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A Co-Designed Active Video Game for Physical Activity Promotion in People With Chronic Obstructive Pulmonary Disease: Pilot Trial

A Co-Designed Active Video Game for Physical Activity Promotion in People With Chronic... Background: People with chronic obstructive pulmonary disease (COPD) who are less active have lower quality of life, greater risk of exacerbations, and greater mortality than those who are more active. The effectiveness of physical activity interventions may facilitate the addition of game elements to improve engagement. The use of a co-design approach with people with COPD and clinicians as co-designers may also improve the effectiveness of the intervention. Objective: The primary aim of this study is to evaluate the feasibility of a co-designed mobile game by examining the usage of the game, subjective measures of game engagement, and adherence to wearing activity trackers. The secondary aim of this study is to estimate the effect of the game on daily steps and daily moderate-to-vigorous physical activity (MVPA). Methods: Participants with COPD who were taking part in the co-design of the active video game (n=9) acted as the experiment group, spending 3 weeks testing the game they helped to develop. Daily steps and MVPA were compared with a control group (n=9) of participants who did not co-design or test the game. Results: Most participants (8/9, 89%) engaged with the game after downloading it. Participants used the game to record physical activity on 58.6% (82/141) of the days the game was available. The highest scores on the Intrinsic Motivation Inventory were seen for the value and usefulness subscale, with a mean of 6.38 (SD 0.6). Adherence to wearing Fitbit was high, with participants in both groups recording steps on >80% of days. Usage of the game was positively correlated with changes in daily steps but not with MVPA. Conclusions: The co-designed mobile app shows promise as an intervention and should be evaluated in a larger-scale trial in this population. (JMIR Serious Games 2021;9(1):e23069) doi: 10.2196/23069 KEYWORDS fitness trackers; chronic obstructive pulmonary disease; physical activity; video games; smartphone; mobile phone quality of life [2,3]. People with COPD are generally less active Introduction than people without COPD [4,5], and physical activity levels generally decline as the disease progresses [6]. Background Inactivity in people with COPD is associated with poorer Chronic obstructive pulmonary disease (COPD) is a leading health-related outcomes, including a lower quality of life, greater cause of death worldwide [1] and is associated with persistent risk of exacerbations, and greater mortality [6-10]. International respiratory symptoms, reduced exercise capacity, and poorer http://games.jmir.org/2021/1/e23069/ JMIR Serious Games 2021 | vol. 9 | iss. 1 | e23069 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Simmich et al guidelines promote regular physical activity in people with Active video games (AVGs), defined as video games that require COPD, generally targeting 30 min of moderate physical activity physical activity to play [32], are another approach that has been on most days [11]. used in an attempt to increase physical activity. A number of studies have investigated the use of AVGs in COPD and other Interventions that are effective in achieving this targeted level chronic respiratory conditions, showing that they can evoke a of physical activity in people with COPD are limited [12,13]. similar physiological response to more traditional exercises (eg, Pulmonary rehabilitation, involving supervised exercise training, stationary bicycle) while being more enjoyable [33]. However, is strongly recommended for people with COPD [14,15], as it the effect that AVGs have on habitual physical activity in an is very effective at increasing exercise capacity [16,17]. Despite unsupervised setting has not been extensively studied in this, many people with COPD struggle to maintain their physical respiratory disease populations [34] or older adults [35]. In activity levels in the months after pulmonary rehabilitation [18], addition, the studies to date have generally used commercially and some do not become more active at all [19]. A longer period available AVGs that are designed for the general population of pulmonary rehabilitation may be more effective at improving rather than for older adults [36] or to address the preferences activity levels, with one systematic review finding that all of people with chronic diseases. Trials of AVGs in older adults studies showing no impact of exercise training on physical with chronic diseases, such as COPD, are required, and such activity had durations of less than 12 weeks, whereas all trials might be expected to demonstrate greater adherence or interventions lasting longer than 12 weeks improved physical effectiveness if those AVGs are designed to take into account activity levels [12]. However, lengthening the duration of the needs and preferences of the patient population involved in pulmonary rehabilitation beyond the 12 weeks may lead to the trial. reduced availability of places in pulmonary rehabilitation programs, which are already limited in many countries [20]. Aims Using a co-design process with people with COPD and Consumer-grade electronic pedometers, such as those developed clinicians, we developed an AVG called Grow Stronger to by Fitbit (Fitbit Inc), have been shown to be valid devices for promote physical activity in people with COPD after pulmonary measuring physical activity in people with COPD [21] and may rehabilitation. A co-design methodology known as participatory enable people with COPD to be more conscious of their physical design was used. Participatory design is a research and design activity levels. Behavioral interventions that use technology practice where the users of a particular system participate as such as wearable pedometers to facilitate self-monitoring of co-designers throughout the design process rather than merely physical activity have shown some short-term effectiveness in as testers providing feedback to designers [37]. A participatory improving physical activity levels in people with COPD [22,23]. design process can, at least in some circumstances, improve the However, the benefits of physical activity may be short lived, effectiveness of serious games for health [38]. possibly because of poor long-term engagement with these interventions [24]. A recent Cochrane review of The primary aim of this study is to evaluate the feasibility of technology-based COPD self-management interventions the Grow Stronger AVG intervention in people with COPD by concluded that “researchers also must take into consideration assessing the usage of and engagement with the AVG, along strategies that will promote long-term engagement with smart with adherence to wearing the Fitbit activity tracker. The technology” [22]. secondary aim of this study is to assess the effect of the Grow Stronger AVG, when combined with a Fitbit activity tracker Gamification is an emerging strategy to improve engagement and Fitbit app, on physical activity in comparison to the Fitbit with digital technology, including within the context of health activity tracker and Fitbit app alone. Primary outcomes included care [25]. Gamification is the use of game design elements in usage of the AVG in the experiment arm of this pilot trial (how nongame contexts [26] and is a common feature in health and often the AVG was used, what types and difficulties of activity fitness apps, including fitness tracker apps [27,28]. Most goals were chosen, and what breathlessness values were commonly, the apps include game features such as digital reported), subjective measures of engagement with the AVG in rewards for goal attainment, avatars (visual representations of the experiment group, and adherence to wearing Fitbit activity players), social or peer pressure (including leaderboards), and trackers in both the experiment and control arms. Secondary the provision of feedback on performance. However, little outcomes were daily steps and daily physical activity levels in research exists on game interventions paired with wearable both the experiment group and control group, as assessed by activity trackers in people with COPD, and trials of gamified the Fitbit activity monitor. interventions in other populations have shown conflicting results. For example, a trial in healthy adolescents of an activity Methods tracking website known as Zamzee (Zamzee Co) demonstrated a 54% increase in moderate-to-vigorous physical activity Overview (MVPA) over 6 weeks [29], but a trial Active Team (Portal Australia), a gamified smartphone app for healthy adults, had This study is a pilot trial nested within an iterative co-design no effect on objectively measured MVPA over 3 months [30]. process to develop an AVG. This co-design process comprised Although both interventions in these studies were gamified, a series of focus groups with people with COPD (n=10) and they differed substantially in the game elements that were used clinicians (n=18), aiming to outline, design, and develop an [29,31], underscoring the impact that different designs can have AVG. For the trial, 9 of the 10 people with COPD who were on the effectiveness of gamification. taking part in the co-design process comprised the experiment group, who received the AVG app in addition to a Fitbit activity http://games.jmir.org/2021/1/e23069/ JMIR Serious Games 2021 | vol. 9 | iss. 1 | e23069 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Simmich et al tracker and Fitbit app. The control group comprised individuals the experiment group), which took part in the focus groups and with COPD who did not take part in the co-design process, who received an activity monitor and the AVG intervention and (2) received only the Fitbit activity tracker and the Fitbit app. a control group, which received an activity monitor but did not take part in focus groups or received access to the AVG. For The study was approved by the Prince Charles Hospital Human the 19-week duration of the co-design process, participants in Research Ethics Committee and ratified by the University of both the experiment and control groups were provided with a Queensland Human Ethics Research Office. consumer-grade wearable activity monitor, namely, a Fitbit Alta The co-design process took place between June 2019 and HR or Fitbit Charge HR 2 (Fitbit Inc.). This activity monitor November 2019, with the pilot trial being conducted for 3 weeks was paired to the participant’s smartphone and was capable of at the end of this process, from October 4, 2019 to October 25, tracking steps, physical activity, and heart rate. Participants in 2019. both groups were provided with instructions on how to use the Fitbit app, and participants in both groups were set up as friends Participants with other participants within their group, allowing participants People who reported they had been clinically diagnosed with to see the weekly step total of other participants and access other COPD were recruited. A letter containing information about social features. It was not possible to blind the participants to the study was sent to recent (previous 12 months) attendees of their group allocation. pulmonary rehabilitation programs across 4 sites operated by The control group did not participate in the focus groups and Queensland Health in the Moreton Bay Region of Queensland, only had in-person contact with the research team during a group Australia. Interested potential participants were screened to enrollment session and study conclusion session. As per Figure ensure they met the inclusion and exclusion criteria. Participants 1, the control group received regular telephone check-ins across were included if they had attended pulmonary rehabilitation in the trial duration to set appropriate step goals on the Fitbit app the past 12 months, were able to read and speak English, and and to provide the same opportunity to raise any device-related were able to exercise independently (with or without the use of issues as was afforded the experiment group before and after mobility aids and supplemental oxygen). Participants were the focus groups. Participants in the experiment group were excluded if they did not have access to a smartphone, were able to trial the test version of the AVG during the final 3 weeks unable to exercise because of medical or physical limitations, of the development process. However, not all participants were required 24-hour supplemental oxygen, or lacked the visual able to download and use the app the day it became available, acuity to view the text displayed on typical mobile devices. resulting in some participants having a shorter period to Procedures experience the AVG than others. At the conclusion of the trial, participants relinquished their wearable fitness trackers, but After all participants were recruited, a randomized sequence of those using the app continued to have access to it for at least a participants was generated. Participants were alternately month after the conclusion of the trial. allocated into 2 groups: (1) an active co-design group (hereafter Figure 1. Contact times, types of contact, and interventions received for each group. Group sessions for the experiment group comprised focus groups in the co-design process along with an install session in week 16, whereas the 2 group sessions for the control group were a group enrolment session in the first week and a study conclusion session in the final week. AVG: active video game. http://games.jmir.org/2021/1/e23069/ JMIR Serious Games 2021 | vol. 9 | iss. 1 | e23069 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Simmich et al Secondary outcome measures collected from all participants Game Intervention included total steps and duration and the intensity of physical The Grow Stronger game and the co-design process undertaken activity. These measures were automatically collected for the to develop it will be described more fully elsewhere. In brief, entire 19-week duration of the study by the Fitbit activity Grow Stronger is a smartphone app that functions as both a trackers provided to participants in both the experiment group game and a physical activity diary. Progress in the game requires and the control group. Devices such as these are considered to the player to report the completion of upper body and lower be valid low-cost devices to measure physical activity in people body physical activities commonly used in the physical with COPD [21]. MVPA was assumed to be the sum of the 2 rehabilitation of people with COPD. The game features a simple highest Fitbit categories for active minutes (fairly active and stick figure image of each activity, and players are provided very active categories). This approach has been previously used with an additional handout with more complete instructions for when comparing consumer-level activity monitors to each activity. Each day, players choose an upper body and lower research-grade accelerometers, demonstrating body activity and set at what difficulty or intensity they wish moderate-to-strong validity for MVPA measured by Fitbit to perform these activities. At the completion of each activity, devices in healthy adults in free-living conditions [42]. users must report their perceived Borg breathlessness value using a slider present in the app to receive their reward for that Before the first focus group, participants also filled in a prestudy activity. survey, providing information on their gender, age, employment status, confidence in technology (on a 0-10 scale), and degree The game features 2 parallel game modes, which can be used of self-perceived functional limitation because of breathlessness, together or separately. The first mode functions as a single as assessed using the Medical Research Council (MRC) dyspnea player mode and uses the theme of growing a garden, where scale [43]. players are rewarded with water in a watering can that can be used to grow a potted plant. The second game mode functions Data Analysis as a cooperative multiplayer game mode and has the theme of Data were analyzed and visualized using Python (Python 3.7; a caravan trip around Australia, visiting multiple well-known Python Software Foundation). Step counts and minutes of Australian destinations. As a team, players are rewarded with activity were collated to a daily figure for each participant, progress on the trip, determined by the average number of which was used to compute each participant’s average for steps activities completed by the team. All data from the use of the per day and MVPA per day over the period before and after the game are reported to a web interface that allows clinicians to AVG was downloaded. Days where no step data were recorded monitor the progress of all players and sends encouraging were ignored when calculating each participant’s average steps messages. A more complete description of the game, along with per day and MVPA per day, effectively interpolating these representative screenshots and a full list of all available missing days with the participant’s own average for that period. activities, is available in Multimedia Appendix 1. One participant in the control group did not wear the Fitbit during the final 3 weeks of the study and so was excluded from Outcome Measures the pre-post comparisons of steps per day and MVPA per day. Several primary outcome measures were collected by the AVG in the experiment group, namely, the usage of the app, type of Owing to the small sample size and nonnormality evident in activities completed, difficulty level selected by participants some outcomes, the Spearman rank correlations were used to for each activity, and reported Borg breathlessness ratings for examine relationships between outcome measures (ie, pre-post each physical activity. Adherence to wearing the Fitbit activity change in daily steps, change in MVPA, game engagement on tracker was assessed using step data collected from the Fitbit GEQ and IMI scales, and game usage). The Spearman rank devices, with nonwear defined as zero steps recorded for an correlation is not affected by skewness and generally copes entire day. better with light-tailed distributions than the Pearson correlation [44]. Additional primary outcome measures of subjective game engagement were collected at the conclusion of the study by As this was a pilot randomized controlled trial, with a sample asking the experiment group to complete 3 questionnaires. First, size determined by optimum focus group size during the the Game Engagement Questionnaire (GEQ) was used [39], co-design process rather than being adequately powered to detect which was measured on a three-level scale (1=no, 2=maybe or differences in primary outcome measures, no statistical tests sort of, 3=yes). Second, 5 subscales of the intrinsic motivation were performed, and data are presented as mean and SD only. inventory (IMI) were employed: interest or enjoyment, perceived competence, effort or importance, value or usefulness, and Results relatedness [40]. Each of these subscales was measured on a seven-point Likert scale (1=completely disagree to 7=completely Participants agree). Finally, a cognitive processing and cognitive activation Figure 2 shows the progression of participants throughout the (CPCA) questionnaire was developed for use in this study, study in a Consolidated Standards of Reporting Trials diagram. adapted from Hollebeek et al [41] and measured on a 7-point Of the 89 participants invited to participate in the study, 37 Likert scale as for the IMI. All questions were given using either responded and were screened against the inclusion and exclusion paper-based or web-based forms immediately after the final criteria. The 25 eligible and consented to participate were focus group. randomized into the 2 arms of the study. Of these, 10 from each group attended the first session and completed the prestudy http://games.jmir.org/2021/1/e23069/ JMIR Serious Games 2021 | vol. 9 | iss. 1 | e23069 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Simmich et al survey. Overall, 2 participants discontinued and withdrew from reported skin irritation from the Fitbit device. Two other the study, both during week 4. One participant withdrew for participants reported some skin irritation, resulting in low Fitbit personal reasons, whereas the other withdrew because of adherence, but did not withdraw from the trial. Figure 2. Consolidated Standards of Reporting Trials diagram showing the flow of participants through the study. One Fitbit device had to be replaced during the trial because of The results from the prestudy survey for the control and issues with synchronization between the activity tracker and experiment groups are shown in Table 1. Aside from the gender phone, but data were not lost. A number of participants also balance, there were no obvious differences between the groups. experienced issues with Bluetooth synchronization, but these Both groups had an MRC dyspnea score between grade 2 and issues were resolved after troubleshooting discussions with the grade 3, indicating moderate functional limitation because of research team, and this did not appear to result in a loss of data breathlessness. for any full day for any participant (although loss of part of the data for that day may have occurred). Table 1. Details of participants who received the full intervention in each arm of the study (n=9). Group Control Experiment Female, n (%) 6 (67) 5 (56) Age (years), mean (SD) 65 (7) 70 (6) Retired, n (%) 8 (89) 9 (100) Confidence with technology (0-10 scale), mean (SD) 5.2 (2) 5.3 (2.3) Medical Research Council dyspnea, mean (SD) 2.4 (1.1) 2.4 (1.2) http://games.jmir.org/2021/1/e23069/ JMIR Serious Games 2021 | vol. 9 | iss. 1 | e23069 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Simmich et al it. Excluding participants who did not use the game at all, the Game Usage Statistics remaining participants logged at least one activity on 58.6% Game Usage Frequency (82/141; SD 21%) of the days when they had access to the game The number of activities logged per day by each participant in during the test period. Note that not all participants downloaded the experiment group is shown in Figure 3. The game allowed and installed the game on their smartphone on the same date. a maximum of 2 activities to be recorded each day. Most Although the test period concluded on October 25, some participants (8/9, 89%) engaged in the game after downloading participants continued to use the game after this date. Figure 3. Number of activities recorded per day for each participant in the experiment group. The period where each participant had downloaded the game, but before the test period had concluded, is indicated by the shaded background. One participant was not shown, as they did not use the game after downloading it on their phone. activity. Outdoor walking was by far the most recorded activity, Types of Activities Recorded recorded 41 times. Walking either indoors or outdoors Figure 4 shows the frequency of activities that were recorded represented 34.5% (57/165) of all recorded activities. using the app as well as which participants recorded which http://games.jmir.org/2021/1/e23069/ JMIR Serious Games 2021 | vol. 9 | iss. 1 | e23069 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Simmich et al Figure 4. Number of times each activity was recorded by participants in the experiment group. using the app are shown in Table 2. The mean Borg Borg Breathlessness Values breathlessness score was 3.8 (SD 1.3). The frequencies of Borg breathlessness values, reported on the 0 to 10 modified Borg breathlessness scale, after activities when Table 2. Frequency for Borg breathlessness values recorded by the experiment group. Breathlessness value (modified Borg scale) Number of events recorded in the app 1 8 2 18 3 32 4 65 5 34 6 3 7 3 8 1 10 1 3. Higher numbers represented greater difficulty for a given Difficulty Values Selected physical activity task. All difficulties were roughly equally The frequency at which participants selected the various represented, with no evident skew to higher or lower difficulties. difficulty or intensity options in using the app is shown in Table http://games.jmir.org/2021/1/e23069/ JMIR Serious Games 2021 | vol. 9 | iss. 1 | e23069 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Simmich et al Table 3. Frequency for difficulty values selected by the experiment group. Selected difficulty Number of events recorded in the app 1 36 2 47 3 36 4 46 The scores on the IMI subscales are shown in Table 4. The Game Engagement highest scores were seen for the value and usefulness subscale, People with COPD in the experiment group completed 3 with a mean of 6.4 (SD 0.6). All other subscales had lower measures of subjective game engagement: IMI, GEQ, and a scores, ranging from approximately 5.1 to 5.7. series of CPCA questions developed for this study. Table 4. Intrinsic Motivation Inventory subscale scores (7-point Likert scale). Subscale Score, mean (SD) Interest and enjoyment 5.4 (0.5) Perceived competence 5.7 (1.0) Effort and importance 5.3 (0.9) Value and usefulness 6.4 (0.6) Relatedness 5.1 (1.1) The total score for the 19 items of the GEQ for each participant scale has a minimum possible score of 19 and a maximum is presented in Table 5. The GEQ score totals ranged from 19 possible score of 57, a score of 30.4 represents 30% (11.4/38) to 39, with a mean GEQ total score of 30.4 (SD 6.9). As this of the distance between these extremes. Table 5. Total scores for the Game Engagement Questionnaire. Participant Game Engagement Questionnaire score 2 28 4 36 6 35 7 26 8 30 10 39 12 19 The results for each individual question in the CPCA ranging from 5.2 to 6.5 on a 7-point Likert scale. Mean scores questionnaire are presented in Table 6. Participants generally were higher for items relating to their health goals (items 1-3), had a moderate to high degree of agreement across all questions, all of which had a mean of 6.5 (SD 0.8). Table 6. Cognitive processing and cognitive engagement individual item results. Question Score, mean (SD) 6.5 (0.8) CPCA1 : Using the game gets me to think about my health goals (n=8) CPCA2: I think about my health goals a lot when I'm using the game (n=8) 6.5 (0.8) CPCA3: Using the game stimulates my interest to learn more about achieving my health goals (n=8) 6.5 (0.8) CPCA4: I spend a lot of time using the game, compared to other ways of being physically active (n=8) 5.4 (1.4) CPCA5: Whenever I'm trying to be more active, I usually use the game (n=5) 5.6 (1.5) CPCA6: The game is what I usually play when I think about being physically active (n=5) 5.2 (2.4) CPCA: cognitive processing and cognitive activation. http://games.jmir.org/2021/1/e23069/ JMIR Serious Games 2021 | vol. 9 | iss. 1 | e23069 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Simmich et al group had a slightly higher average adherence than the Fitbit Wear Adherence experiment group, wearing the Fitbit on 94.5% (1069/1131) of Figure 5 shows the weekly average adherence to Fitbit activity days compared with 84.3% (975/1157) of days in the experiment trackers for participants across the study period, as calculated group. This was especially evident during the middle of the by days with a nonzero