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Engaging Elderly People in Telemedicine Through Gamification

Engaging Elderly People in Telemedicine Through Gamification Background: Telemedicine can alleviate the increasing demand for elderly care caused by the rapidly aging population. However, user adherence to technology in telemedicine interventions is low and decreases over time. Therefore, there is a need for methods to increase adherence, specifically of the elderly user. A strategy that has recently emerged to address this problem is gamification. It is the application of game elements to nongame fields to motivate and increase user activity and retention. Objective: This research aims to (1) provide an overview of existing theoretical frameworks for gamification and explore methods that specifically target the elderly user and (2) explore user classification theories for tailoring game content to the elderly user. This knowledge will provide a foundation for creating a new framework for applying gamification in telemedicine applications to effectively engage the elderly user by increasing and maintaining adherence. Methods: We performed a broad Internet search using scientific and nonscientific search engines and included information that described either of the following subjects: the conceptualization of gamification, methods to engage elderly users through gamification, or user classification theories for tailored game content. Results: Our search showed two main approaches concerning frameworks for gamification: from business practices, which mostly aim for more revenue, emerge an applied approach, while academia frameworks are developed incorporating theories on motivation while often aiming for lasting engagement. The search provided limited information regarding the application of gamification to engage elderly users, and a significant gap in knowledge on the effectiveness of a gamified application in practice. Several approaches for classifying users in general were found, based on archetypes and reasons to play, and we present them along with their corresponding taxonomies. The overview we created indicates great connectivity between these taxonomies. Conclusions: Gamification frameworks have been developed from different backgrounds—business and academia—but rarely target the elderly user. The effectiveness of user classifications for tailored game content in this context is not yet known. As a next step, we propose the development of a framework based on the hypothesized existence of a relation between preference for game content and personality. (JMIR Serious Games 2015;3(2):e9) doi: 10.2196/games.4561 KEYWORDS gamification; framework; elderly; older adults; eHealth; telemedicine; adherence; engagement; classification; player type; personality http://games.jmir.org/2015/2/e9/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e9 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES de Vette et al Introduction Methods It is expected that 25% of the European population will be older In a succession of 3 Internet searches, a broad approach to the than 65 years in 2050 because of global population aging [1]. subject of gamification was taken to gain insight into the many Current socioeconomic structures cannot provide enough work developments in gamification that occur both inside and outside force and capital to meet the needs of this rapidly growing of the scientific world. We performed a search in the scientific elderly population [2]. Telemedicine refers to health services search engines PubMed, Scopus, and Google Scholar and in that enable patients to receive treatment in their daily living diverse nonscientific sources: from game designer blogs and environment, whereby distance is bridged by information conference videos to MOOCs (massive open online courses) communication technology (ICT) and at least one health care and YouTube videos. In this paper, gamification is defined as professional is involved, alleviating the increasing demand for the use of elements from games in nongame contexts to improve elderly care by extending the time of autonomy and user experience and engagement without making that system a independence [3]. Although telemedicine technology seems full game as is the case with serious games including exergames promising, practical implementation still leaves much to be (combination of exercise and gaming) [10,11]. desired. Several studies have shown that adherence to First, we have researched the conceptualization of gamification telemedicine interventions, such as therapy supporting a healthy from a theoretical perspective (see Multimedia Appendix 1). lifestyle, is low [4] and decreases over time [5], even though Keywords used in combination with gamification were used, these studies showed a significant effect on health outcomes including derivatives of these words: “theory,” “definition,” [6]. Clearly, there is a need for strategies that motivate elderly “concept,” “framework,” and “analysis.” In addition, keywords people to use, and keep using, the technologies offered. (and derivatives of these) implying practical use were used: Gamification, the application of game elements to nongame “method,” “application,” and “gamify” (singular). Then, a search fields, may be such a strategy [7]. There is a rapid growth in for gamification combined with “criticism,” “downsides”, and the number of initiatives that use gamification, illustrating a “negative” was performed. Second, we investigated the use of variety of approaches developed from various viewpoints, gamification in applications for the elderly population (see including education, behavior change, physical health, and Multimedia Appendix 1), entering the following combinations mental health. However, a lack of a refined conceptualization of keywords: “gamification,” “gamif*,” “game,” and “gaming” of this strategy exists in these disciplines, and gamification, for with “elder*,” “elderly,” “senior,” “old*,” and “aging.” Finally, elderly people in particular, remains an even further through the same search method, we have researched user underexplored area. In general, it is not yet known which one classifications that categorize users by their motivation or of these approaches is the best for the durable engagement stimulant to play in order to gain insight into the user and further necessary for better adherence. determine how to tailor content to the user (see Multimedia Appendix 2). Keywords used were “[user, player, gamer]” Choice and personalization of content [8], or tailoring, is known combined with “[type, taxonomy, classification, model, style].” to be beneficial for intrinsic motivation [9], which in turn increases long-term engagement needed for adherence. To Included in the results were articles and other works that present provide this tailored content, insight is needed into how users a theoretical basis for the development of gamification, defined should (or want to) be addressed through gamification and how as the presence of a framework that is either theoretical and/or these needs can be classified is required. To our knowledge, based on established scientific foundations or proven effective information on the practical implementation of existing through evaluation in practice. Therefore, beyond the scope of classifications is not yet available. We believe that once an our paper are numerous works on gamified applications with a overview of existing frameworks for gamification and user black box design. classification is established, a gamification strategy that is effective in realizing long-term engagement for the elderly user Results can be developed. Gamification Frameworks For this purpose, the aim of the paper is to (1) provide an This section demonstrates the current state of gamification, understanding of the theoretical background of gamification, starting with the concept of gamification in a broader sense and including existing frameworks for developing gamification both then focusing on gamification for elderly people. We provide in general and specifically for the elderly population, and (2) an overview of existing frameworks for gamification along with explore existing user classification theories that may serve for their contexts and backgrounds. With this, we aim to define the the tailoring of game content to the target user. Because of the status quo in research and provide a deeper understanding of newness of this field of research, we opt for a broad view on the concept and its use and misuse. activities in gamification that occur not only within but also outside of scientific research. In future research, we will work The Conceptualization of Gamification toward a user classification of the elderly population that can Gamification has gained popularity in diverse fields such as be used to develop evidence-based gamification strategies and (interactive) marketing and scientific applications, generating tangible design guidelines for gamification in health care. different definitions of gamification. Currently, there is no consensus about a definition, mainly due to the underlying perception of what the game elements are exactly in terms of http://games.jmir.org/2015/2/e9/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e9 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES de Vette et al level of abstraction and whether the gamified application is with gameful experiences that support the value creation of the game-like or not. Gamification is often roughly defined as the user [15]. In the middle of these definitions, we see gamification use of elements from games in nongame contexts; a more refined as the use of game elements that create a game-like experience definition regards gamification as the identification of that which in a nongame context without creating a full game. makes games captivating and engaging followed by the transfer We found a couple of approaches toward the conceptualization