e.g. clothes, glasses, accessories). The type of educational games will especially focus on promoting the acquisition of knowledge by children. The following types of educational games were identified: Questions-Answer quizzes (e.g. wheel of fortune, Trivia) and Matching/memory games.
Based on this initial design, we organised the first workshops with the objective of collecting the children preferences and feedback about those four gamification elements. Five workshops were organized in four schools (Spain, Greece and Brazil). A total of 56 children between 9 and 12 years old were involved organized by groups of 3, 4 5 children (depending on the total children per workshop) with 29 girls and 27 boys to balance gender aspects. The number of votes for the five different stories provided to children is shown in Table 1 (children had to select two stories, their favorite one as option 1 and the second as option 2). Each vote weights 1 and the votes as Option 1 apply an extra 5% weight to the selected story. The selected storytelling and world were the secret agent with a total weighted score of 9,3. The number of votes for the three different type of mentors provided to children is shown in Table 2 (children had to select two types of mentors, their favorite one as option 1 and the second as option 2). The score calculation is the same as the one used with the story. The Human-type mentor was selected with a total score of 15,4.
And the human-type mentor most voted was the hologram man which is the final design implemented in the gamified app.
Regarding the items for personalizing the mentor, all types of the items were welcome; and finally, the proposed types of educational games were well-accepted.
FINAL DESIGN OF THE OCARIOT EXPERIENCE Based on the feedback from the first validation workshops, the design of the OCARIoT experience was refined around the storytelling of becoming a secret agent (see Figure 1), where the children have to develop three abilities related with the healthy habits.
The look & feel of the app has followed the aesthetics of this agent secret storytelling, challenging children with a set of missions to be completed in the real-world about healthy habits (e.g. physical activity, food intaking). The missions can be individual, if they are performed by the child alone, or social, if they are performed together with family or at school. And each mission is associated at least with one of the abilities to be developed: Dexterity: It is related to physical activity. Intelligence: It is used to teach children all the knowledge related to healthy habits in nutrition and physical activity mainly.
Discipline: It is used for providing children awareness and self-control over the impulses for eating and actions related to sleep, especially to promote better choices with daily food and on weekends.
In order to provide personalized missions to each child, it is
important to establish a baseline to know the current status
of the child. To do so, we use the baseline data collected
through questionnaires (such as Physical Activity
Questionnaire for Children - PAQ-C [7] or Child Eating
Behaviour Questionnaire – CEBQ [
To collect relevant data from children in an easy way about their daily activity and food consumption, we have defined the “secret agent report” feature. The child has to submit an agent report weekly answering some specific questions related to the missions achieved during that period. The mentor design also evolved based on the feedback received from children by providing a more cartoonish design. As explained before, the mentor will be the virtual character that represents the agent trainer who will guide the child during the experience. It provides not only support about how to use the app through a tutorial, but also tips, recommendations and reminders about missions. The child would personalise the mentor with a set of different items, such as accessories, hair and colors (see Figure 2). The personalization items can be bought using coins earned achieving missions and playing the educational games. The mentor supports children on how to use the app through a tutorial, which explains, the rules, the objective, the rewards and all the things the child should know to go inside the experience and back again.
The educational games give the child the ability (knowledge) to overcome a mission (actions to carry out in real life). The four types of educational games will be integrated in the app: “Trivia”, “True or False”, “Matching pairs” and “Find them all”. By playing these educational games, the child will also win points that can be used to buy the personalization items.
The progress is based on the abilities achieved with each mission, the earned coins and the badges achievement in order to show the advancement and current state of child every moment.
Based on this final design, we arranged the second validation workshops to evaluate how the children interact with the app, if the graphical interface was easy to use and understand and if they could perform the proposed activities autonomously. Three workshops were organized in the same four schools (in Spain, Greece and Brazil). A total of 75 children between 8 and 13 years old were involved; 34 girls and 41 boys.
In order to collect their feedback, we used a Software Usability Scale (SUS)-questionnaire adapted for children, where each question was rated using a scale of 1-5, 1 being the lowest (no/nothing), 5 being the highest (yes/great):
Q4: I had some problems to complete the missions. Q5: The navigation through the game was easy and I found what I was looking for.
Q8: I will need the support of an adult to play the game. The received feedback was very positive. The main conclusions about the app were that is easy to use, the role of the mentor is well integrated, and the tutorial will be relevant to introduce the app and also to explain its features. The next table shows a summary of the media results per question and pilot site.
CONCLUSION AND FUTURE WORK Although gamification and game design are showing a great potential for health applications, little is known whether and how effectively it can drive healthy improvement and wellbeing outcomes; specially in childhood obesity domain. This is why we started OCARIoT, aiming to combine personalised health interventions with a gamification strategy addressing the specific needs of obesity in children (between 9 and 12 years old).
Besides, in order to enhance and assess the impact on the solution, health professionals are involved as a core part of the project. We started to design the gamification strategy based on the health requirements provided by the professionals and perform several validation workshops with children. The received feedback was very promising, with a positive engagement from children to use the app and complete the challenges related to healthy habits. As future work, we are working on the final piloting phase to be completed next year in order to evaluate the empirical evidence on the effect of gamification on childhood obesity and healthy habits acquisition.
ACKNOWLEDGMENTS The authors gratefully acknowledge funding from the European Union's Horizon 2020 program under the grant agreement nº 777082 and the Brazilian's Ministry of Science, Technology, Innovation and Communication through RNP, agreement nº 3007 (www.ocariot.com).