step count divided by total days and study period when adherence in the experiment group decreased expressed as a percentage. Overall, participants in the control for several weeks. Figure 5. Average weekly adherence to wearing Fitbits in each group before and after the Grow Stronger app was downloaded by the experiment group. The period where each participant had downloaded the game is indicated by the shaded background. The control group, which did not download the game, were aligned with the majority of the experiment group for ease of comparison. As weeks are assumed to start on Mondays, but most participants downloaded the game on a Friday (day 0), the value for the final week before the game was downloaded (the last week in the unshaded area) included values from days 1 and 2 after the game was downloaded. All participants are included in the data presented in this figure. Ctrl: control; Exp: experiment. day, representing a decrease of 81 steps per day or a 2% Steps decrease. In the period before the experiment group downloaded Across all weeks before the game intervention was downloaded, Grow Stronger, the control group was averaging 6394 (SD 4306, the experiment group averaged 4730 (SD 1959, range range 2700-15,000) steps per day, which then decreased by 800 1493-7522) steps per day, as shown in Figure 6. Steps in the steps per day (800/6394, 12.5%) to 5593 (SD 4277; range experiment group in the weeks after downloading the Grow 1924-14,367) steps per day. Stronger AVG averaged 4649 (SD 2357, range 1853-8130) per Figure 6. Average steps per day and MVPA per day in each group before and after the game was downloaded. Ctrl: control; Exp: experiment; MVPA: moderate-to-vigorous physical activity. http://games.jmir.org/2021/1/e23069/ JMIR Serious Games 2021 | vol. 9 | iss. 1 | e23069 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Simmich et al Individual step count charts for each participant are shown in the primary outcome measures (game adherence, game Multimedia Appendix 2 for the experiment and control groups. engagement on GEQ, and game engagement on IMI), the Spearman correlation coefficients were calculated. Table 7 MVPA shows the results in the form of a correlation matrix (a scatter As shown in Figure 6, before the game intervention was matrix for these comparisons can be found in Multimedia downloaded, the experiment group was averaged 33 (SD 30; Appendix 3). There appeared to be a moderately high positive range 3-76) min of MVPA per day, and in this period, the correlation, with a Spearman rank correlation coefficient of 0.62 control group had an average daily MVPA of 34 (SD 41; range between the pre-post change in daily step and the usage of the 3-120) min. During the game intervention, the experiment group Grow Stronger app (as assessed by percentage of days during was averaging 42 (SD 48; range 2-122) min of MVPA, and the the test period with at least one activity logged). Physical activity control group was averaging 33 (SD 62; range 1-182) min of was weakly correlated with game usage. The total score on the MVPA each day. This represented an increase of approximately GEQ correlated moderately strongly and positively with the 9 min per day or a 26% increase for the experiment group and mean score on the IMI, with correlation coefficients of 0.61. an approximately 1 min or 2% decrease for the control group The pre-post change in daily steps appeared to be strongly per day. negatively correlated with both the subjective measures of game engagement, with correlation coefficients of −0.79 for the GEQ Correlations Between Outcome Measures and −0.71 for the IMI. The subjective measures of game To explore the relationships within and between the secondary engagement (GEQ or IMI) did not appear to correlate with outcome measures (pre-post change in MVPA and steps) and changes in daily MVPA or to game adherence. Table 7. Spearman rank correlation matrix between primary and secondary outcomes in the experiment group. Outcome measures Spearman rank correlation ΔSteps per day Game usage Game Engagement Intrinsic Motivation Inventory Δ Moderate-to-vigorous Questionnaire physical activity per day ΔModerate-to-vigorous physical 1.00 — — — activity per day (pre-post) ΔSteps per day (pre-post) 0.21 1.00 — — — Game usage (percentage of days 0.45 0.62 1.00 — — with activities logged on Grow Stronger ) Game Engagement Questionnaire 0.21 −0.79 0.07 1.00 — Intrinsic Motivation Inventory 0.19 −0.71 −0.19 0.61 1.00 Δ: change in. —: These cells are deliberately left blank. The table is symmetrical about the diagonal, so the data are not repeated. weeks but filled in the daily symptom diary just 16 times on Discussion average [46]. Similarly, in the pilot trial of Condition Coach (Roessingh Research and Development), which included a Summary of Primary Findings website with a symptom diary and exercise module, the website This study assessed the feasibility of the AVG intervention by was visited on 86% of the days available, but the exercise measuring usage of the AVG in the experiment arm of this pilot module was only completed on 21% of the days [47]. Although trial and adherence to wearing Fitbit activity trackers in both the pilot trial lasted 9 months compared with just 3 weeks in the experiment and control arms. The usage of the game in this this study, adherence to the Condition Coach exercise portal study was moderate, with participants who used the game was clearly low throughout: only 5 of the 12 participants recording at least one activity on 58.6% (82/141) of the days. completed any exercises in the exercise portal. In comparison, This is slightly lower than the usage rates reported in the first 8 of the 9 participants completed at least one activity in Grow few weeks of similar studies of apps or websites for physical Stronger. However, these other apps were able to send activity promotion. For example, 68% of users of the gamified notifications to participants during these trials, whereas our Active Team app were accessing the gamified app each day by Grow Stronger app lacked the ability to provide notifications, day 7, although this fell to 31% by day 91 [45]. However, usage which may have improved usage if it was available. of Grow Stronger was measured by days with logged activities; The Fitbit was worn on 84% of the days by participants in the therefore, it may be expected to be lower than a usage experiment group and on 94% of the days by participants in the measurement based on days where the intervention was merely control group. These values are comparable with those reported accessed. The difference between these 2 methods of measuring by Wan et al [48], where pedometer wear adherence ranged usage was illustrated by the pilot trial of ActivityCoach between 80% and 90% in people with COPD. It is worth noting, (Roessingh Research and Development), which found that however, that this pedometer was worn on the hip, pocket, or participants visited the website an average of 23 times over 4 http://games.jmir.org/2021/1/e23069/ JMIR Serious Games 2021 | vol. 9 | iss. 1 | e23069 | p. 10 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Simmich et al with a lanyard, in contrast to the wrist-worn Fitbits provided in modified for the purposes of this trial, no comparisons to other this study. Adherence is thought to be higher for wrist-worn studies are available. activity trackers than hip-worn in adolescents [49], although It is also noteworthy that a response rate of around 41% (37/89) several participants in our study reported skin irritation, which was observed among participants invited to participate in this may have decreased wear adherence. study. Although we cannot determine the reason for Difficulty options selected in the app by participants were nonresponse, some may not have responded because of lack of roughly equally distributed, indicating that the difficulty options access to, or reservations about, technological interventions. A presented were adequate for participants with COPD. Reported recent survey of people with COPD attending pulmonary Borg breathlessness values were clustered around 3 to 5 on the rehabilitation in metropolitan areas of Australia found that 48% modified Borg scale, indicating moderate shortness of breath had personal access to a smartphone and 57% felt that their and representing an appropriate target for exercise in people technology skills were adequate or better [53]. Nonetheless, the with COPD [50]. results of that survey and the engagement of participants in our study suggest that a substantial portion of people with COPD Engagement with the game in the experiment group as assessed are willing to use technology in their rehabilitation. on the GEQ averaged 30.4, out of a minimum possible score of 19 and a maximum possible score of 57. This is comparable Summary of Secondary Findings with the GEQ results originally reported during the development In addition to the primary findings mentioned previously, this of the GEQ, which were generally around 30 to 32 for study also examined the effect on daily steps and daily physical adolescents and undergraduates playing common video games activity levels of the combination of the Grow Stronger AVG [39]. However, the result in this study is lower than the score and Fitbit activity tracker with the Fitbit app, compared with given by healthy adults for AVGs [51], which would have the Fitbit activity tracker with the Fitbit app alone, in patients corresponded to a score of 42 if the adapted GEQ with a with COPD. A noteworthy finding of this study was that the seven-point scale used in that study was transformed into the experiment group performed an average of 9 min more MVPA three-point scale used in this study and in the original after downloading the game, whereas the MVPA in the control development study of the GEQ. The scores on the GEQ found group remained roughly similar. Although these results must in this study may be lower than that seen by other games because be interpreted cautiously because of the low sample size of this several items on the GEQ assess the subjective experiences of pilot trial and the large sample SD in the results, this nonetheless immersion and flow that may not be elicited by a game, such suggests that the AVG may have a positive effect on physical as Grow Stronger, which does not provide real-time feedback activity in this population. To the best of our knowledge, no to players. GEQ results for games similar to Grow Stronger are published research has examined the effect on physical activity unfortunately not available for comparison. of a mobile game intervention combined with a wearable activity tracker versus an activity tracker alone in patients with COPD. Participants in the experiment group appeared to have given a higher average rating for the value and usefulness subscale of Another secondary finding of this study was that the average the IMI than other subscales such as interest or enjoyment, steps per day decreased by 13% in the control group but only relatedness, and effort or importance. This would suggest that by 2% in the experiment group. Despite the large variability in participants were primarily motivated to play Grow Stronger this small sample, this finding is consistent with the hypothesis because they saw value in it rather than because they enjoyed that AVG could ameliorate the decline in physical activity often the game, felt a degree of relatedness to other players, or were experienced after pulmonary rehabilitation [18]. It is also motivated to put effort into it. It is possible that by being possible that the activity tracker itself caused an initial increase involved in the design of the game from its inception, in daily steps, which slowly waned over the duration of the participants in this trial were especially aware of the value or study before being partly counteracted by the effect of the AVG potential usefulness of the game. In addition, it has been shown in the experiment group. Other studies of people with COPD that multiplayer AVGs offer greater relatedness than single have, however, examined the combination of activity trackers player ones [52], so designing Grow Stronger to provide the with mobile apps to encourage daily steps [23]. These mobile option of a single player experience in addition to multiplayer apps were not considered games and lacked clear game features may have diluted ratings on the relatedness dimension. but did incorporate behavior change techniques (such as self-monitoring, goal setting, and social support) that could have The CPCA scale showed somewhat higher mean scores for an effect similar to game design elements. For example, Moy health goal questions than physical activity questions, indicating et al [54] and Wan et al [48] compared the effect of a pedometer that participants primarily associated the game with achieving alone to the same pedometer combined with a website health goals rather than performing physical activity. This could intervention, which encouraged incremental goal setting, be because of the design of the game, which allowed players to allowed social communication between users, and provided perform physical activity away from their smartphone and then educational and motivational messages. These studies, to return to their phone to play Grow Stronger. This temporal respectively, showed steps per day increased 13% in the asynchrony between being physically active and playing the intervention group, with no significant change in the control game may have decreased the association between the game group at 17 weeks [54], and an increase of 19% in steps per day and physical activity, whereas participation in the design process