of this knowledge to nongame contexts, increasing user of gamification. One emerges from business practices, such as enjoyment [12,13]. While some see gamification as a way to marketing, customer loyalty, and employee engagement; the act upon psychological principles as certain game techniques other from academia and not sales driven, often specifically do [14], others define gamification as applying gameful aiming to incorporate theories on motivation, engagement, and interaction or design with a specific intention without creating behavior change. Table 1 illustrates this division of the found a full-fledged game [10] or as the process of improving a service articles by author, grouped according to their focus. Table 1. Frameworks for gamification in business and academia. Business Academia Cunningham and Zichermann (2011) Aparicio et al (2012) Werbach and Hunter (2012) Nicholson (2012) Duggan (Badgeville, 2012) Sakamoto et al (2012) In business-oriented, or corporate, gamification, the number of the mechanics presented do not contribute to a gameful successful initiatives, in terms of increased user engagement or experience [25,26]. Robertson [25] states that gamification turns revenue, that use gamification has been rapidly increasing in into “pointsification” when game elements are simply stripped the past few years [16]. It is estimated that the market spend on from games and placed in another application. With this, gamification solutions will grow exponentially until 2016, and structural components of games are perceived and used at that time 40% of the world’s top market value companies elsewhere to function as core mechanics, ignoring the fact that will be using gamification [17,18]. In gamification for the these mechanics should be the inner workings of games. Bogost marketing of consumer products, a well-known success story criticizes this practice using the term “exploitationware” in an is that of Nike+ by Nike. This gamified running log app, article [26] and blog entry titled “Gamification is Bullshit” [27] currently used by 5 million players to track their daily exercise and states that gamification disassociates the practice from goals, caused revenues in the running category to increase by games created for the sole purpose of making an easy profit. A 30% in 2011 alone [19]. An example of successful enterprise design may be poor as well when it extensively uses external gamification is that of software company SAP. After SAP conditions or reinforcements, as known from operant launched a new, gamified version of their online employee and conditioning [28]. These reinforcements often function as main customer community platform, employee usage increased by mechanisms to manipulate behavior and usually present in the 400% and community feedback by 96% [20]. Gamification form of point and reward systems. A shift from intrinsic to appears to be more than a fad, illustrated by the existence and extrinsic motivation can occur through offering external awards, ongoing success of companies such as Badgeville [21,22], which known as the overjustification effect [29], which may lead to provides a platform for gamification of enterprise applications an early loss of interest of the user. The initial interest in the and serves major companies such as Samsung, Deloitte, and (gamified) activity may also disappear once the rewards are no Dell [23]. longer, or insufficiently, offered [30], an effect called the “hedonic treadmill” [31]. From this we observe that the There are several authors within this business orientation, such development of a good game design concept is often as Cunningham and Zichermann [12], who provide guidelines disappearing into the background in corporate gamification for gamification by listing game elements and mechanics such initiatives, while it is as essential for creating an engaging as feedback, achievement, social engagement loops, experience as it is for traditional games. reinforcement, and status, including practical examples. Werbach and Hunter [14] simplify gamification and consider Scientific research from within academia, the second approach it a tool for business strategy. Their method offers practical we distinguish, includes few frameworks on the theoretical guidelines on how to dissect existing games and use them to foundations of gamification. Aparicio et al [32] developed a gamify other applications. Although this approach lacks intricate framework focusing on intrinsic motivation by incorporating game mechanics, gamification is used as a comprehensible tool, concepts from self-determination theory [33]. According to this presenting game elements as a set of building blocks that, used theory, intrinsic motivation can increase by satisfying the together, can provide the gamified application. following psychological factors: competence, autonomy, and relatedness. The framework procedure tells us to (1) identify However, the way gamification is applied in business context the main objective, (2) identify which intrinsically motivating receives a lot of criticism as analysts estimate that the bigger factors should be included, (3) determine which game mechanics part of current gamified applications will not meet their business should be used according to these factors, and (4) evaluate the objectives, mainly due to poor design [24]. Game designers framework in its final application. Nicholson [34] presents a criticize the Cunningham and Zichermann method, stating that complex framework for meaningful gamification, integrating http://games.jmir.org/2015/2/e9/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e9 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES de Vette et al user-centered design [35] in combination with Several differences between the frameworks from business and self-determination, situated motivational affordance [36], academia (Table 2) can be observed. The business frameworks situational relevance [37], and universal design for learning are very concrete; they are simple, provide practical guidelines, [38]. From these core theories, Nicholson [34] suggests how to and, most importantly, have proven their success in this context. provide more intrinsically motivating gamification leading to In academia, gamification has not yet reached this state of meaningful engagement. Self-determination can be found along maturity. The frameworks found on both sides are contradictory: with the transtheoretical model of behavior change [39] in the those from academia are conceptual and complex and provide framework of Sakamoto et al [40], describing a value-based methods that are much more difficult to apply. Therefore, among framework. The authors present 5 core values (informative, these are no empirically supported frameworks showing their empathetic, persuasive, economic, and ideological value) that, effectiveness in practice. The frameworks from business are when used with other game mechanics, can be used to create simplified, therefore lacking depth, which may suffice for attractive and intrinsically motivating gamification services. marketing purposes but possibly not for long-term goals needed for telemedicine applications. Table 2. The contrast between business and academic frameworks. Business Academia Applied Conceptual Simplicity Complexity Practical guidelines Methods inexplicit Proven worthy in practice Earlier stage of development, less empirical support Lacking depth, oversimplified Solid scientific foundation Short-term engagement suffices Aiming for durable motivation Immensely popular Mostly unknown By contrast, Minge et al [43] see gamification as an opportunity Gamification for Elderly Users to decrease feelings of fear and frustration that elderly people While gamification is gaining popularity in telemedicine [41], have toward technology. However, the authors emphasize that limited information was found on appropriate designs for success depends on careful design. For example, the study engaging elderly users. Our search for gamification frameworks participants did not enjoy aspects of quantification and did not return any information on how to address the elderly comparison, which are otherwise very common elements of users. We therefore present existing literature that describes games. explorations of designing gamification for this population group IJsselsteijn et al [44] also state that digital games hold significant (Table 3). Gerling and Masuch [7] indicate that gamification positive potential for elderly users, including therapeutic value holds significant potential for elderly users, particularly in and social bonding. Elderly users are underrepresented as gamifying physical and cognitive therapy. The authors state consumers of digital games because the games offered are not that the main challenge for developing such apps lies within the in line with their accessibility and usability demands or their unfamiliarity of older adults with games, making it difficult to interests and needs. Design requirements are needed to offer draw content from existing digital games. Link et al [42] face the elderly engaging content. According to IJsselsteijn et al [44], a similar challenge after examining a set of game mechanics however, no empirical data are available on the categorization (points, status, and badges) and concluding that these have the of elderly gamers that is necessary to do so, including how this desired impact on youth but not on older adults. would translate into game content. Table 3. Overview of papers described. Source Topic IJsselsteijn et al (2007) [44] Design opportunities for engaging games for elderly Gerling et al (2011) [7] Potential of gamification for engaging (frail) elderly Minge et al (2011) [43] Attitude of elderly toward gamification Link et al (2014) [42] Effect of game elements on motivation of elderly describe people regarding their gaming preferences [32], and Classifying Users: Player Taxonomies none were found for the elderly user in particular [44]. In this User classification holds a key role in the development of section, we discuss several approaches for classifying users in tailored game content, as it gives thorough insight into the general, broadly divided into archetypes and reasons to play. preferences that individuals or subgroups within a target group Archetypes, player types [46,47] (Bartle, Marczewski), and may have [45]. However, there are limited valid methods to http://games.jmir.org/2015/2/e9/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e9 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES de Vette et al gaming personality (types) [48] (Vandenberghe) describe the various approaches are visualized in a diagram. At the end of player characteristics while reasons to play, player motivation this section, we summarize and compare these user taxonomies [49,50] (Yee), and kinds of fun [51,52] (LeBlanc, Lazzaro) take in a chart. motivating elements as a starting point. In Figure 1, these Figure 1. Approaches to classify the user. rewards. This results in 6 player types (Figure 3). The axes are Archetypes equal to the Bartle model but replace player for user and world The earliest and most cited player taxonomy in a gaming context for system. is the Bartle player type theory. It was developed for the first Another approach to create player archetypes is through virtual multiuser environment, text-based dungeons (multiuser personality. Personality traits have been extensively studied and dungeons, or MUDs), by observing and analyzing player researched since the 1880s [55] and, although thousands of traits patterns. Bartle proposes 4 player types (Figure 2) based on two can be found to describe personality [56], a statistical factor primary interests in gameplay: between the emphasis on players analysis demonstrated 5 main factors that many psychologists or on the environment and between acting (to) and interacting believe are sufficient [57,58]. The five-factor model (FFM), or (with). Achievers are interested in actions on the world and find Big Five, is currently the most popular and has shown to be mastery of the game and competition most compelling; explorers reputable, predictive (even normally distributed), reliable, like to interact with the world and enjoy discovery. Socializers crossculturally tested, and universal [59-63]. are most interested in interacting with other players and enjoy the game for friendships and contacts, while killers are interested In the context of games and gaming, several attempts on in acting on other players, demonstrating their superiority. predicting the effectiveness of the application of FFM showed According to Bartle, a good MUD contains the 4 player types inconsistent results [64,65]. In one study, personality traits have in equilibrium [46]—not necessarily of equal number—and the been related to preference for game genres [66]. A low player types were created to balance the design of these predictive capability was found, which may be caused by a lack multiplayer games to accommodate for all player types’ play of evidence on whether the FFM is a valid method to measure style. The application of this model outside its context is personality in a game or not [67,68]; however, direct correlations something Bartle himself advises against [45], especially for between the FFM and gaming were researched and described use in gamification. Furthermore, this model has been criticized by Vandenberghe [48]. He states that personality is very for lacking proper validation with empirical data and means to accurately predictive of gaming preferences and that people assess players to a type [53,49] and for missing similarity play with the same motivations they have in real life or look to between the virtual world of the MUD and the gamified express a particular part of personality that is unsatisfied in real application. Bartle suggests that the types are exclusive but, in life. In his model, the 5 domains of play, a translation of the practice, they can be overlapping or mixing [12]. original FFM traits is made into aspects of gaming motivation (Table 4). Each player is ranked on a linear scale on each of the Similarly, but in the context of enterprise gamification, 5 domains, thereby creating a character description rather than Marczewski [54] proposes a conceptual taxonomy choosing a categorization into a single player type. At the same time, the intrinsic motivations from different theories—autonomy; domains provide insight into the type of content that satisfies purpose and mastery; change—and the extrinsic motivation, the player. http://games.jmir.org/2015/2/e9/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e9 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES de Vette et al Table 4. Five-factor model traits and corresponding gaming motivation traits (deduced from Vandenberghe [48]). Low score Trait High score Cautious, predictable Openness to experience Inventive, curious Repeating, conventional Novelty Open, imaginative experiences Careless, impulsive Conscientiousness Efficient, organized Low effort and self-control Challenge High effort and self-control Reserved, solitary Extraversion Energetic, outgoing Relaxing, low social engagement Stimulation Exciting, high social engagement Analytical, detached Agreeableness Friendly, compassionate Competition, defeating Harmony Cooperation, helping Confident, secure Neuroticism Nervous, sensitive Cheerful, comforting Threat Gloom, horror, high tension Two examples illustrate specific gaming elements derived from scoring high on adventurousness correlates with a preference motivation facets. First, the imagination of the user correlates for exploration and a desire for encountering new things, much with a preference for either fantasy or realism: someone who like the Bartle type explorer, whereas a low score indicates a scores high on imagination will tend to prefer games that take preference for local play styles such as building or farming that place in exotic worlds, whereas someone with a low score will do not involve leaving the boundary of the known [69]. prefer games that take place in a world much like ours. Second, Figure 2. Bartle’s player type model. Figure 3. Marczewski’s player type model. http://games.jmir.org/2015/2/e9/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e9 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES de Vette et al A taxonomy of game aesthetics, or what makes a game fun, can Reasons to Play be found in the mechanics, dynamics, and aesthetics framework Yee [70] proposes a taxonomy based on users’ reasons to play by LeBlanc et al [51]. As much as 8 kinds of fun are defined: and used a long-term, qualitative analysis and factor analytical sensation, fantasy, narrative, challenge, fellowship, discovery, approach to create a taxonomy based on player motivations in expression, and submission. These aesthetics are used to MMORPGs (massive multiplayer online role-play games). The describe why certain players engage with certain games and model by Yee consists of 10 subcomponents factored into 3 more regard the game than categorize the player. Similarly, also main components with which they are most correlated (Figure focusing on fun as a reason to play, Lazzaro [52] conducted a 4). Each subcomponent is linked to game elements from which study to clarify how to address emotions in games without using players derive satisfaction. He finds that the killer must be a storyline by learning what (adult) players found were good omitted and merged into his component of achievement and the gaming experiences. The “4 keys” to fun are original explorer type must be divided into mechanics and discovery. The Yee model is similar to Bartle’s but overcomes • Hard fun: players like challenge, strategy, problem solving, several of its weaknesses. For example, the components of experiencing frustration. Bartle types are not highly correlated, the types overlap and are • Easy fun: players like intrigue and curiosity and enjoy not distinctive, and a practical way to assess users is lacking. immersion. However, similar to the Bartle typology is its narrow focus on • Altered states: players search for internal sensations such massive online gaming. as excitement. • The people factor: players use games for social experiences. Figure 4. Yee’s model motivations of play in MMORPGs: the components and subcomponents. (interacting with the world), and immersion (discovery, Overview of Taxonomies exploration). Although Yee does not have a separate type for Although the taxonomies aforementioned appear very different the killer or disruptor, provocation and domination are present concerning the types of classes, many parallels can be found in achievement. Linking to Lazzaro and LeBlanc, achievement between the characteristics of each class. We present the results is similar to the concept of hard fun and challenge; easy fun in an overview chart (Figure 5). The top row in gray shows the (which includes the motive of immersion) and discovery are author of the model, and under each author the defined classes similar to exploring; and the people factor and fellowship and (types, motivations, facets, etc) are shown. Arrows indicate a expression relate to the social aspect. The model of direct derivative of a model, as explained in the previous section; Vandenberghe not only seems all-embracing, but it also adds a black lines indicate which classes show highly similar dimension to each personality trait. The killer can be linked to characteristics. The dotted line indicates that classes only have a very low score on harmony, the achiever to a high score on several characteristics in common. The colors indicate which challenge, the explorer to a high score on novelty, the socializer classes belong to the same group. This overview shows that to a high score on stimulation. The trait threat is quite unique there is great connectivity between the models and highlights and