in the intervention group versus a decrease of 5% in steps per may have increased the association between playing the game day in the control group after 13 weeks [48]. These 2 studies and reflecting on health goals. As this scale was significantly http://games.jmir.org/2021/1/e23069/ JMIR Serious Games 2021 | vol. 9 | iss. 1 | e23069 | p. 11 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Simmich et al demonstrated an increase in the steps for the intervention with relationship in the context of either smartphone AVGs or AVGs little change to the control group, whereas we found little change for older adults. in the experiment group but a decrease in the control group. A Subjective measures of game engagement did not appear to be decrease in daily steps in the control group was also observed correlated with game usage, which is contrary to a previous in a trial of a mobile app that enabled clinician feedback study that demonstrated a correlation between the IMI rating combined with activity tracker compared with activity tracker of a smartphone game to improve physical activity and the usage alone at 3 or 6 months [55]. However, in contrast to this study of said game [58]. However, the correlation in that study was where daily steps decreased only in the control group, in that assessed before and after a 24-week intervention in a group of study, both the control group and the experiment group 18 people with diabetes. At just 3 weeks with only 9 people decreased steps per day by approximately 14%. Vorrink et al with COPD, this study may not have been long enough for a [55] suggested that either the use of a smartphone app rather correlation between game usage and subjective game enjoyment than a website or the involvement of health professionals could to arise or be large enough to detect whether such a correlation have contributed to the lack of difference between groups, but did exist. In addition, that study [58] employed a linear the Grow Stronger intervention used in this pilot trial was also regression rather than the Spearman correlation as used in this a mobile app and also involved clinicians, yet a difference study, precluding direct comparison between the 2 studies. between groups was observed. Furthermore, although both Moy et al [54] and Vorrink et al [55] used activity tracking websites Limitations or apps that were specifically designed for users with chronic This study is limited in several ways. As a pilot trial with a diseases, only the intervention used in a study by Vorrink et al small number of participants and short duration, with the sample [55] consulted people with COPD during the design phase and size, and trial duration oriented around the co-design process, only after the initial design had been developed [56]. this trial was underpowered to detect differences in steps and physical activity, which could be expected from such a short The observed change in daily steps was positively correlated intervention. A larger and longer duration trial would be required with game usage, indicating that those who used the game more in the future to gain a meaningful estimate of the effect of the often also had a greater increase (or smaller decrease) in daily AVG on daily steps and physical activity. In addition, steps. This is consistent with walking, which is the most participants in the experiment group were co-designers of the commonly recorded activity in the game. A correlation between intervention, so they may have been more invested in the game game usage and MVPA was also present but weaker than that that they helped to create. Therefore, this study’s results may between steps and game usage. A stronger correlation between not be generalizable to a population who are naïve to the game. game usage and physical activity may have been expected, given that a recent study found that those in the top quartile for the Furthermore, the trial period formed part of the design process, usage of a gamified smartphone app, Active Team, increased with feedback from participants used to develop a final version their daily physical activity by 18 min (around 17% of baseline), of the game intervention beyond the test version trialed in this whereas users in the lowest 3 quartiles of app usage decreased study. Therefore, the results of this study do not account for the their daily physical activity by 8 min (around 8% of baseline) effect that these revisions may have had on the effectiveness of [45]. Physical activity in that study was assessed by or adherence to the final version of the game, which will be research-grade accelerometry rather than the wearable activity tested in future studies. For instance, the version of the Grow tracker provided to participants, as was used in this study. It is Stronger app used in this study was not able to record usage possible that Fitbit activity trackers did not count toward the data regarding when participants accessed the app for purposes MVPA measurement of the short bouts of strength training that other than to record the completion of an activity. As such, no the Grow Stronger app encouraged participants to do. data were available on how often participants used the pause button feature or used the app to interact with one another or Surprisingly, subjective game engagement, as measured on the check their individual or team progress. Similarly, as mentioned, GEQ and IMI, appeared to be negatively correlated to steps but the app was unable to send notifications, and app usage was not correlated to MVPA. This is contrary to the implicit likely lower than it would be with reminder notifications hypothesis that the engaging nature of AVGs would encourage enabled. The future version of the app will address these both more steps and more physical activity. This also conflicts limitations. with the results of other AVGs in other populations such as children, where an increased level of intrinsic motivation and As this pilot trial was embedded within a co-design process, enjoyment were correlated with increased physical activity [57]. the control condition was selected without full knowledge of It is possible that those who found Grow Stronger most the eventual design of Grow Stronger and so may not have been enjoyable were more likely to have performed other forms of an ideal comparison. The control group received Fitbit activity physical activity encouraged by the app, such as upper limb trackers and the Fitbit app under the assumption that the AVG strength exercises, in place of their usual walking. If strength provided to the experiment group would most closely resemble training could not be readily detected as MVPA by the Fitbit, the Fitbit app, albeit in the form of a game. However, as a result this would not appear as a correlation between game engagement of the co-design process, Grow Stronger more closely resembled and MVPA. Possible reasons for the negative relationship a mobile exercise diary. As such, future studies aiming to between subjective game engagement and physical activity explore the effect of the game elements of Grow Stronger on remains speculative, as no other studies have examined this physical activity should compare this game with a mobile exercise diary app that functions similar to Grow Stronger but http://games.jmir.org/2021/1/e23069/ JMIR Serious Games 2021 | vol. 9 | iss. 1 | e23069 | p. 12 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Simmich et al lacks game elements. In addition, the use of any digital It is also worth noting that the CPCA questions used herein, technologies in COPD may not represent the usual standard of although they were based on previously validated scales, were care for people with COPD. Therefore, future research may also modified significantly to fit the purposes of this study and so compare Grow Stronger with usual care of people with COPD may no longer retain their validity. Future research should seek after pulmonary rehabilitation, namely, providing a control to validate these measures or use alternative validated measures. group with an entirely unsupervised home exercise program. Finally, no objective tests of lung function or functional status In this study, activity outcome measures were recorded by were performed, nor were results from such tests available for commercial-grade Fitbit activity monitors, rather than a this trial. Although it is very likely that all participants had research-grade physical activity monitor, which presents 2 main COPD, as they all had attended a pulmonary rehabilitation class limitations. First, although older hip-worn Fitbit devices have that requires referral by a physician, future research may benefit been shown to have a good correlation with research-grade from confirmation of a clinical COPD diagnosis. In addition, activity monitors [21] in people with COPD, this study was the results of spirometry or exercise tolerance tests could be conducted with newer wrist-worn Fitbit activity monitors for used to appropriately stratify participants in a future trial. which such validity data are not known in COPD. The Conclusions wrist-worn Fitbit Charge 2 devices used in this study have To our knowledge, this is the first study that trials an AVG shown high validity for step counts but only moderate validity designed by people with COPD and clinicians to maintain or for MVPA when compared with research-grade accelerometry enhance physical activity levels. Although the results are limited in older adults [59]. Second, the Fitbit devices were part of the because of the small sample size, this study is an initial intervention given to both groups, and data from such devices demonstration of the potential value of an app that facilitates were visible to participants, which may have caused participants physical activities for people with COPD. Future work is to alter their physical activity in response. Future studies may required to further improve adherence and to investigate the therefore benefit from employing accelerometers with long-term effects of this intervention. Despite this, the Grow established validity for MVPA and concealing such Stronger app shows promise as an intervention worthy of a measurements from participants. larger-scale trial in this population. Acknowledgments The authors would like to thank Bitlink for their work in developing the software used in this study. Additional thanks go to Anita Keightley for her assistance with recruitment of participants in this study. Conflicts of Interest None declared. Multimedia Appendix 1 Screenshots and description of the Grow Stronger smartphone app. [DOCX File , 698 KB-Multimedia Appendix 1] Multimedia Appendix 2 Daily step counts for individual participants in the experiment group and control group. [DOCX File , 307 KB-Multimedia Appendix 2] Multimedia Appendix 3 A scatter matrix for correlations between the primary and secondary outcome measures in the experiment group. [DOCX File , 73 KB-Multimedia Appendix 3] References 1. GBD 2016 Causes of Death Collaborators. 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People attending pulmonary rehabilitation demonstrate a substantial engagement with technology and willingness to use telerehabilitation: a survey. J Physiother 2017 Jul;63(3):175-181 [FREE Full text] [doi: 10.1016/j.jphys.2017.05.010] [Medline: 28652080] 54. Moy ML, Collins RJ, Martinez CH, Kadri R, Roman P, Holleman RG, et al. An internet-mediated pedometer-based program improves health-related quality-of-life domains and daily step counts in copd: a randomized controlled trial. Chest 2015 Jul;148(1):128-137. [doi: 10.1378/chest.14-1466] [Medline: 25811395] 55. Vorrink SNW, Kort HSM, Troosters T, Zanen P, Lammers JJ. Efficacy of an mHealth intervention to stimulate physical activity in COPD patients after pulmonary rehabilitation. Eur Respir J 2016 Oct;48(4):1019-1029. [doi: 10.1183/13993003.00083-2016] [Medline: 27587557] 56. Vorrink SNW, Kort HSM, Troosters T, Lammers JJ. A mobile phone app to stimulate daily physical activity in patients with chronic obstructive pulmonary disease: development, feasibility, and pilot studies. JMIR Mhealth Uhealth 2016 Jan 26;4(1):e11 [FREE Full text] [doi: 10.2196/mhealth.4741] [Medline: 26813682] 57. Gao Z, Podlog L, Huang C. Associations among children's situational motivation, physical activity participation, and enjoyment in an active dance video game. J of Sport and Health Sci 2013 Jun;2(2):122-128 [FREE Full text] [doi: 10.1016/j.jshs.2012.07.001] 58. Höchsmann C, Infanger D, Klenk C, Königstein K, Walz SP, Schmidt-Trucksäss A. Effectiveness of a behavior change technique-based smartphone game to improve intrinsic motivation and physical activity adherence in patients with Type 2 diabetes: randomized controlled trial. JMIR Serious Games 2019 Feb 13;7(1):e11444 [FREE Full text] [doi: 10.2196/11444] [Medline: 30758293] 59. Tedesco S, Sica M, Ancillao A, Timmons S, Barton J, O'Flynn B. Validity evaluation of the Fitbit Charge2 and the Garmin vivosmart HR+ in free-living environments in an older adult Cohort. JMIR Mhealth Uhealth 2019 Jun 19;7(6):e13084 [FREE Full text] [doi: 10.2196/13084] [Medline: 31219048] Abbreviations AVG: active video game COPD: chronic obstructive pulmonary disease CPCA: cognitive processing and cognitive activation GEQ: Game Engagement Questionnaire IMI: Intrinsic Motivation Inventory MRC: Medical Research Council MVPA: moderate-to-vigorous physical activity http://games.jmir.org/2021/1/e23069/ JMIR Serious Games 2021 | vol. 9 | iss. 1 | e23069 | p. 16 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Simmich et al Edited by N Zary; submitted 31.07.20; peer-reviewed by H Lewthwaite, L Mantoani; comments to author 19.09.20; revised version received 12.11.20; accepted 26.11.20; published 27.01.21 Please cite as: Simmich J, Mandrusiak A, Smith ST, Hartley N, Russell TG A Co-Designed Active Video Game for Physical Activity Promotion in People With Chronic Obstructive Pulmonary Disease: Pilot Trial JMIR Serious Games 2021;9(1):e23069 URL: http://games.jmir.org/2021/1/e23069/ doi: 10.2196/23069 PMID: 33502321 ©Joshua Simmich, Allison Mandrusiak, Stuart Trevor Smith, Nicole Hartley, Trevor Glen Russell. Originally published in JMIR Serious Games (http://games.jmir.org), 27.01.2021. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on http://games.jmir.org, as well as this copyright and license information must be included. http://games.jmir.org/2021/1/e23069/ JMIR Serious Games 2021 | vol. 9 | iss. 1 | e23069 | p. 17 (page number not for citation purposes) XSL FO RenderX http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JMIR Serious Games JMIR Publications