only linked to submission. According to Vandenberghe, that the model of Vandenberghe covers all class properties of this trait may not be pointing out what keeps a player playing the other models (except for the player in the Marczewski but what makes the player decide to stop playing. model). None of the taxonomies presented target the elderly user In the models of Marczewski and Yee, which both have Bartle specifically. Furthermore, we do not know of any methods as point of reference, we see a clear analogy between the regarding the mapping of this target group on the existing achievers and socializers and also in the attributes of the free taxonomies, mainly because the gaming industry does not focus spirit (interacting with the system, autonomy), the explorer on this group as a consumer for video games. Moreover, the http://games.jmir.org/2015/2/e9/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e9 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES de Vette et al taxonomies are in most cases designed for use in a specific is not given a singular class label or a combination of those. application, such as enterprise gamification or MMORPGs, and Instead, a complete character description can be created based it is not known how suitable they are for application in on preference for certain aspects or elements of games. What telemedicine interventions. We can identify many parallels makes this theory even more attractive is that it describes the between the models, and we consider that the 5 domains of play user based on personality, a universal understanding regardless stand out from the rest. Unlike the other models, an individual of age. Figure 5. Chart of connections between taxonomies (arrow: direct derivative of, line: high similarity in concept, dots: closely related concepts). also be oversimplified, which suffices for marketing purposes Discussion but possibly not for long-term engagement needed in telemedicine. Second, frameworks created within academia Principal Findings target for higher causes, such as better education and health The first objective of this study was to provide an overview of outcomes. These frameworks often make use of established theoretical frameworks for the application of gamification and theories but are complex, and, at the time of writing, not used of methods for gamification that specifically target the elderly in practice. In both approaches, no appropriate framework was user. Second, we have explored user classification theories, found to design gamification for elderly users and application which are needed to gain insight into the user and serve as a in telemedicine. Therefore, a new framework should be created tool to effectively tailor content. We have found that current that is of sufficient depth but applicable in practice and frameworks for gamification rarely target the elderly user. The supported by empirical data on its effectiveness. To do so, we effectiveness of the use of user classifications for tailored game would position our future research in academia and take example content is not yet known, neither are there indications for of the studies presented within this approach. Just like the classifying the elderly user with these theories. How can we use authors discussed [32,34,40], we would aim for qualitative, these results to systematically design effective gamified long-term engagement and focus on stimulating intrinsic telemedicine applications for elderly? motivation. Frameworks for gamification emerge from two main approaches. Our study showed two approaches for user classification First, there is a business-oriented approach, with examples of theories: archetypes, where classes are user types with associated success in practice, using an easy-to-apply framework to gamify preferences, and reasons to play, where classes are based on applications. However, the frameworks from this approach may attributes that describe the user preference. None of the found http://games.jmir.org/2015/2/e9/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e9 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES de Vette et al taxonomies seem to be applicable in telemedicine for elderly gamification to motivate and engage. Serious games and users due to the very different context and audience for which exergames for elderly users [71,72] were not included in our they have been developed and the fact that we are not familiar study because our present focus is on improving adherence to with the use of these taxonomies in practice. However, a high existing health interventions by means of gamification, and level of understanding of the target group will greatly contribute serious games are full games that require a different approach. to designing effectively engaging content. This can be achieved However, gamification in persuasive (game) design [73-75] or by a taxonomy for game design specifically for elderly users. vice versa and gamification for behavior change [76] [77] Creating such a taxonomy and corresponding game content can deserve to be explored. Furthermore, because a well-designed be difficult, because older adults may relate to video games game concept is essential for creating a motivating experience differently than younger users as they might not be able to draw for the user, relevant game design principles that consider the from earlier experience with video games. To create such a aspect of experience on engagement such as flow [78,79], classification, it would be most desirable to observe the behavior immersion [50], and customization [8] can prove useful in of intended users in games, but the scarcity of elderly gamers reaching our goals. Furthermore, we emphasize the necessity (and limited availability of games for elderly people) does not of a good game design concept to successfully gamify an provide sufficiently representative subjects for the whole target application for engagement. The framework we aim to develop group. in the future should always leave room for the creative process that is involved. We may be able to predict the preference of a Although from the taxonomies found none seem directly suitable user for different types of content but how content is then for creating our future framework, the 5 domains of the play designed according to these preferences to appeal to the player model [48] exceed the stereotypical classes of the other models could be more art than science. by providing a detailed insight and overview of motivations users may have. The model provides an overview of both player Conclusion and preferences (where others use, for example, game genres, We suggest developing a framework for gamification that is which are ambiguous, not clearly outlined, and differing for based on solid scientific foundations and includes a user each producer of video games) and is moreover based on a classification that specifically assesses the elderly user. We base universally applicable psychological concept that may help in this classification on the 5 domains of the play model that overcoming the particular challenge of mapping a group of users predicts the existence of a relation between preference for game onto a taxonomy who have not been exposed to games at a content and personality. In a study, we need to explore this young age. Therefore, we believe the model by Vandenberghe relation as well as opportunities for use for the intended target advances on earlier classifications, thus making it unique and group and context. When we know more of these aspects, a worthwhile to explore further for use in game design for elderly gamification framework can be developed by which the users. classification of the elderly user is used to effectively create tailored, engaging game content. Subsequently, the framework Advantages of creating a framework within the academic needs to be put to practice and evaluated for empirical support approach are the possibility of using solid scientifically of its effectiveness. established theories and incorporating existing motivational theories and instruments that relate to the objective of Acknowledgments This work is part of the PERSSILAA project [80] and the MAGGY project [81]. PERSSILAA (Personalised ICT Supported Service for Independent Living and Active Ageing) is sponsored by the EU (FP7-ICT-2013-10). MAGGY (Mobile Activity Game for Elderly) is sponsored by the Netherlands Organization for Scientific Research (NWO), Creative Industry Program (314-99-002). Conflicts of Interest None declared. Multimedia Appendix 1 Keywords first search. [PDF File (Adobe PDF File), 8KB-Multimedia Appendix 1] Multimedia Appendix 2 Keywords second search. 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MAGGY: Mobile Activity Game for Elderly. URL: http://www.maggygame.nl/ [accessed 2015-12-08] [WebCite Cache ID 6dchqNdu5] Abbreviations FFM: five-factor model ICT: information communication technology MMORPG: massive multiplayer online role-play games MOOC: massive open online course MUD: multiuser dungeon http://games.jmir.org/2015/2/e9/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e9 | p. 12 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES de Vette et al Edited by G Eysenbach; submitted 20.04.15; peer-reviewed by H Van Dijk, J Lumsden; comments to author 07.05.15; revised version received 30.07.15; accepted 30.09.15; published 18.12.15 Please cite as: de Vette F, Tabak M, Dekker - van Weering M, Vollenbroek-Hutten M JMIR Serious Games 2015;3(2):e9 URL: http://games.jmir.org/2015/2/e9/ doi: 10.2196/games.4561 PMID: 26685287 ©Frederiek de Vette, Monique Tabak, Marit Dekker - van Weering, Miriam Vollenbroek-Hutten. 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Engaging Elderly People in Telemedicine Through Gamification

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Abstract

Background: Telemedicine can alleviate the increasing demand for elderly care caused by the rapidly aging population. However, user adherence to technology in telemedicine interventions is low and decreases over time. Therefore, there is a need for methods to increase adherence, specifically of the elderly user. A strategy that has recently emerged to address this problem is gamification. It is the application of game elements to nongame fields to motivate and increase user activity and retention. Objective: This research aims to (1) provide an overview of existing theoretical frameworks for gamification and explore methods that specifically target the elderly user and (2) explore user classification theories for tailoring game content to the elderly user. This knowledge will provide a foundation for creating a new framework for applying gamification in telemedicine applications to effectively engage the elderly user by increasing and maintaining adherence. Methods: We performed a broad Internet search using scientific and nonscientific search engines and included information that described either of the following subjects: the conceptualization of gamification, methods to engage elderly users through gamification, or user classification theories for tailored game content. Results: Our search showed two main approaches concerning frameworks for gamification: from business practices, which mostly aim for more revenue, emerge an applied approach, while academia frameworks are developed incorporating theories on motivation while often aiming for lasting engagement. The search provided limited information regarding the application of gamification to engage elderly users, and a significant gap in knowledge on the effectiveness of a gamified application in practice. Several approaches for classifying users in general were found, based on archetypes and reasons to play, and we present them along with their corresponding taxonomies. The overview we created indicates great connectivity between these taxonomies. Conclusions: Gamification frameworks have been developed from different backgrounds—business and academia—but rarely target the elderly user. The effectiveness of user classifications for tailored game content in this context is not yet known. As a next step, we propose the development of a framework based on the hypothesized existence of a relation between preference for game content and personality. (JMIR Serious Games 2015;3(2):e9) doi: 10.2196/games.4561 KEYWORDS gamification; framework; elderly; older adults; eHealth; telemedicine; adherence; engagement; classification; player type; personality http://games.jmir.org/2015/2/e9/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e9 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES de Vette et al Introduction Methods It is expected that 25% of the European population will be older In a succession of 3 Internet searches, a broad approach to the than 65 years in 2050 because of global population aging [1]. subject of gamification was taken to gain insight into the many Current socioeconomic structures cannot provide enough work developments in gamification that occur both inside and outside force and capital to meet the needs of this rapidly growing of the scientific world. We performed a search in the scientific elderly population [2]. Telemedicine refers to health services search engines PubMed, Scopus, and Google Scholar and in that enable patients to receive treatment in their daily living diverse nonscientific sources: from game designer blogs and environment, whereby distance is bridged by information conference videos to MOOCs (massive open online courses) communication technology (ICT) and at least one health care and YouTube videos. In this paper, gamification is defined as professional is involved, alleviating the increasing demand for the use of elements from games in nongame contexts to improve elderly care by extending the time of autonomy and user experience and engagement without making that system a independence [3]. Although telemedicine technology seems full game as is the case with serious games including exergames promising, practical implementation still leaves much to be (combination of exercise and gaming) [10,11]. desired. Several studies have shown that adherence to First, we have researched the conceptualization of gamification telemedicine interventions, such as therapy supporting a healthy from a theoretical perspective (see Multimedia Appendix 1). lifestyle, is low [4] and decreases over time [5], even though Keywords used in combination with gamification were used, these studies showed a significant effect on health outcomes including derivatives of these words: “theory,” “definition,” [6]. Clearly, there is a need for strategies that motivate elderly “concept,” “framework,” and “analysis.” In addition, keywords people to use, and keep using, the technologies offered. (and derivatives of these) implying practical use were used: Gamification, the application of game elements to nongame “method,” “application,” and “gamify” (singular). Then, a search fields, may be such a strategy [7]. There is a rapid growth in for gamification combined with “criticism,” “downsides”, and the number of initiatives that use gamification, illustrating a “negative” was performed. Second, we investigated the use of variety of approaches developed from various viewpoints, gamification in applications for the elderly population (see including education, behavior change, physical health, and Multimedia Appendix 1), entering the following combinations mental health. However, a lack of a refined conceptualization of keywords: “gamification,” “gamif*,” “game,” and “gaming” of this strategy exists in these disciplines, and gamification, for with “elder*,” “elderly,” “senior,” “old*,” and “aging.” Finally, elderly people in particular, remains an even further through the same search method, we have researched user underexplored area. In general, it is not yet known which one classifications that categorize users by their motivation or of these approaches is the best for the durable engagement stimulant to play in order to gain insight into the user and further necessary for better adherence. determine how to tailor content to the user (see Multimedia Appendix 2). Keywords used were “[user, player, gamer]” Choice and personalization of content [8], or tailoring, is known combined with “[type, taxonomy, classification, model, style].” to be beneficial for intrinsic motivation [9], which in turn increases long-term engagement needed for adherence. To Included in the results were articles and other works that present provide this tailored content, insight is needed into how users a theoretical basis for the development of gamification, defined should (or want to) be addressed through gamification and how as the presence of a framework that is either theoretical and/or these needs can be classified is required. To our knowledge, based on established scientific foundations or proven effective information on the practical implementation of existing through evaluation in practice. Therefore, beyond the scope of classifications is not yet available. We believe that once an our paper are numerous works on gamified applications with a overview of existing frameworks for gamification and user black box design. classification is established, a gamification strategy that is effective in realizing long-term engagement for the elderly user Results can be developed. Gamification Frameworks For this purpose, the aim of the paper is to (1) provide an This section demonstrates the current state of gamification, understanding of the theoretical background of gamification, starting with the concept of gamification in a broader sense and including existing frameworks for developing gamification both then focusing on gamification for elderly people. We provide in general and specifically for the elderly population, and (2) an overview of existing frameworks for gamification along with explore existing user classification theories that may serve for their contexts and backgrounds. With this, we aim to define the the tailoring of game content to the target user. Because of the status quo in research and provide a deeper understanding of newness of this field of research, we opt for a broad view on the concept and its use and misuse. activities in gamification that occur not only within but also outside of scientific research. In future research, we will work The Conceptualization of Gamification toward a user classification of the elderly population that can Gamification has gained popularity in diverse fields such as be used to develop evidence-based gamification strategies and (interactive) marketing and scientific applications, generating tangible design guidelines for gamification in health care. different definitions of gamification. Currently, there is no consensus about a definition, mainly due to the underlying perception of what the game elements are exactly in terms of http://games.jmir.org/2015/2/e9/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e9 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES de Vette et al level of abstraction and whether the gamified application is with gameful experiences that support the value creation of the game-like or not. Gamification is often roughly defined as the user [15]. In the middle of these definitions, we see gamification use of elements from games in nongame contexts; a more refined as the use of game elements that create a game-like experience definition regards gamification as the identification of that which in a nongame context without creating a full game. makes games captivating and engaging followed by the transfer We found a couple of approaches toward the conceptualization of this knowledge to nongame contexts, increasing user of gamification. One emerges from business practices, such as enjoyment [12,13]. While some see gamification as a way to marketing, customer loyalty, and employee engagement; the act upon psychological principles as certain game techniques other from academia