A Co-Designed Active Video Game for Physical Activity Promotion in People With Chronic Obstructive Pulmonary Disease: Pilot Trial

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Abstract

Background: People with chronic obstructive pulmonary disease (COPD) who are less active have lower quality of life, greater risk of exacerbations, and greater mortality than those who are more active. The effectiveness of physical activity interventions may facilitate the addition of game elements to improve engagement. The use of a co-design approach with people with COPD and clinicians as co-designers may also improve the effectiveness of the intervention. Objective: The primary aim of this study is to evaluate the feasibility of a co-designed mobile game by examining the usage of the game, subjective measures of game engagement, and adherence to wearing activity trackers. The secondary aim of this study is to estimate the effect of the game on daily steps and daily moderate-to-vigorous physical activity (MVPA). Methods: Participants with COPD who were taking part in the co-design of the active video game (n=9) acted as the experiment group, spending 3 weeks testing the game they helped to develop. Daily steps and MVPA were compared with a control group (n=9) of participants who did not co-design or test the game. Results: Most participants (8/9, 89%) engaged with the game after downloading it. Participants used the game to record physical activity on 58.6% (82/141) of the days the game was available. The highest scores on the Intrinsic Motivation Inventory were seen for the value and usefulness subscale, with a mean of 6.38 (SD 0.6). Adherence to wearing Fitbit was high, with participants in both groups recording steps on >80% of days. Usage of the game was positively correlated with changes in daily steps but not with MVPA. Conclusions: The co-designed mobile app shows promise as an intervention and should be evaluated in a larger-scale trial in this population. (JMIR Serious Games 2021;9(1):e23069) doi: 10.2196/23069 KEYWORDS fitness trackers; chronic obstructive pulmonary disease; physical activity; video games; smartphone; mobile phone quality of life [2,3]. People with COPD are generally less active Introduction than people without COPD [4,5], and physical activity levels generally decline as the disease progresses [6]. Background Inactivity in people with COPD is associated with poorer Chronic obstructive pulmonary disease (COPD) is a leading health-related outcomes, including a lower quality of life, greater cause of death worldwide [1] and is associated with persistent risk of exacerbations, and greater mortality [6-10]. International respiratory symptoms, reduced exercise capacity, and poorer http://games.jmir.org/2021/1/e23069/ JMIR Serious Games 2021 | vol. 9 | iss. 1 | e23069 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Simmich et al guidelines promote regular physical activity in people with Active video games (AVGs), defined as video games that require COPD, generally targeting 30 min of moderate physical activity physical activity to play [32], are another approach that has been on most days [11]. used in an attempt to increase physical activity. A number of studies have investigated the use of AVGs in COPD and other Interventions that are effective in achieving this targeted level chronic respiratory conditions, showing that they can evoke a of physical activity in people with COPD are limited [12,13]. similar physiological response to more traditional exercises (eg, Pulmonary rehabilitation, involving supervised exercise training, stationary bicycle) while being more enjoyable [33]. However, is strongly recommended for people with COPD [14,15], as it the effect that AVGs have on habitual physical activity in an is very effective at increasing exercise capacity [16,17]. Despite unsupervised setting has not been extensively studied in this, many people with COPD struggle to maintain their physical respiratory disease populations [34] or older adults [35]. In activity levels in the months after pulmonary rehabilitation [18], addition, the studies to date have generally used commercially and some do not become more active at all [19]. A longer period available AVGs that are designed for the general population of pulmonary rehabilitation may be more effective at improving rather than for older adults [36] or to address the preferences activity levels, with one systematic review finding that all of people with chronic diseases. Trials of AVGs in older adults studies showing no impact of exercise training on physical with chronic diseases, such as COPD, are required, and such activity had durations of less than 12 weeks, whereas all trials might be expected to demonstrate greater adherence or interventions lasting longer than 12 weeks improved physical effectiveness if those AVGs are designed to take into account activity levels [12]. However, lengthening the duration of the needs and preferences of the patient population involved in pulmonary rehabilitation beyond the 12 weeks may lead to the trial. reduced availability of places in pulmonary rehabilitation programs, which are already limited in many countries [20]. Aims Using a co-design process with people with COPD and Consumer-grade electronic pedometers, such as those developed clinicians, we developed an AVG called Grow Stronger to by Fitbit (Fitbit Inc), have been shown to be valid devices for promote physical activity in people with COPD after pulmonary measuring physical activity in people with COPD [21] and may rehabilitation. A co-design methodology known as participatory enable people with COPD to be more conscious of their physical design was used. Participatory design is a research and design activity levels. Behavioral interventions that use technology practice where the users of a particular system participate as such as wearable pedometers to facilitate self-monitoring of co-designers throughout the design process rather than merely physical activity have shown some short-term effectiveness in as testers providing feedback to designers [37]. A participatory improving physical activity levels in people with COPD [22,23]. design process can, at least in some circumstances, improve the However, the benefits of physical activity may be short lived, effectiveness of serious games for health [38]. possibly because of poor long-term engagement with these interventions [24]. A recent Cochrane review of The primary aim of this study is to evaluate the feasibility of technology-based COPD self-management interventions the Grow Stronger AVG intervention in people with COPD by concluded that “researchers also must take into consideration assessing the usage of and engagement with the AVG, along strategies that will promote long-term engagement with smart with adherence to wearing the Fitbit activity tracker. The technology” [22]. secondary aim of this study is to assess the effect of the Grow Stronger AVG, when combined with a Fitbit activity tracker Gamification is an emerging strategy to improve engagement and Fitbit app, on physical activity in comparison to the Fitbit with digital technology, including within the context of health activity tracker and Fitbit app alone. Primary outcomes included care [25]. Gamification is the use of game design elements in usage of the AVG in the experiment arm of this pilot trial (how nongame contexts [26] and is a common feature in health and often the AVG was used, what types and difficulties of activity fitness apps, including fitness tracker apps [27,28]. Most goals were chosen, and what breathlessness values were commonly, the apps include game features such as digital reported), subjective measures of engagement with the AVG in rewards for goal attainment, avatars (visual representations of the experiment group, and adherence to wearing Fitbit activity players), social or peer pressure (including leaderboards), and trackers in both the experiment and control arms. Secondary the provision of feedback on performance. However, little outcomes were daily steps and daily physical activity levels in research exists on game interventions paired with wearable both the experiment group and control group, as assessed by activity trackers in people with COPD, and trials of gamified the Fitbit activity monitor. interventions in other populations have shown conflicting results. For example, a trial in healthy adolescents of an activity Methods tracking website known as Zamzee (Zamzee Co) demonstrated a 54% increase in moderate-to-vigorous physical activity Overview (MVPA) over 6 weeks [29], but a trial Active Team (Portal Australia), a gamified smartphone app for healthy adults, had This study is a pilot trial nested within an iterative co-design no effect on objectively measured MVPA over 3 months [30]. process to develop an AVG. This co-design process comprised Although both interventions in these studies were gamified, a series of focus groups with people with COPD (n=10) and they differed substantially in the game elements that were used clinicians (n=18), aiming to outline, design, and develop an [29,31], underscoring the impact that different designs can have AVG. For the trial, 9 of the 10 people with COPD who were on the effectiveness of gamification. taking part in the co-design process comprised the experiment group, who received the AVG app in addition to a Fitbit activity http://games.jmir.org/2021/1/e23069/ JMIR Serious Games 2021 | vol. 9 | iss. 1 | e23069 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Simmich et al tracker and Fitbit app. The control group comprised individuals the experiment group), which took part in the focus groups and with COPD who did not take part in the co-design process, who received an activity monitor and the AVG intervention and (2) received only the Fitbit activity tracker and the Fitbit app. a control group, which received an activity monitor but did not take part in focus groups or received access to the AVG. For The study was approved by the Prince Charles Hospital Human the 19-week duration of the co-design process, participants in Research Ethics Committee and ratified by the University of both the experiment and control groups were provided with a Queensland Human Ethics Research Office. consumer-grade wearable activity monitor, namely, a Fitbit Alta The co-design process took place between June 2019 and HR or Fitbit Charge HR 2 (Fitbit Inc.). This activity monitor November 2019, with the pilot trial being conducted for 3 weeks was paired to the participant’s smartphone and was capable of at the end of this process, from October 4, 2019 to October 25, tracking steps, physical activity, and heart rate. Participants in 2019. both groups were provided with instructions on how to use the Fitbit app, and participants in both groups were set up as friends Participants with other participants within their group, allowing participants People who reported they had been clinically diagnosed with to see the weekly step total of other participants and access other COPD were recruited. A letter containing information about social features. It was not possible to blind the participants to the study was sent to recent (previous 12 months) attendees of their group allocation. pulmonary rehabilitation programs across 4 sites operated by The control group did not participate in the focus groups and Queensland Health in the Moreton Bay Region of Queensland, only had in-person contact with the research team during a group Australia. Interested potential participants were screened to enrollment session and study conclusion session. As per Figure ensure they met the inclusion and exclusion criteria. Participants 1, the control group received regular telephone check-ins across were included if they had attended pulmonary rehabilitation in the trial duration to set appropriate step goals on the Fitbit app the past 12 months, were able to read and speak English, and and to provide the same opportunity to raise any device-related were able to exercise independently (with or without the use of issues as was afforded the experiment group before and after mobility aids and supplemental oxygen). Participants were the focus groups. Participants in the experiment group were excluded if they did not have access to a smartphone, were able to trial the test version of the AVG during the final 3 weeks unable to exercise because of medical or physical limitations, of the development process. However, not all participants were required 24-hour supplemental oxygen, or lacked the visual able to download and use the app the day it became available, acuity to view the text displayed on typical mobile devices. resulting in some participants having a shorter period to Procedures experience the AVG than others. At