and not sales driven, often specifically do [14], others define gamification as applying gameful aiming to incorporate theories on motivation, engagement, and interaction or design with a specific intention without creating behavior change. Table 1 illustrates this division of the found a full-fledged game [10] or as the process of improving a service articles by author, grouped according to their focus. Table 1. Frameworks for gamification in business and academia. Business Academia Cunningham and Zichermann (2011) Aparicio et al (2012) Werbach and Hunter (2012) Nicholson (2012) Duggan (Badgeville, 2012) Sakamoto et al (2012) In business-oriented, or corporate, gamification, the number of the mechanics presented do not contribute to a gameful successful initiatives, in terms of increased user engagement or experience [25,26]. Robertson [25] states that gamification turns revenue, that use gamification has been rapidly increasing in into “pointsification” when game elements are simply stripped the past few years [16]. It is estimated that the market spend on from games and placed in another application. With this, gamification solutions will grow exponentially until 2016, and structural components of games are perceived and used at that time 40% of the world’s top market value companies elsewhere to function as core mechanics, ignoring the fact that will be using gamification [17,18]. In gamification for the these mechanics should be the inner workings of games. Bogost marketing of consumer products, a well-known success story criticizes this practice using the term “exploitationware” in an is that of Nike+ by Nike. This gamified running log app, article [26] and blog entry titled “Gamification is Bullshit” [27] currently used by 5 million players to track their daily exercise and states that gamification disassociates the practice from goals, caused revenues in the running category to increase by games created for the sole purpose of making an easy profit. A 30% in 2011 alone [19]. An example of successful enterprise design may be poor as well when it extensively uses external gamification is that of software company SAP. After SAP conditions or reinforcements, as known from operant launched a new, gamified version of their online employee and conditioning [28]. These reinforcements often function as main customer community platform, employee usage increased by mechanisms to manipulate behavior and usually present in the 400% and community feedback by 96% [20]. Gamification form of point and reward systems. A shift from intrinsic to appears to be more than a fad, illustrated by the existence and extrinsic motivation can occur through offering external awards, ongoing success of companies such as Badgeville [21,22], which known as the overjustification effect [29], which may lead to provides a platform for gamification of enterprise applications an early loss of interest of the user. The initial interest in the and serves major companies such as Samsung, Deloitte, and (gamified) activity may also disappear once the rewards are no Dell [23]. longer, or insufficiently, offered [30], an effect called the “hedonic treadmill” [31]. From this we observe that the There are several authors within this business orientation, such development of a good game design concept is often as Cunningham and Zichermann [12], who provide guidelines disappearing into the background in corporate gamification for gamification by listing game elements and mechanics such initiatives, while it is as essential for creating an engaging as feedback, achievement, social engagement loops, experience as it is for traditional games. reinforcement, and status, including practical examples. Werbach and Hunter [14] simplify gamification and consider Scientific research from within academia, the second approach it a tool for business strategy. Their method offers practical we distinguish, includes few frameworks on the theoretical guidelines on how to dissect existing games and use them to foundations of gamification. Aparicio et al [32] developed a gamify other applications. Although this approach lacks intricate framework focusing on intrinsic motivation by incorporating game mechanics, gamification is used as a comprehensible tool, concepts from self-determination theory [33]. According to this presenting game elements as a set of building blocks that, used theory, intrinsic motivation can increase by satisfying the together, can provide the gamified application. following psychological factors: competence, autonomy, and relatedness. The framework procedure tells us to (1) identify However, the way gamification is applied in business context the main objective, (2) identify which intrinsically motivating receives a lot of criticism as analysts estimate that the bigger factors should be included, (3) determine which game mechanics part of current gamified applications will not meet their business should be used according to these factors, and (4) evaluate the objectives, mainly due to poor design [24]. Game designers framework in its final application. Nicholson [34] presents a criticize the Cunningham and Zichermann method, stating that complex framework for meaningful gamification, integrating http://games.jmir.org/2015/2/e9/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e9 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES de Vette et al user-centered design [35] in combination with Several differences between the frameworks from business and self-determination, situated motivational affordance [36], academia (Table 2) can be observed. The business frameworks situational relevance [37], and universal design for learning are very concrete; they are simple, provide practical guidelines, [38]. From these core theories, Nicholson [34] suggests how to and, most importantly, have proven their success in this context. provide more intrinsically motivating gamification leading to In academia, gamification has not yet reached this state of meaningful engagement. Self-determination can be found along maturity. The frameworks found on both sides are contradictory: with the transtheoretical model of behavior change [39] in the those from academia are conceptual and complex and provide framework of Sakamoto et al [40], describing a value-based methods that are much more difficult to apply. Therefore, among framework. The authors present 5 core values (informative, these are no empirically supported frameworks showing their empathetic, persuasive, economic, and ideological value) that, effectiveness in practice. The frameworks from business are when used with other game mechanics, can be used to create simplified, therefore lacking depth, which may suffice for attractive and intrinsically motivating gamification services. marketing purposes but possibly not for long-term goals needed for telemedicine applications. Table 2. The contrast between business and academic frameworks. Business Academia Applied Conceptual Simplicity Complexity Practical guidelines Methods inexplicit Proven worthy in practice Earlier stage of development, less empirical support Lacking depth, oversimplified Solid scientific foundation Short-term engagement suffices Aiming for durable motivation Immensely popular Mostly unknown By contrast, Minge et al [43] see gamification as an opportunity Gamification for Elderly Users to decrease feelings of fear and frustration that elderly people While gamification is gaining popularity in telemedicine [41], have toward technology. However, the authors emphasize that limited information was found on appropriate designs for success depends on careful design. For example, the study engaging elderly users. Our search for gamification frameworks participants did not enjoy aspects of quantification and did not return any information on how to address the elderly comparison, which are otherwise very common elements of users. We therefore present existing literature that describes games. explorations of designing gamification for this population group IJsselsteijn et al [44] also state that digital games hold significant (Table 3). Gerling and Masuch [7] indicate that gamification positive potential for elderly users, including therapeutic value holds significant potential for elderly users, particularly in and social bonding. Elderly users are underrepresented as gamifying physical and cognitive therapy. The authors state consumers of digital games because the games offered are not that the main challenge for developing such apps lies within the in line with their accessibility and usability demands or their unfamiliarity of older adults with games, making it difficult to interests and needs. Design requirements are needed to offer draw content from existing digital games. Link et al [42] face the elderly engaging content. According to IJsselsteijn et al [44], a similar challenge after examining a set of game mechanics however, no empirical data are available on the categorization (points, status, and badges) and concluding that these have the of elderly gamers that is necessary to do so, including how this desired impact on youth but not on older adults. would translate into game content. Table 3. Overview of papers described. Source Topic IJsselsteijn et al (2007) [44] Design opportunities for engaging games for elderly Gerling et al (2011) [7] Potential of gamification for engaging (frail) elderly Minge et al (2011) [43] Attitude of elderly toward gamification Link et al (2014) [42] Effect of game elements on motivation of elderly describe people regarding their gaming preferences [32], and Classifying Users: Player Taxonomies none were found for the elderly user in particular [44]. In this User classification holds a key role in the development of section, we discuss several approaches for classifying users in tailored game content, as it gives thorough insight into the general, broadly divided into archetypes and reasons to play. preferences that individuals or subgroups within a target group Archetypes, player types [46,47] (Bartle, Marczewski), and may have [45]. However, there are limited valid methods to http://games.jmir.org/2015/2/e9/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e9 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES de Vette et al gaming personality (types) [48] (Vandenberghe) describe the various approaches are visualized in a diagram. At the end of player characteristics while reasons to play, player motivation this section, we summarize and compare these user taxonomies [49,50] (Yee), and kinds of fun [51,52] (LeBlanc, Lazzaro) take in a chart. motivating elements as a starting point. In Figure 1, these Figure 1. Approaches to classify the user. rewards. This results in 6 player types (Figure 3). The axes are Archetypes equal to the Bartle model but replace player for user and world The earliest and most cited player taxonomy in a gaming context for system. is the Bartle player type theory. It was developed for the first Another approach to create player archetypes is through virtual multiuser environment, text-based dungeons (multiuser personality. Personality traits have been extensively studied and dungeons, or MUDs), by observing and analyzing player researched since the 1880s [55] and, although thousands of traits patterns. Bartle proposes 4 player types (Figure 2) based on two can be found to describe personality [56], a statistical factor primary interests in gameplay: between the emphasis on players analysis demonstrated 5 main factors that many psychologists or on the environment and between acting (to) and interacting believe are sufficient [57,58]. The five-factor model (FFM), or (with). Achievers are interested in actions on the world and find Big Five, is currently the most popular and has shown to be mastery of the game and competition most compelling; explorers reputable, predictive (even normally distributed), reliable, like to interact with the world and enjoy discovery. Socializers crossculturally tested, and universal [59-63]. are most interested in interacting with other players and enjoy the game for friendships and contacts, while killers are interested In the context of games and gaming, several attempts on in acting on other players, demonstrating their superiority. predicting the effectiveness of the application of FFM showed According to Bartle, a good MUD contains the 4 player types inconsistent results [64,65]. In one study, personality traits have in equilibrium [46]—not necessarily of equal number—and the been related to preference for game genres [66]. A low player types were created to balance the design of these predictive capability was found, which may be caused by a lack multiplayer games to accommodate for all player types’ play of evidence on whether the FFM is a valid method to measure style. The application of this model outside its context is personality in a game or not [67,68]; however, direct correlations something Bartle himself advises against [45], especially for between the FFM and gaming were researched and described use in gamification. Furthermore, this model has been criticized by Vandenberghe [48]. He states that personality is very for lacking proper validation with empirical data and means to accurately predictive of gaming preferences and that people assess players to a type [53,49] and for missing similarity play with the same motivations they have in real life or look to between the virtual world of the MUD and the gamified express a particular part of personality that is unsatisfied in real application. Bartle suggests that the types are exclusive but, in life. In his model, the 5 domains of play, a translation of the practice, they can be overlapping or mixing [12]. original FFM traits is made into aspects of gaming motivation (Table 4). Each player is ranked on a linear scale on each of the Similarly, but in the context of enterprise gamification, 5 domains, thereby creating a character description rather than Marczewski [54] proposes a conceptual taxonomy choosing a categorization into a single player type. At the same time, the intrinsic motivations from different theories—autonomy; domains provide insight into the type of content that satisfies purpose and mastery; change—and the extrinsic motivation, the player. http://games.jmir.org/2015/2/e9/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e9 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES de Vette et al Table 4. Five-factor model traits and corresponding gaming motivation traits (deduced from Vandenberghe [48]). Low score Trait High score Cautious, predictable Openness to experience Inventive, curious Repeating, conventional Novelty Open, imaginative experiences Careless, impulsive Conscientiousness Efficient, organized Low effort and self-control Challenge High effort and self-control Reserved, solitary Extraversion Energetic, outgoing Relaxing, low social engagement Stimulation Exciting, high social engagement Analytical, detached Agreeableness Friendly, compassionate Competition, defeating Harmony Cooperation, helping Confident, secure Neuroticism Nervous, sensitive Cheerful, comforting Threat Gloom, horror, high tension Two examples illustrate specific gaming elements derived from scoring high on adventurousness correlates with a preference motivation facets. First, the imagination of the user correlates for exploration and a desire for encountering new things, much with a preference for either fantasy or realism: someone who like the Bartle type explorer, whereas a low score indicates a scores high on imagination will tend to prefer games that take preference for local play styles such as building or farming that place in exotic worlds, whereas someone with a low score will do not involve leaving the boundary of the known [69]. prefer games that take place in a world much like ours. Second, Figure 2. Bartle’s player type model. Figure 3. Marczewski’s player type model. http://games.jmir.org/2015/2/e9/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e9 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES de Vette et al A taxonomy of game aesthetics, or what makes a game fun, can Reasons to Play be found in the mechanics, dynamics, and aesthetics framework Yee [70] proposes a taxonomy based on users’ reasons to play by LeBlanc et al [51]. As much as 8 kinds of fun are defined: and used a long-term, qualitative analysis and factor analytical sensation, fantasy, narrative, challenge, fellowship, discovery, approach to create a taxonomy based on player motivations in expression, and submission. These aesthetics are used to MMORPGs (massive multiplayer online role-play games). The describe why certain players engage with certain games and model by Yee consists of 10 subcomponents factored into 3 more regard the game than categorize the player. Similarly, also main components with which they are most correlated (Figure focusing on fun as a reason to play, Lazzaro [52] conducted a 4). Each subcomponent is linked to game elements from which study to clarify how to address emotions in games without using players derive satisfaction. He finds that the killer must be a storyline by learning what (adult) players found were good omitted and merged into his component of achievement and the gaming experiences. The “4 keys” to fun are original explorer type must be divided into mechanics and discovery. The Yee model is similar to Bartle’s but overcomes • Hard fun: players like challenge, strategy, problem solving, several of its weaknesses. For example, the components of experiencing frustration. Bartle types are not highly correlated, the types overlap and are • Easy fun: players like intrigue and curiosity and enjoy not distinctive, and a practical way to assess users is lacking. immersion. However, similar to the Bartle typology is its narrow focus on • Altered states: players search for internal sensations such massive online gaming. as excitement. • The people factor: players use games for social experiences. Figure 4. Yee’s model motivations of play in MMORPGs: the components and subcomponents. (interacting with the world), and immersion (discovery, Overview of Taxonomies exploration). Although Yee does not have a separate type for Although the taxonomies aforementioned appear very different the killer or disruptor, provocation and domination are present concerning the types of classes, many parallels can be found in achievement. Linking to Lazzaro and LeBlanc, achievement between the characteristics of each class. We present the results is similar to the concept of hard fun and challenge; easy fun in an overview chart (Figure 5). The top row in gray shows the (which includes the motive of immersion) and discovery are author of the model, and under each author the defined classes similar to exploring; and the people factor and fellowship and (types, motivations, facets, etc) are shown. Arrows indicate a expression relate to the social aspect. The model of direct derivative of a model, as explained in the previous section; Vandenberghe not only seems all-embracing, but it also adds a black lines indicate which classes show highly similar dimension to each personality trait. The killer can be linked to characteristics. The dotted line indicates that classes only have a very low score on harmony, the achiever to a high score on several characteristics in common. The colors indicate which challenge, the explorer to a high score on novelty, the socializer classes belong to the same group. This overview shows that to a high score on stimulation. The trait threat is quite unique there is great connectivity between the models and highlights and only linked to submission. According to Vandenberghe, that the model of Vandenberghe covers all class properties of this trait may not be pointing out what keeps a player playing the other models (except for the player in the Marczewski but what makes the player decide to stop playing. model). None of the taxonomies