the conclusion of the trial, participants relinquished their wearable fitness trackers, but After all participants were recruited, a randomized sequence of those using the app continued to have access to it for at least a participants was generated. Participants were alternately month after the conclusion of the trial. allocated into 2 groups: (1) an active co-design group (hereafter Figure 1. Contact times, types of contact, and interventions received for each group. Group sessions for the experiment group comprised focus groups in the co-design process along with an install session in week 16, whereas the 2 group sessions for the control group were a group enrolment session in the first week and a study conclusion session in the final week. AVG: active video game. http://games.jmir.org/2021/1/e23069/ JMIR Serious Games 2021 | vol. 9 | iss. 1 | e23069 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Simmich et al Secondary outcome measures collected from all participants Game Intervention included total steps and duration and the intensity of physical The Grow Stronger game and the co-design process undertaken activity. These measures were automatically collected for the to develop it will be described more fully elsewhere. In brief, entire 19-week duration of the study by the Fitbit activity Grow Stronger is a smartphone app that functions as both a trackers provided to participants in both the experiment group game and a physical activity diary. Progress in the game requires and the control group. Devices such as these are considered to the player to report the completion of upper body and lower be valid low-cost devices to measure physical activity in people body physical activities commonly used in the physical with COPD [21]. MVPA was assumed to be the sum of the 2 rehabilitation of people with COPD. The game features a simple highest Fitbit categories for active minutes (fairly active and stick figure image of each activity, and players are provided very active categories). This approach has been previously used with an additional handout with more complete instructions for when comparing consumer-level activity monitors to each activity. Each day, players choose an upper body and lower research-grade accelerometers, demonstrating body activity and set at what difficulty or intensity they wish moderate-to-strong validity for MVPA measured by Fitbit to perform these activities. At the completion of each activity, devices in healthy adults in free-living conditions [42]. users must report their perceived Borg breathlessness value using a slider present in the app to receive their reward for that Before the first focus group, participants also filled in a prestudy activity. survey, providing information on their gender, age, employment status, confidence in technology (on a 0-10 scale), and degree The game features 2 parallel game modes, which can be used of self-perceived functional limitation because of breathlessness, together or separately. The first mode functions as a single as assessed using the Medical Research Council (MRC) dyspnea player mode and uses the theme of growing a garden, where scale [43]. players are rewarded with water in a watering can that can be used to grow a potted plant. The second game mode functions Data Analysis as a cooperative multiplayer game mode and has the theme of Data were analyzed and visualized using Python (Python 3.7; a caravan trip around Australia, visiting multiple well-known Python Software Foundation). Step counts and minutes of Australian destinations. As a team, players are rewarded with activity were collated to a daily figure for each participant, progress on the trip, determined by the average number of which was used to compute each participant’s average for steps activities completed by the team. All data from the use of the per day and MVPA per day over the period before and after the game are reported to a web interface that allows clinicians to AVG was downloaded. Days where no step data were recorded monitor the progress of all players and sends encouraging were ignored when calculating each participant’s average steps messages. A more complete description of the game, along with per day and MVPA per day, effectively interpolating these representative screenshots and a full list of all available missing days with the participant’s own average for that period. activities, is available in Multimedia Appendix 1. One participant in the control group did not wear the Fitbit during the final 3 weeks of the study and so was excluded from Outcome Measures the pre-post comparisons of steps per day and MVPA per day. Several primary outcome measures were collected by the AVG in the experiment group, namely, the usage of the app, type of Owing to the small sample size and nonnormality evident in activities completed, difficulty level selected by participants some outcomes, the Spearman rank correlations were used to for each activity, and reported Borg breathlessness ratings for examine relationships between outcome measures (ie, pre-post each physical activity. Adherence to wearing the Fitbit activity change in daily steps, change in MVPA, game engagement on tracker was assessed using step data collected from the Fitbit GEQ and IMI scales, and game usage). The Spearman rank devices, with nonwear defined as zero steps recorded for an correlation is not affected by skewness and generally copes entire day. better with light-tailed distributions than the Pearson correlation [44]. Additional primary outcome measures of subjective game engagement were collected at the conclusion of the study by As this was a pilot randomized controlled trial, with a sample asking the experiment group to complete 3 questionnaires. First, size determined by optimum focus group size during the the Game Engagement Questionnaire (GEQ) was used [39], co-design process rather than being adequately powered to detect which was measured on a three-level scale (1=no, 2=maybe or differences in primary outcome measures, no statistical tests sort of, 3=yes). Second, 5 subscales of the intrinsic motivation were performed, and data are presented as mean and SD only. inventory (IMI) were employed: interest or enjoyment, perceived competence, effort or importance, value or usefulness, and Results relatedness [40]. Each of these subscales was measured on a seven-point Likert scale (1=completely disagree to 7=completely Participants agree). Finally, a cognitive processing and cognitive activation Figure 2 shows the progression of participants throughout the (CPCA) questionnaire was developed for use in this study, study in a Consolidated Standards of Reporting Trials diagram. adapted from Hollebeek et al [41] and measured on a 7-point Of the 89 participants invited to participate in the study, 37 Likert scale as for the IMI. All questions were given using either responded and were screened against the inclusion and exclusion paper-based or web-based forms immediately after the final criteria. The 25 eligible and consented to participate were focus group. randomized into the 2 arms of the study. Of these, 10 from each group attended the first session and completed the prestudy http://games.jmir.org/2021/1/e23069/ JMIR Serious Games 2021 | vol. 9 | iss. 1 | e23069 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Simmich et al survey. Overall, 2 participants discontinued and withdrew from reported skin irritation from the Fitbit device. Two other the study, both during week 4. One participant withdrew for participants reported some skin irritation, resulting in low Fitbit personal reasons, whereas the other withdrew because of adherence, but did not withdraw from the trial. Figure 2. Consolidated Standards of Reporting Trials diagram showing the flow of participants through the study. One Fitbit device had to be replaced during the trial because of The results from the prestudy survey for the control and issues with synchronization between the activity tracker and experiment groups are shown in Table 1. Aside from the gender phone, but data were not lost. A number of participants also balance, there were no obvious differences between the groups. experienced issues with Bluetooth synchronization, but these Both groups had an MRC dyspnea score between grade 2 and issues were resolved after troubleshooting discussions with the grade 3, indicating moderate functional limitation because of research team, and this did not appear to result in a loss of data breathlessness. for any full day for any participant (although loss of part of the data for that day may have occurred). Table 1. Details of participants who received the full intervention in each arm of the study (n=9). Group Control Experiment Female, n (%) 6 (67) 5 (56) Age (years), mean (SD) 65 (7) 70 (6) Retired, n (%) 8 (89) 9 (100) Confidence with technology (0-10 scale), mean (SD) 5.2 (2) 5.3 (2.3) Medical Research Council dyspnea, mean (SD) 2.4 (1.1) 2.4 (1.2) http://games.jmir.org/2021/1/e23069/ JMIR Serious Games 2021 | vol. 9 | iss. 1 | e23069 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Simmich et al it. Excluding participants who did not use the game at all, the Game Usage Statistics remaining participants logged at least one activity on 58.6% Game Usage Frequency (82/141; SD 21%) of the days when they had access to the game The number of activities logged per day by each participant in during the test period. Note that not all participants downloaded the experiment group is shown in Figure 3. The game allowed and installed the game on their smartphone on the same date. a maximum of 2 activities to be recorded each day. Most Although the test period concluded on October 25, some participants (8/9, 89%) engaged in the game after downloading participants continued to use the game after this date. Figure 3. Number of activities recorded per day for each participant in the experiment group. The period where each participant had downloaded the game, but before the test period had concluded, is indicated by the shaded background. One participant was not shown, as they did not use the game after downloading it on their phone. activity. Outdoor walking was by far the most recorded activity, Types of Activities Recorded recorded 41 times. Walking either indoors or outdoors Figure 4 shows the frequency of activities that were recorded represented 34.5% (57/165) of all recorded activities. using the app as well as which participants recorded which http://games.jmir.org/2021/1/e23069/ JMIR Serious Games 2021 | vol. 9 | iss. 1 | e23069 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Simmich et al Figure 4. Number of times each activity was recorded by participants in the experiment group. using the app are shown in Table 2. The mean Borg Borg Breathlessness Values breathlessness score was 3.8 (SD 1.3). The frequencies of Borg breathlessness values, reported on the 0 to 10 modified Borg breathlessness scale, after activities when Table 2. Frequency for Borg breathlessness values recorded by the experiment group. Breathlessness value (modified Borg scale) Number of events recorded in the app 1 8 2 18 3 32 4 65 5 34 6 3 7 3 8 1 10 1 3. Higher numbers represented greater difficulty for a given Difficulty Values Selected physical activity task. All difficulties were roughly equally The frequency at which participants selected the various represented, with no evident skew to higher or lower difficulties. difficulty or intensity options in using the app is shown in Table http://games.jmir.org/2021/1/e23069/ JMIR Serious Games 2021 | vol. 9 | iss. 1 | e23069 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Simmich et al Table 3. Frequency for difficulty values selected by the experiment group. Selected difficulty Number of events recorded in the app 1 36 2 47 3 36 4 46 The scores on the IMI subscales are shown in Table 4. The Game Engagement highest scores were seen for the value and usefulness subscale, People with COPD in the experiment group completed 3 with a mean of 6.4 (SD 0.6). All other subscales had lower measures of subjective game engagement: IMI, GEQ, and a scores, ranging from approximately 5.1 to 5.7. series of CPCA questions developed for this study. Table 4. Intrinsic Motivation Inventory subscale scores (7-point Likert scale). Subscale Score, mean (SD) Interest and enjoyment 5.4 (0.5) Perceived competence 5.7 (1.0) Effort and importance 5.3 (0.9) Value and usefulness 6.4 (0.6) Relatedness 5.1 (1.1) The total score for the 19 items of the GEQ for each participant scale has a minimum possible score of 19 and a maximum is presented in Table 5. The GEQ score totals ranged from 19 possible score of 57, a score of 30.4 represents 30% (11.4/38) to 39, with a mean GEQ total score of 30.4 (SD 6.9). As this of the distance between these extremes. Table 5. Total scores for the Game Engagement Questionnaire. Participant Game Engagement Questionnaire score 2 28 4 36 6 35 7 26 8 30 10 39 12 19 The results for each individual question in the CPCA ranging from 5.2 to 6.5 on a 7-point Likert scale. Mean scores questionnaire are presented in Table 6. Participants generally were higher for items relating to their health goals (items 1-3), had a moderate to high degree of agreement across all questions, all of which had a mean of 6.5 (SD 0.8). Table 6. Cognitive processing and cognitive engagement individual item results. Question Score, mean (SD) 6.5 (0.8) CPCA1 : Using the game gets me to think about my health goals (n=8) CPCA2: I think about my health goals a lot when I'm using the game (n=8) 6.5 (0.8) CPCA3: Using the game stimulates my interest to learn more about achieving my health goals (n=8) 6.5 (0.8) CPCA4: I spend a lot of time using the game, compared to