presented target the elderly user In the models of Marczewski and Yee, which both have Bartle specifically. Furthermore, we do not know of any methods as point of reference, we see a clear analogy between the regarding the mapping of this target group on the existing achievers and socializers and also in the attributes of the free taxonomies, mainly because the gaming industry does not focus spirit (interacting with the system, autonomy), the explorer on this group as a consumer for video games. Moreover, the http://games.jmir.org/2015/2/e9/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e9 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES de Vette et al taxonomies are in most cases designed for use in a specific is not given a singular class label or a combination of those. application, such as enterprise gamification or MMORPGs, and Instead, a complete character description can be created based it is not known how suitable they are for application in on preference for certain aspects or elements of games. What telemedicine interventions. We can identify many parallels makes this theory even more attractive is that it describes the between the models, and we consider that the 5 domains of play user based on personality, a universal understanding regardless stand out from the rest. Unlike the other models, an individual of age. Figure 5. Chart of connections between taxonomies (arrow: direct derivative of, line: high similarity in concept, dots: closely related concepts). also be oversimplified, which suffices for marketing purposes Discussion but possibly not for long-term engagement needed in telemedicine. Second, frameworks created within academia Principal Findings target for higher causes, such as better education and health The first objective of this study was to provide an overview of outcomes. These frameworks often make use of established theoretical frameworks for the application of gamification and theories but are complex, and, at the time of writing, not used of methods for gamification that specifically target the elderly in practice. In both approaches, no appropriate framework was user. Second, we have explored user classification theories, found to design gamification for elderly users and application which are needed to gain insight into the user and serve as a in telemedicine. Therefore, a new framework should be created tool to effectively tailor content. We have found that current that is of sufficient depth but applicable in practice and frameworks for gamification rarely target the elderly user. The supported by empirical data on its effectiveness. To do so, we effectiveness of the use of user classifications for tailored game would position our future research in academia and take example content is not yet known, neither are there indications for of the studies presented within this approach. Just like the classifying the elderly user with these theories. How can we use authors discussed [32,34,40], we would aim for qualitative, these results to systematically design effective gamified long-term engagement and focus on stimulating intrinsic telemedicine applications for elderly? motivation. Frameworks for gamification emerge from two main approaches. Our study showed two approaches for user classification First, there is a business-oriented approach, with examples of theories: archetypes, where classes are user types with associated success in practice, using an easy-to-apply framework to gamify preferences, and reasons to play, where classes are based on applications. However, the frameworks from this approach may attributes that describe the user preference. None of the found http://games.jmir.org/2015/2/e9/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e9 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES de Vette et al taxonomies seem to be applicable in telemedicine for elderly gamification to motivate and engage. Serious games and users due to the very different context and audience for which exergames for elderly users [71,72] were not included in our they have been developed and the fact that we are not familiar study because our present focus is on improving adherence to with the use of these taxonomies in practice. However, a high existing health interventions by means of gamification, and level of understanding of the target group will greatly contribute serious games are full games that require a different approach. to designing effectively engaging content. This can be achieved However, gamification in persuasive (game) design [73-75] or by a taxonomy for game design specifically for elderly users. vice versa and gamification for behavior change [76] [77] Creating such a taxonomy and corresponding game content can deserve to be explored. Furthermore, because a well-designed be difficult, because older adults may relate to video games game concept is essential for creating a motivating experience differently than younger users as they might not be able to draw for the user, relevant game design principles that consider the from earlier experience with video games. To create such a aspect of experience on engagement such as flow [78,79], classification, it would be most desirable to observe the behavior immersion [50], and customization [8] can prove useful in of intended users in games, but the scarcity of elderly gamers reaching our goals. Furthermore, we emphasize the necessity (and limited availability of games for elderly people) does not of a good game design concept to successfully gamify an provide sufficiently representative subjects for the whole target application for engagement. The framework we aim to develop group. in the future should always leave room for the creative process that is involved. We may be able to predict the preference of a Although from the taxonomies found none seem directly suitable user for different types of content but how content is then for creating our future framework, the 5 domains of the play designed according to these preferences to appeal to the player model [48] exceed the stereotypical classes of the other models could be more art than science. by providing a detailed insight and overview of motivations users may have. The model provides an overview of both player Conclusion and preferences (where others use, for example, game genres, We suggest developing a framework for gamification that is which are ambiguous, not clearly outlined, and differing for based on solid scientific foundations and includes a user each producer of video games) and is moreover based on a classification that specifically assesses the elderly user. We base universally applicable psychological concept that may help in this classification on the 5 domains of the play model that overcoming the particular challenge of mapping a group of users predicts the existence of a relation between preference for game onto a taxonomy who have not been exposed to games at a content and personality. In a study, we need to explore this young age. Therefore, we believe the model by Vandenberghe relation as well as opportunities for use for the intended target advances on earlier classifications, thus making it unique and group and context. When we know more of these aspects, a worthwhile to explore further for use in game design for elderly gamification framework can be developed by which the users. classification of the elderly user is used to effectively create tailored, engaging game content. Subsequently, the framework Advantages of creating a framework within the academic needs to be put to practice and evaluated for empirical support approach are the possibility of using solid scientifically of its effectiveness. established theories and incorporating existing motivational theories and instruments that relate to the objective of Acknowledgments This work is part of the PERSSILAA project [80] and the MAGGY project [81]. PERSSILAA (Personalised ICT Supported Service for Independent Living and Active Ageing) is sponsored by the EU (FP7-ICT-2013-10). MAGGY (Mobile Activity Game for Elderly) is sponsored by the Netherlands Organization for Scientific Research (NWO), Creative Industry Program (314-99-002). Conflicts of Interest None declared. Multimedia Appendix 1 Keywords first search. [PDF File (Adobe PDF File), 8KB-Multimedia Appendix 1] Multimedia Appendix 2 Keywords second search. 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MAGGY: Mobile Activity Game for Elderly. URL: http://www.maggygame.nl/ [accessed 2015-12-08] [WebCite Cache ID 6dchqNdu5] Abbreviations FFM: five-factor model ICT: information communication technology MMORPG: massive multiplayer online role-play games MOOC: massive open online course MUD: multiuser dungeon http://games.jmir.org/2015/2/e9/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e9 | p. 12 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES de Vette et al Edited by G Eysenbach; submitted 20.04.15; peer-reviewed by H Van Dijk, J Lumsden; comments to author 07.05.15; revised version received 30.07.15; accepted 30.09.15; published 18.12.15 Please cite as: de Vette F, Tabak M, Dekker - van Weering M, Vollenbroek-Hutten M JMIR Serious Games 2015;3(2):e9 URL: http://games.jmir.org/2015/2/e9/ doi: 10.2196/games.4561 PMID: 26685287 ©Frederiek de Vette, Monique Tabak, Marit Dekker - van Weering, Miriam Vollenbroek-Hutten. Originally published in JMIR Serious Games (http://games.jmir.org), 18.12.2015. This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), 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/2015/2/e9/ JMIR Serious Games 2015 | vol. 3 | iss. 2 | e9 | p. 13 (page number not for citation purposes) XSL FO RenderX

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JMIR Serious Games – JMIR Publications

Published: Dec 18, 2015

Keywords: gamification; framework; elderly; older adults; eHealth; telemedicine; adherence; engagement; classification; player type; personality

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