other ways of being physically active (n=8) 5.4 (1.4) CPCA5: Whenever I'm trying to be more active, I usually use the game (n=5) 5.6 (1.5) CPCA6: The game is what I usually play when I think about being physically active (n=5) 5.2 (2.4) CPCA: cognitive processing and cognitive activation. http://games.jmir.org/2021/1/e23069/ JMIR Serious Games 2021 | vol. 9 | iss. 1 | e23069 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Simmich et al group had a slightly higher average adherence than the Fitbit Wear Adherence experiment group, wearing the Fitbit on 94.5% (1069/1131) of Figure 5 shows the weekly average adherence to Fitbit activity days compared with 84.3% (975/1157) of days in the experiment trackers for participants across the study period, as calculated group. This was especially evident during the middle of the by days with a nonzero step count divided by total days and study period when adherence in the experiment group decreased expressed as a percentage. Overall, participants in the control for several weeks. Figure 5. Average weekly adherence to wearing Fitbits in each group before and after the Grow Stronger app was downloaded by the experiment group. The period where each participant had downloaded the game is indicated by the shaded background. The control group, which did not download the game, were aligned with the majority of the experiment group for ease of comparison. As weeks are assumed to start on Mondays, but most participants downloaded the game on a Friday (day 0), the value for the final week before the game was downloaded (the last week in the unshaded area) included values from days 1 and 2 after the game was downloaded. All participants are included in the data presented in this figure. Ctrl: control; Exp: experiment. day, representing a decrease of 81 steps per day or a 2% Steps decrease. In the period before the experiment group downloaded Across all weeks before the game intervention was downloaded, Grow Stronger, the control group was averaging 6394 (SD 4306, the experiment group averaged 4730 (SD 1959, range range 2700-15,000) steps per day, which then decreased by 800 1493-7522) steps per day, as shown in Figure 6. Steps in the steps per day (800/6394, 12.5%) to 5593 (SD 4277; range experiment group in the weeks after downloading the Grow 1924-14,367) steps per day. Stronger AVG averaged 4649 (SD 2357, range 1853-8130) per Figure 6. Average steps per day and MVPA per day in each group before and after the game was downloaded. Ctrl: control; Exp: experiment; MVPA: moderate-to-vigorous physical activity. http://games.jmir.org/2021/1/e23069/ JMIR Serious Games 2021 | vol. 9 | iss. 1 | e23069 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Simmich et al Individual step count charts for each participant are shown in the primary outcome measures (game adherence, game Multimedia Appendix 2 for the experiment and control groups. engagement on GEQ, and game engagement on IMI), the Spearman correlation coefficients were calculated. Table 7 MVPA shows the results in the form of a correlation matrix (a scatter As shown in Figure 6, before the game intervention was matrix for these comparisons can be found in Multimedia downloaded, the experiment group was averaged 33 (SD 30; Appendix 3). There appeared to be a moderately high positive range 3-76) min of MVPA per day, and in this period, the correlation, with a Spearman rank correlation coefficient of 0.62 control group had an average daily MVPA of 34 (SD 41; range between the pre-post change in daily step and the usage of the 3-120) min. During the game intervention, the experiment group Grow Stronger app (as assessed by percentage of days during was averaging 42 (SD 48; range 2-122) min of MVPA, and the the test period with at least one activity logged). Physical activity control group was averaging 33 (SD 62; range 1-182) min of was weakly correlated with game usage. The total score on the MVPA each day. This represented an increase of approximately GEQ correlated moderately strongly and positively with the 9 min per day or a 26% increase for the experiment group and mean score on the IMI, with correlation coefficients of 0.61. an approximately 1 min or 2% decrease for the control group The pre-post change in daily steps appeared to be strongly per day. negatively correlated with both the subjective measures of game engagement, with correlation coefficients of −0.79 for the GEQ Correlations Between Outcome Measures and −0.71 for the IMI. The subjective measures of game To explore the relationships within and between the secondary engagement (GEQ or IMI) did not appear to correlate with outcome measures (pre-post change in MVPA and steps) and changes in daily MVPA or to game adherence. Table 7. Spearman rank correlation matrix between primary and secondary outcomes in the experiment group. Outcome measures Spearman rank correlation ΔSteps per day Game usage Game Engagement Intrinsic Motivation Inventory Δ Moderate-to-vigorous Questionnaire physical activity per day ΔModerate-to-vigorous physical 1.00 — — — activity per day (pre-post) ΔSteps per day (pre-post) 0.21 1.00 — — — Game usage (percentage of days 0.45 0.62 1.00 — — with activities logged on Grow Stronger ) Game Engagement Questionnaire 0.21 −0.79 0.07 1.00 — Intrinsic Motivation Inventory 0.19 −0.71 −0.19 0.61 1.00 Δ: change in. —: These cells are deliberately left blank. The table is symmetrical about the diagonal, so the data are not repeated. weeks but filled in the daily symptom diary just 16 times on Discussion average [46]. Similarly, in the pilot trial of Condition Coach (Roessingh Research and Development), which included a Summary of Primary Findings website with a symptom diary and exercise module, the website This study assessed the feasibility of the AVG intervention by was visited on 86% of the days available, but the exercise measuring usage of the AVG in the experiment arm of this pilot module was only completed on 21% of the days [47]. Although trial and adherence to wearing Fitbit activity trackers in both the pilot trial lasted 9 months compared with just 3 weeks in the experiment and control arms. The usage of the game in this this study, adherence to the Condition Coach exercise portal study was moderate, with participants who used the game was clearly low throughout: only 5 of the 12 participants recording at least one activity on 58.6% (82/141) of the days. completed any exercises in the exercise portal. In comparison, This is slightly lower than the usage rates reported in the first 8 of the 9 participants completed at least one activity in Grow few weeks of similar studies of apps or websites for physical Stronger. However, these other apps were able to send activity promotion. For example, 68% of users of the gamified notifications to participants during these trials, whereas our Active Team app were accessing the gamified app each day by Grow Stronger app lacked the ability to provide notifications, day 7, although this fell to 31% by day 91 [45]. However, usage which may have improved usage if it was available. of Grow Stronger was measured by days with logged activities; The Fitbit was worn on 84% of the days by participants in the therefore, it may be expected to be lower than a usage experiment group and on 94% of the days by participants in the measurement based on days where the intervention was merely control group. These values are comparable with those reported accessed. The difference between these 2 methods of measuring by Wan et al [48], where pedometer wear adherence ranged usage was illustrated by the pilot trial of ActivityCoach between 80% and 90% in people with COPD. It is worth noting, (Roessingh Research and Development), which found that however, that this pedometer was worn on the hip, pocket, or participants visited the website an average of 23 times over 4 http://games.jmir.org/2021/1/e23069/ JMIR Serious Games 2021 | vol. 9 | iss. 1 | e23069 | p. 10 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Simmich et al with a lanyard, in contrast to the wrist-worn Fitbits provided in modified for the purposes of this trial, no comparisons to other this study. Adherence is thought to be higher for wrist-worn studies are available. activity trackers than hip-worn in adolescents [49], although It is also noteworthy that a response rate of around 41% (37/89) several participants in our study reported skin irritation, which was observed among participants invited to participate in this may have decreased wear adherence. study. Although we cannot determine the reason for Difficulty options selected in the app by participants were nonresponse, some may not have responded because of lack of roughly equally distributed, indicating that the difficulty options access to, or reservations about, technological interventions. A presented were adequate for participants with COPD. Reported recent survey of people with COPD attending pulmonary Borg breathlessness values were clustered around 3 to 5 on the rehabilitation in metropolitan areas of Australia found that 48% modified Borg scale, indicating moderate shortness of breath had personal access to a smartphone and 57% felt that their and representing an appropriate target for exercise in people technology skills were adequate or better [53]. Nonetheless, the with COPD [50]. results of that survey and the engagement of participants in our study suggest that a substantial portion of people with COPD Engagement with the game in the experiment group as assessed are willing to use technology in their rehabilitation. on the GEQ averaged 30.4, out of a minimum possible score of 19 and a maximum possible score of 57. This is comparable Summary of Secondary Findings with the GEQ results originally reported during the development In addition to the primary findings mentioned previously, this of the GEQ, which were generally around 30 to 32 for study also examined the effect on daily steps and daily physical adolescents and undergraduates playing common video games activity levels of the combination of the Grow Stronger AVG [39]. However, the result in this study is lower than the score and Fitbit activity tracker with the Fitbit app, compared with given by healthy adults for AVGs [51], which would have the Fitbit activity tracker with the Fitbit app alone, in patients corresponded to a score of 42 if the adapted GEQ with a with COPD. A noteworthy finding of this study was that the seven-point scale used in that study was transformed into the experiment group performed an average of 9 min more MVPA three-point scale used in this study and in the original after downloading the game, whereas the MVPA in the control development study of the GEQ. The scores on the GEQ found group remained roughly similar. Although these results must in this study may be lower than that seen by other games because be interpreted cautiously because of the low sample size of this several items on the GEQ assess the subjective experiences of pilot trial and the large sample SD in the results, this nonetheless immersion and flow that may not be elicited by a game, such suggests that the AVG may have a positive effect on physical as Grow Stronger, which does not provide real-time feedback activity in this population. To the best of our knowledge, no to players. GEQ results for games similar to Grow Stronger are published research has examined the effect on physical activity unfortunately not available for comparison. of a mobile game intervention combined with a wearable activity tracker versus an activity tracker alone in patients with COPD. Participants in the experiment group appeared to have given a higher average rating for the value and usefulness subscale of Another secondary finding of this study was that the average the IMI than other subscales such as interest or enjoyment, steps per day decreased by 13% in the control group but only relatedness, and effort or importance. This would suggest that by 2% in the experiment group. Despite the large variability in participants were primarily motivated to play Grow Stronger this small sample, this finding is consistent with the hypothesis because they saw value in it rather than because they enjoyed that AVG could ameliorate the decline in physical activity often the game, felt a degree of relatedness to other players, or were experienced after pulmonary rehabilitation [18]. It is also motivated to put effort into it. It is possible that by being possible that the activity tracker itself caused an initial increase involved in the design of the game from its inception, in daily steps, which slowly waned over the duration of the participants in this trial were especially aware of the value or study before being partly counteracted by the effect of the AVG potential usefulness of the game. In addition, it has been shown in the experiment group. Other studies of people with COPD that multiplayer AVGs offer greater relatedness than single have, however, examined the combination of activity trackers player ones [52], so designing Grow Stronger to provide the with mobile apps to encourage daily steps [23]. These mobile option of a single player experience in addition to multiplayer apps were not considered games and lacked clear game features may have diluted ratings on the relatedness dimension. but did incorporate behavior change techniques (such as self-monitoring, goal setting, and social support) that could have The CPCA scale showed somewhat higher mean scores for an effect similar to game design elements. For example, Moy health goal questions than physical activity questions, indicating et al [54] and Wan et al [48] compared the effect of a pedometer that participants primarily associated the game with achieving alone to the same pedometer combined with a website health goals rather than performing physical activity. This could intervention, which encouraged incremental goal setting, be because of the design of the game, which allowed players to allowed social communication between users, and provided perform physical activity away from their smartphone and then educational and motivational messages. These studies, to return to their phone to play Grow Stronger. This temporal respectively, showed steps per day increased 13% in the asynchrony between being physically active and playing the intervention group, with no significant change in the control game may have decreased the association between the game group at 17 weeks [54], and an increase of 19% in steps per day and physical activity, whereas participation in the design process in the intervention group versus a decrease of 5% in steps per may have increased the association between playing the game day in the control group after 13 weeks [48]. These 2 studies and reflecting on health goals. As this scale was significantly http://games.jmir.org/2021/1/e23069/ JMIR Serious Games 2021 | vol. 9 | iss. 1 | e23069 | p. 11 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Simmich et al demonstrated an increase in the steps for the intervention with relationship in the context of either smartphone AVGs or AVGs little change to the control group, whereas we found little change for older adults. in the experiment group but a decrease in the control group. A Subjective measures of game engagement did not appear to be decrease in daily steps in the control group was also observed correlated with game usage, which is contrary to a previous in a trial of a mobile app that enabled clinician feedback study that demonstrated a correlation between the IMI rating combined with activity tracker compared with activity tracker of a smartphone game to improve physical activity and the usage alone at 3 or 6 months [55]. However, in contrast to this study of said game [58]. However, the correlation in that study was where daily steps decreased only in the control group, in that assessed before and after a 24-week intervention in a group of study, both the control group and the experiment group 18 people with diabetes. At just 3 weeks with only 9 people decreased steps per day by approximately 14%. Vorrink et al with COPD, this study may not have been long enough for a [55] suggested that either the use of a smartphone app rather correlation between game usage and subjective game enjoyment than a website or the involvement of health professionals could to arise or be large enough to detect whether such a correlation have contributed to the lack of difference between groups, but did exist. In addition, that study [58] employed a linear the Grow Stronger intervention used in this pilot trial was also regression rather than the Spearman correlation as used in this a mobile app and also involved clinicians, yet a difference study, precluding direct comparison between the 2 studies. between groups was observed. Furthermore, although both Moy et al [54] and Vorrink et al [55] used activity tracking websites Limitations or apps that were specifically designed for users with chronic This study is limited in several ways. As a pilot trial with a diseases, only the intervention used in a study by Vorrink et al small number of participants and short duration, with the sample [55] consulted people with COPD during the design phase and size, and trial duration oriented around the co-design process, only after the initial design had been developed [56]. this trial was underpowered to detect differences in steps and physical activity, which could be expected from such a short The observed change in daily steps was positively correlated intervention. A larger and longer duration trial would be required with game usage, indicating that those who used the game more in the future to gain a meaningful estimate of the effect of the often also had a greater increase (or smaller decrease) in daily AVG on daily steps and physical activity. In addition, steps. This is consistent with walking, which is the most participants in the experiment group were co-designers of the commonly recorded activity in the game. A correlation between intervention, so they may have been more invested in the game game usage and MVPA was also present but weaker than that that they helped to create. Therefore, this study’s results may between steps and game usage. A stronger correlation between not be generalizable to a population who are naïve to the game. game usage and physical activity may have been expected, given that a recent study found that those in the top quartile for the Furthermore, the trial period formed part of the design process, usage of a gamified smartphone app, Active Team, increased with feedback from participants used to develop a final version their daily physical activity by 18 min (around 17% of baseline), of the game intervention beyond the test version trialed in this whereas users in the lowest 3 quartiles of app usage decreased study. Therefore, the results of this study do not account for the their daily physical activity by 8 min (around 8% of baseline) effect that these revisions may have had on the effectiveness of [45]. Physical activity in that study was assessed by or adherence to the final version of the game, which will be research-grade accelerometry rather than the wearable activity tested in future studies. For instance, the version of the Grow tracker provided to participants, as was used in this study. It is Stronger app used in this study was not able to record usage possible that Fitbit activity trackers did not count toward the data regarding when participants accessed the app for purposes MVPA measurement of the short bouts of strength training that other than to record the completion of an activity. As such, no the Grow Stronger app encouraged participants to do. data were available on how often participants used the pause button feature or used the app to interact with one another or Surprisingly, subjective game engagement, as measured on the check their individual or team progress. Similarly, as mentioned, GEQ and IMI, appeared to be negatively correlated to steps but the app was unable to send notifications, and app usage was not correlated to MVPA. This is contrary to the implicit likely lower than it would be with reminder notifications hypothesis that the engaging nature of AVGs would encourage enabled. The future version of the app will address these both more steps and more physical activity. This also conflicts limitations. with the results of other AVGs in other populations such as children, where an increased level of intrinsic motivation and As this pilot trial was embedded within a co-design process, enjoyment were correlated with increased physical activity [57]. the control condition was selected without full knowledge of It is possible that those who found Grow Stronger most the eventual design of Grow Stronger and so may not have been enjoyable were more likely to have performed other forms of an ideal comparison. The control group received Fitbit activity physical activity encouraged by the app, such as upper limb trackers and the Fitbit app under the assumption that the AVG strength exercises, in place of their usual walking. If strength provided to the experiment group would most closely resemble training could not be readily detected as MVPA by the Fitbit, the Fitbit app, albeit in the form of a game. However, as a result this would not appear as a correlation between game engagement of the co-design process, Grow Stronger more closely resembled and MVPA. Possible reasons for the negative relationship a mobile exercise diary. As such, future studies aiming to between subjective game engagement and physical activity explore the effect of the game elements of Grow Stronger on remains speculative, as no other studies have examined this physical activity should compare this game with a mobile exercise diary app that functions similar to Grow Stronger but http://games.jmir.org/2021/1/e23069/ JMIR Serious Games 2021 | vol. 9 | iss. 1 | e23069 | p. 12 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Simmich et al lacks game elements. In addition, the use of any digital It is also worth noting that the CPCA questions used herein, technologies in COPD may not represent the usual standard of although they were based on previously validated scales, were care for people with COPD. Therefore, future research may also modified significantly to fit the purposes of this study and so compare Grow Stronger with usual care of people with COPD may no longer retain their validity. Future research should seek after pulmonary rehabilitation, namely, providing a control to validate these measures or use alternative validated measures. group with an entirely unsupervised home exercise program. Finally, no objective tests of lung function or functional status In this study, activity outcome measures were recorded by were performed, nor were results from such tests available for commercial-grade Fitbit activity monitors, rather than a this trial. Although it is very likely that all participants had research-grade physical activity monitor, which presents 2 main COPD, as they all had attended a pulmonary rehabilitation class limitations. First, although older hip-worn Fitbit devices have that requires referral by a physician, future research may benefit been shown to have a good correlation with research-grade from confirmation of a clinical COPD diagnosis. In addition, activity monitors [21] in people with COPD, this study was the results of spirometry or exercise tolerance tests could be conducted with newer wrist-worn Fitbit activity monitors for used to appropriately stratify participants in a future trial. which such validity data are not known in COPD. The Conclusions wrist-worn Fitbit Charge 2 devices used in this study have To our knowledge, this is the first study that trials an AVG shown high validity for step counts but only moderate validity designed by people with COPD and clinicians to maintain or for MVPA when compared with research-grade accelerometry enhance physical activity levels. Although the results are limited in older adults [59]. Second, the Fitbit devices were part of the because of the small sample size, this study is an initial intervention given to both groups, and data from such devices demonstration of the potential value of an app that facilitates were visible to participants, which may have caused participants physical activities for people with COPD. Future work is to alter their physical activity in response. Future studies may required to further improve adherence and to investigate the therefore benefit from employing accelerometers with long-term effects of this intervention. Despite this, the Grow established validity for MVPA and concealing such Stronger app shows promise as an intervention worthy of a measurements from participants. larger-scale trial in this population. Acknowledgments The authors would like to thank Bitlink for their work in developing the software used in this study. Additional thanks go to Anita Keightley for her assistance with recruitment of participants in this study. Conflicts of Interest None declared. Multimedia Appendix 1 Screenshots and description of the Grow Stronger smartphone app. [DOCX File , 698 KB-Multimedia Appendix 1] Multimedia Appendix 2 Daily step counts for individual participants in the experiment group and control group. [DOCX File , 307 KB-Multimedia Appendix 2] Multimedia Appendix 3 A scatter matrix for correlations between the primary and secondary outcome measures in the experiment group. [DOCX File , 73 KB-Multimedia Appendix 3] References 1. GBD 2016 Causes of Death Collaborators. 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JMIR Mhealth Uhealth 2019 Jun 19;7(6):e13084 [FREE Full text] [doi: 10.2196/13084] [Medline: 31219048] Abbreviations AVG: active video game COPD: chronic obstructive pulmonary disease CPCA: cognitive processing and cognitive activation GEQ: Game Engagement Questionnaire IMI: Intrinsic Motivation Inventory MRC: Medical Research Council MVPA: moderate-to-vigorous physical activity http://games.jmir.org/2021/1/e23069/ JMIR Serious Games 2021 | vol. 9 | iss. 1 | e23069 | p. 16 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Simmich et al Edited by N Zary; submitted 31.07.20; peer-reviewed by H Lewthwaite, L Mantoani; comments to author 19.09.20; revised version received 12.11.20; accepted 26.11.20; published 27.01.21 Please cite as: Simmich J, Mandrusiak A, Smith ST, Hartley N, Russell TG A Co-Designed Active Video Game for Physical Activity Promotion in People With Chronic Obstructive Pulmonary Disease: Pilot Trial JMIR Serious Games 2021;9(1):e23069 URL: http://games.jmir.org/2021/1/e23069/ doi: 10.2196/23069 PMID: 33502321 ©Joshua Simmich, Allison Mandrusiak, Stuart Trevor Smith, Nicole Hartley, Trevor Glen Russell. Originally published in JMIR Serious Games (http://games.jmir.org), 27.01.2021. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on http://games.jmir.org, as well as this copyright and license information must be included. http://games.jmir.org/2021/1/e23069/ JMIR Serious Games 2021 | vol. 9 | iss. 1 | e23069 | p. 17 (page number not for citation purposes) XSL FO RenderX

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JMIR Serious Games – JMIR Publications

Published: Jan 27, 2021

Keywords: fitness trackers; chronic obstructive pulmonary disease; physical activity; video games; smartphone; mobile phone

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